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Based on observation and the review of documentation in 6 personnel records (Records 1, 2, 3, 4, 5, and 6) it was determined the hospital failed to ensure staff completed required trainings and failed to maintain required certifications.

Findings:

The review of documentation in employee training records on 3/29/2017 at 0915, failed to reflect that 2 of 4 nursing staff (Staff 1 and 3) had received the required annual infection control training for 2016.

The review of documentation in employee training records on 3/29/2017 at 0915, failed to reflect that 3 of 4 nursing staff (Staff 1, 3, and 4) had received the required annual disaster and fire drill training for 2016.

The review of documentation in employee training records on 3/29/2017 at 0915, failed to reflect that 1 of 4 nursing staff (Staff 1) had a current job description.

Observation of the dietary area was completed on 3/28/2017 at 1140 with the Assistant Supervisor. Review of Food Handlers certifications was completed at this time. The review of documentation failed to reflect that 1 staff (Staff 6) had a current Food Handlers certification. Documentation revealed that his/her Food Halnders certification had expired on 03/21/2017.

Based on observation and interview, it was determined the hospital failed to maintain the physical environment to ensure the safety of patients, staff and public.

Findings:

Observation of the ED at 1130 on 3/27/2017 revealed the following:

- In the housekeeping closet was a shelf above the floor sink containing an eye wash faucet. There was an accumulation of dirt, grime and water stains on this shelf. There was a wrench and a pair of stained rubber gloves on this shelf next to the faucet.

- Another shelf in the housekeeping closet revealed open containers of cleaning chemicals, open containers of Sani-cloths, an open bottle of bleach, various open spray cleaners and coffee cups stored adjacent to each other.

- The floor sink in the closet had evidence of an accumulation of dirt and grime. The sink drain was covered in dried debris.

- The floor and the walls in the closet was stained and had evidence of an accumulation of rust, dirt and debris.

Observation of Med/Surg department at 1050 on 3/27/2017 revealed the following:

- The medication room sink was stained and there was pooled water on the counter top. Paper medication cups were on a paper towel on the wet counter top, adjacent to the sink.

- 5 cardboard supply boxes were stored under the sink. These supplies included but were not limited to sterile syringes. On top of 1 of the cardboard boxes was a 3-ring binder. The binder was on a paper towel that had evidence of water stains and damage.

- There was an accumulation of dirt, dust, and debris in the isolation cart drawers which contained patient supplies.

- Entry into the dirty utility room was impeded due to a garbage can blocking the door. The floor in the utility room had evidence of an accumulation of dirt and debris.

- The inside of the tub had evidence of an accumulation of dirt and debris. A soiled mop was stored in the tub.

Observation of the Labor and Delivery suite at 1350 on 3/27/2017 revealed the following:

- There was an accumulation of dust on the horizontal surfaces.

- The floor in the housekeeping closet had evidence of an accumulation of dirt, grime, and debris.

- The tub was stained and was being used to store a ladder. A bucket on the floor adjacent to the tub was soiled and contained industrial floor brooms with accumulated dirt and debris in the brushes. Another dirty bucket was balanced on top of the broom brushes. This bucket contained a used toilet plunger.

- The O2 tank was unsecured.

Observation of the Rehabilitation department at 1545 on 3/28/2017 revealed the following:

- A paper plate of uncovered, partially eaten food on a shelf in a patient supply cupboard.

- A TENS unit with a used syringe and attached needle was found in a patient supply cupboard. An interview with the department manager revealed the TENS units were "seldom used" and he/she was unsure why a used, empty syringe with attached needle would be stored or left in the unit.

Based on observation, interview, review of PM documentation and policies and procedures, it was determined the facility failed to develop and implement written policies and procedures to ensure that all facility and patient care equipment had been maintained to ensure an acceptable level of safety and quality.

Findings:

The review of documentation failed to reflect the facility had written policies and procedures for equipment preventative maintenance.

The review of documentation failed to reflect a current and complete inventory list of equipment used in the facility, including but not limited to, patient care, mechanical, and electrical equipment.

Observation of the outpatient clinic and the rehabilitation areas on 3/28/2017 between 1420 and 1545 revealed the following:

- A Huntleigh Dopplex D900 had no inventory and/or property ID number(s). There was no documentation available for review to verify that any PM had been completed for this item;

- An electric hospital bed had no inventory and/or property ID number(s). There was no documentation available for review to verify that any PM had been completed for this item;

- An electric treatment chair had no inventory and/or property ID number(s). There was no documentation available for review to verify that any PM had been completed for this item;

- Fitness equipment, including an exercise bicycle and treadmill had no inventory and/or property ID number(s). There was no documentation available for review to verify that any PM had been completed for this item;

- A TENS unit had no inventory and/or property ID number(s). There was no documentation available for review to verify that any PM had been completed for this item.

Review of the document titled, "Active Equipment List for BMH" dated 12/29/2016 failed to reflect that the items listed above were included on the equipment list. Documentation failed to reflect that the electric hospital beds and treatment chairs used throughout the facility had been included on the equipment list.

