HospitalInspections.org

Based on record review and staff interview, the facility failed to ensure that nursing care plans were developed for 4 out of 20 inpatients (Patients 6, 7, 8 and 14). This failed practice had the potential to affect all patients of the facility. The facility had 143 inpatients for fiscal year ending 12/31/22.

Findings include:

A. Review of Patient 6's medical record (5/2/23 at 10:00 AM) revealed an inpatient admission of 2/4/23-2/9/23 for Congestive Heart Failure, Coagulopathy, Atrial Fibrillation with RVR and Hypertension. Review of the entire medical record revealed a lack of evidence of a nursing care plan.

-Review of Patient 7's medical record (5/2/23 at 10:21 AM) revealed an inpatient admission of 3/1/23-3/4/23 for Acute on Chronic Hypoxic Respiratory Failure, Chronic Obstructive Pulmonary Disease, Atrial Fibrillation and Hypertension. Review of the entire medical record revealed a lack of evidence of a nursing care plan.

-Review of Patient 8's medical record (5/2/23 at 10:45 AM) revealed an inpatient admission of 4/7/23-4/8/23 for Acute Pancreatitis, Hypertriglyceridemia and Alcohol Abuse. Review of the entire medical record revealed a lack of evidence of a nursing care plan.

-Review of Patient 14's medical record (5/2/23 at 2:05 PM) revealed an inpatient admission of 4/23/23-4/24/23 for Colonic Stricture. Review of the entire medical record revealed a lack of evidence of a nursing care plan.

B. Interview with Director of Nursing (5/3/2023 at 2:00 PM) confirmed the above medical records lacked nursing care plans.

Based on record review and staff interview, the facility failed to provide any documentation/evidence of testing/training for the facility staff as required for Emergency Preparedness procedures for the previous 13 months prior to May 1, 2023. Review of the Emergency Preparedeness binder revealed an outdated map from before two recent building additions to the facility; resulting in inability to account for each service area and the needed response for healthcare systems overall comprehensive emergency compliance. This failed practice had the potential to affect all patients and staff of the facility. The facility listed 193 employees and provided care in the previous year ending 12/31/22 for 176 inpatients, 119 observation patients, 375 surgeries and 1782 emergency room patients.

Findings include:

A. Review of the Facility documents originally provided on 5/3/23 at 9:45am for staff drills/education on emergency training, included 13 (thirteen) events for Table Top Exercises, Full Scale Events, Real (Live) Events and Drills in a summary log listed for time period from June 2018 - September 2020. A committee meeting was held on 2/2/21 with minutes recording the upcoming events for the facility training. No further meeting information or drills was found until further inquiry with Director of Nursing on 5/3/23 at 4:45pm. Additional information was found online showing the last documented evidence for drills for facility were held on 2/23/22 and 3/22/22.
-On 2/23/22 an Active Shooter training exercise was conducted at the facility however, no records were available to determine who was involved with this training.
-On 3/22/22, several staff attended an offsite HazMat (hazardous materials) training for the County, however no record of attendance was available.
No further evidence of Emergency preparedness drills/training/testing plan were available in the facility at the time of the survey.


B. The facility map/legend of the campus provided in the Emergency Preparedness Binder was from the original campus prior to renovation/two additions. The original hospital campus included surgery services, emergency room, and a rural health clinic. The recent additions of a specialty clinic including rehabilitation therapy departments, and finance/business office area were not included on the map/legend.

C. Interview with Director of Nursing (5/3/23 at 3:15 PM) revealed the previous person in charge of emergency training during the Covid Pandemic was no longer employed by facility and the position had not yet been filled.