HospitalInspections.org

Based on record review and interview, the faciity failed to ensure staff are certified in accordance with applicable Federal, State and local laws and regulations.

Findings included:
Review of Nurse Aide Registry Status for employee #7 on the afternoon of 7/27/22 reflected certification expiration date of 6/22/2022.

During an interview on the afternoon of 7/27/2022, Staff #16 stated the employee "had been working as a facility (COVID) screener and just recently returned to the floor. Somehow her certification renewal was missed." She continued to state "the expectation for our staff is that licenses and certifications are renewed prior to expiration. I have a system in place to ensure this occurs and this employee was missed because of her recent change in status at the facility. She has worked the floor since her certification expired."

Based on observation and interview, the facility failed to ensure trash was stored in a manner to prevent the infestation of pest or rodents in 1 of 3 trash dumpsters.

This deficient practice had the likelihood to cause harm to all patients.

Findings included:

Observation on 7/27/22 at 9:00 am revealed one dumpster with the lid open. Observation on 7/27/22 at 1:30 pm revealed the same dumpster with the lid open.


Staff #16 confirmed the observation 7/27/22 at 1:30 pm.

Based on a review of documentation and interview the facility failed to ensure that patient discharge summaries were completed within 30 days of discharge for 1 of 3 patients reviewed (patient #7).

Findings included:

Patient #7 was discharged from the facility on 11/3/21. Review of Patient # 7's medical record revealed a history and physical dated 10/27/21. No discharge summary was located in the medical record.

In an interview on 7/27/22 staff member #16 verified that there was no discharge summary in the medical record.

Based on observation and interview, the facility failed to post the Emergency Medical Treatment and Active Labor Act (EMTALA) signage in the emergency department ambulance entrance.

Findings included:

An observation of the facility's emergency department ambulance entrance, on the morning of 7/26/22, revealed there was no EMTALA signage.

During an interview on the morning of 7/26/22, in the facility's emergency department ambulance entrance, Staff #16, CNO, confirmed patients come in to this entrance and that the signage was missing.