HospitalInspections.org

Based on observations, staff interview, review of the facility Maintenance requisition/repair form, email correspondence, and Housekeeping Procedures policy, the facility failed to provide a clean and orderly environment for the safety of the staff and patients for one (1) of four (4) days of survey.

Findings Include:

Observation of the Emergency Department (ED) entry hall on 9/17/2024 at 10:00 a.m. with the Director of Nursing (DON) revealed two (2) water-stained ceiling tiles in the ED entry hall. Confirmed by the DON.

Observation of ED room #1 on 09/17/2024 at 10:05 a.m. with the DON revealed numerous areas of peeling paint on all four (4) walls of the room, three (3) open holes on the interior wall of the room approximately one (1) inch in diameter, thick accumulation of dust noted on the top of the wall mounted cardiac monitor, under the stretcher, the ceiling exhaust vent, and the overbed light. Confirmed by the DON.

Observation of ED room #2 on 09/17/2024 at 10:12 a.m. with the DON revealed numerous areas of peeling paint on all four (4) walls, six (6) small open holes on the wall by the sink approximately ½ inch in diameter, multiple areas of cracked sheetrock with pieces of the sheetrock flaking on the interior wall, thick accumulation of dust on the wall mounted cardiac monitor, under the stretcher, and on the overbed light. Confirmed by the DON.

Observation of ED room #3 on 09/17/2024 at 10:40 a.m. with the DON and the Maintenance Director revealed numerous areas of peeling paint on all four (4) walls, thick accumulation of dust on the wall mounted cardiac monitor and the overbed light. Confirmed by the DON and the Maintenance Director.

Observation of the outpatient laboratory area on 09/17/2024 at 1:40 p.m. with the DON revealed numerous areas of peeling paint on the entry side of the room with multiple areas of cracked sheetrock with flaking of sheetrock. Confirmed by the DON.

Observation of unoccupied inpatient room #207 on 09/17/2024 at 2:00 p.m. with the DON revealed multiple holes in the wall by the sink area ranging from ½ inch to one (1) inch in diameter, two (2) stained ceiling tiles with visible mold, one (1) ceiling tile with a hole approximately two (2) inches in diameter, one (1) nail sticking out of the wall approximately one (1) inch by the sink, and thick accumulation of dust on the overbed light. Confirmed by the DON.

Observation of unoccupied inpatient room #225 on 09/17/2024 at 2:08 p.m. room with the DON and the Maintenance Director revealed thick accumulation of dust on overbed light. Confirmed by the DON and the Maintenance Director.

Observation of unoccupied inpatient room #234 on 09/17/2024 at 2:14 p.m. with the DON and the Maintenance Director revealed numerous holes, ranging in diameter from ½ inch to 1 inch, in the wall by the sink, numerous areas of peeling paint on all four (4) walls, and thick accumulation of dust on the overbed light. Confirmed with the DON and the Maintenance Director.

Observation of unoccupied inpatient room #235 on 09/17/2024 at 2:24 pm with the DON and the Maintenance Director revealed numerous areas of peeling paint on three (3) walls, bed mattress with white powdered substance observed, large open hole above the window with flaking sheetrock approximately six (6) inches in diameter, and three (3) water-stained ceiling tiles. Confirmed with the DON and the Maintenance Director.

Observation of unoccupied inpatient room #236 on 09/17/2024 at 2:39 p.m. with the DON, the Maintenance Director, and the Administrative Director revealed numerous areas of peeling paint on three (3) walls, thick accumulation of dust on the overbed light and under the bed, two (2) water stained ceiling tiles, multiple holes in the wall, ranging in diameter from ½ inch to one (1) inch by the sink, one (1) open hole in the bathroom wall by the toilet approximately two (2) inches by four (4) inches, and the bathroom call light box with clear tape securing the call light box to the wall. Confirmed by the DON, the Maintenance Director, and the Administrative Director.

An interview with the DON on 09/17/2024 at 10:00 a.m. confirmed the ceiling tiles in the ED entry hall need to be replaced due to the water-stained areas.

An interview with the DON on 09/17/2024 at 10:05 a.m. confirmed in ED room #1 that maintenance has been notified of the walls needing repair, and environmental services (housekeeping) is supposed to clean all ED rooms daily and as needed.

An interview with the DON on 09/17/2024 at 10:12 a.m. confirmed the staff or directors email maintenance for needed repairs.

An interview on 09/17/2024 at 10:35 am with the Maintenance Director confirmed he has received some emails, but he has to prioritize the work that needs to be completed and that he also has to do the lawn service as well.

An interview on 09/17/2024 at 2:08 p.m. with the DON confirmed the housekeeping department is supposed to clean the rooms daily and a monthly deep cleaning is to be performed. The DON and the Maintenance Director confirmed all the rooms on the inpatient unit are open and available for new admissions, including the current unoccupied rooms, room #207, #225, #234, #235, #236.

An interview on 09/18/2024 at 11:00 a.m. with the DON confirmed there is no Maintenance Logbook for needed repairs available.

Review of the facility policy, Housekeeping Procedures, revised date 6/2016, " ...Daily Patient Room Cleaning ...2) Horizontal dusting. With a cloth and disinfectant wipe all horizontal (flat) surfaces. 3) Spot clean. With a cloth and disinfectant spot clean all vertical surfaces ...The goal of cleaning is Infection control ...Complete Room Cleaning ...Every room must be Deep Cleaned at least 1x/month ...Deep Clean Checkoff List ...Pull out bed ...wipe down bed frames ...clean and dust off bed frame ...clean ceilings, vents, and light fixtures ...clean and wipe down vents ...".

No Deep Clean checklist submitted for review.

No policy for maintenance repairs submitted for review.

No Maintenance Logbook or email correspondence for needed repairs submitted for review.

During exit conference on 09/19/2024 at 12:30 p.m. with the DON (CNO), the Nurse Manager, the Director of HIM, Maintenance Director, and the Administrative Director, survey findings were discussed, and no further documentation was submitted for review.

Based on staff interview, Physician (Provider) Credential record review, review of the provider schedule, review of the facility's Regular Board Meeting minutes, facility's By-Laws of The Governing Board, facility's Medical Staff & Allied Health Professionals Staff Bylaws Rules and Regulations, facility policy and procedure review the facility failed to ensure documented evidence of provider credentialing for one (1) of ten provider credential records reviewed: Provider #7.

Findings Include:

An interview with Director of Nursing (DON) and Director of Health Information Management (HIM) on 09/18/2024 at 11:23 a.m. confirmed Provider #7 does not currently have clinical privileges.

Review of the provider credential record titled, "Request for Reappointment and/or Renewal of Clinical Privileges" for Provider #7 revealed, clinical privileges expired June 2024. Additionally, Provider #7 submitted form titled, "Request for Reappointment and/or Renewal/Change of Clinical Privileges" dated 09/12/2024.

Review of the provider schedule for the months of July, August, and September 2024 revealed, Provider #7 was scheduled and worked the following shifts: 07/07/2024, 07/22/2024, 08/02/2024, 08/23/2024, 09/01/2024, and 09/13/2024.

Review of the facility's "Regular Board Meeting" minutes dated 07/22/2024 revealed, " ...presented the following providers to the board for reappointment of privileges and initial credentialing which all have been approved by the Medical Staff ...". Provider #7 was not included in this list.

Review of the facility's "By-Laws of The Governing Board" with no date revealed, " ...ARTICLE VIII Medical Staff ...All applications for appointment to the Medical Staff shall be in writing, shall be signed by the applicant, and shall be submitted on a form prescribed by the governing body after recommendation of Medical Staff Credential Committee ...At the first regular Medical Staff meeting thereafter, the CEO shall present the application to the Medical Staff, at which time; it shall be either rejected or referred to the Medical Staff Credentials Committee ...".

Review of the facility's "Medical Staff and Allied Health Professionals Staff Bylaws Rules and Regulations" Approved by Medical Staff 06/15/2023, Approved by Board of Directors 11/27/2023 revealed, " ...reappointment application shall be submitted to the Medical Staff Office or designee at least sixty (60) days prior to the month the appointee's current appointment ends. The Credentials Committee ...shall review all pertinent information available including all information provided form other committees of the Medical Staff and from hospital management for the purpose of determining its recommendations for staff reappointment, for the granting of clinical privileges for the ensuing reappointment ...".

Review of the facility's policy titled, "Credentialing Policy/Procedure" with no date revealed, "Procedure ...Regular appointment is for a period of two years. Temporary privileges may be granted by the administrator and/or Chief of Staff until the application has been processed ...".

During the exit conference on 09/19/2024 at 12:45 p.m. with Nurse Manager, Health Information Management, Chief Nursing Officer, Plant Operations Director, Quality Director and Administrative Director, survey findings were discussed, and no further documentation was submitted for review.

Based on observation, staff interview, and review of the manufacturer's guidelines, the facility failed to have a policy in place to prevent the use of single patient use oxygen connection tubing from being used for multi-patient use to prevent the spread of infection in the healthcare facility for one (1) of four (4) days of survey.

Findings Include:

Observation of the Radiology Department on 09/17/2024 at 11:50 a.m. with the Radiology Director revealed in the Computed Tomography (CT) room one (1) opened, unlabeled, unbagged oxygen connection tubing connected to the wall oxygen flow meter and hanging on the flow meter. Confirmed by the Radiology Director.

Observation of the inpatient therapy department on 09/17/2024 at 4:15 p.m. with the Certified Occupational Therapy Assistant (COTA) #1 revealed one (1) opened, unlabeled, unbagged oxygen connection tubing connected to the wall oxygen flowmeter and hanging on the flow meter. Confirmed by the COTA #1.

An interview with the Radiology Director on 09/17/2024 at 11:50 a.m. confirmed the oxygen connection tubing hanging on the flow meter is used. The Radiology Director states, "we reuse the oxygen connection tubing to connect patients to the oxygen flow meter when patients come in for CT, and just hang it on the flow meter when the CT is completed". She further confirmed the oxygen connection tubing is not changed between patients, it is reused and connected to the patient's oxygen tubing when the patient comes for a CT.

An interview with the COTA #1 on 09/17/2024 at 4:15 p.m. confirmed the oxygen connection tubing is used for multiple patients. The COTA further confirmed, when a patient comes in with oxygen in use, the staff connect the oxygen connection tubing to the current oxygen tubing to give the patients extended tubing to be able to perform therapy.

Review of the manufacturer's guidelines for Medline seven (7) foot crush resistant oxygen tubing, " ...single patient use ...".

No policy for changing, labeling, or use of oxygen connection tubing submitted for review.

During exit conference on 09/19/2024 at 12:30 p.m. with the DON (CNO), the Nurse Manager, the Director of HIM, Maintenance Director, and the Administrative Director, survey findings were discussed, and no further documentation was submitted for review.