During an interview with the Director of Facilities on 3/27/2017 at 0845, he/she indicated that all biomedical equipment checks were completed twice a year by St. Charles Health System's Biomedical Services.

During an interview with the CNO on 3/28/2017 at 1415, he/she indicated the hospital did not include durable medical equipment, including hospital beds and treatment chairs, on the PM list. During this interview he/she confirmed these items were not documented on the hospital-wide medical equipment inventory list.

Based on observations it was determined the facility failed to ensure that expired drugs were not available for patient use and drugs and biologicals were stored appropriately.

Findings:

Observation of the Med/Surg department at 1050 on 03/27/2017 revealed the following:

- An open and partially used single-use vial of bacteriostatic water;

- 2 15 ml vials of sterile water on the emergency cart, expired 03/19/2017.

Observation of the Diagnostic Imaging department on 03/28/2017 revealed the following:

- 2 spray bottles of a chemical cleaning solution, a spray bottle of window cleaner, and a spray bottle of a hospital grade disinfectant were stored in a patient supply cupboard. These items were stored adjacent to bottles of oral contrast suspensions and boxes of oral contrast dissolvable granules that were administered to patients.

The review of documentation revealed the hospital had failed to design, implement, monitor and evaluate a mechanism, including but not limited to written policies and procedures, to ensure that expired drugs and biologicals were not available for patients use.

Based on interviews, review of documentation and review of 12 medical staff personnel records (Records 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12) reviewed for TB risk assessment documentation, it was determined the hospital failed to design, implement, monitor and evaluate a mechanism to ensure TB risk assessments, testing and documentation had been completed.

Findings:

Review of documentation on 3/27/2017 at 1030 included the TB risk assessments in medical staff personnel records. Documentation revealed the following:

- Record 1: Staff 1 was a CRNA with an appointment date of 5/2011. Documentation revealed he/she had 1 documented TST given on 9/29/2015 and read on 10/1/2015. Documentation failed to reflect any additional TST's or TB risk assessments had been completed subsequent to that date;

- Record 2: Documentation revealed Staff 2 was a CRNA with an appointment date of 6/9/2009. Documentation failed to reflect that he/she had ever had a TB risk assessment, TB screening, or TST completed;

- Record 3: Documentation revealed Staff 3 was a CRNA with an appointment date of 4/2008. Documentation revealed he/she had 1 documented TST given on 3/17/2011 and read on 3/19/2011. Documentation failed to reflect any additional TST's or TB risk assessments had been completed subsequent to that date;

- Record 4: Documentation revealed Staff 4 was an MD with an appointment date of 1/19/2017. Documentation failed to reflect that he/she had ever had a TB risk assessment, TB screening, or TST completed;

- Record 5: Documentation revealed Staff 5 was an MD with an appointment date of 01/19/2017. Documentation failed to reflect that he/she had ever had a TB risk assessment, TB screening, or TST completed;

- Record 6: Documentation revealed Staff 6 was a DO with an appointment date of 12/2013. Documentation failed to reflect that he/she had ever had a TB risk assessment, TB screening, or TST completed;

- Record 7: Documentation revealed Staff 7 was an MD with an appointment date of 12/17/2015. Documentation failed to reflect that he/she had ever had a TB risk assessment, TB screening, or TST completed;

- Record 8: Documentation revealed Staff 8 was an FNP with an appointment date of 10/18/2012. Documentation failed to reflect that he/she had ever had a TB risk assessment, TB screening, or TST completed.

Similar findings were noted in the remaining records reviewed (Records 9, 10, 11, and 12).

During an interview with the CNO on 3/27/2017 at 1330 he/she stated, "Before I came in December they weren't doing TB or keeping track of it. It was a mess."

Review of documentation on 3/27/2017 at 1030 included the hospital's "TB Exposure Plan" dated 1/2014. Directions in this plan included, but were not limited to, "New Employee PPD - Every new employee will have a two-step PPD administered and read prior to (or shortly after) starting date of employment, the second dose will be administered 2 weeks after the first PPD...Annual PPD...Blue Mountain Hospital's risk assessment indicated a low-risk category, therefore HCW's need to complete a TB Risk Screening yearly but do not need a TST unless they have experienced an unprotected exposure."





























































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Based on the review of documentation it was determined the hospital failed to ensure medical records were complete and accurately documented.

Findings:

The review of documentation in 5 medical records (Records 11, 12, 16, 21 and 22) for patients who had received a blood transfusion revealed 1 record (Record 12) that did not have complete documentation about the transfusion.

Record 12: Documentation revealed Patient 12 received a blood transfusion on 11/28/2017. The transfusion was started at 2140. Documentation failed to reflect the time the transfusion was completed.

Instructions in an undated policy titled, "Blood/Blood Component-Transfusion" included but were not limited to, "Documentation....Time transfusion ended..."

Based on interview and the review of documentation, it was determined the hospital failed to ensure signed consent forms were obtained.

Findings:

Record 21: Review of documentation revealed that Patient 21 was admitted to the Day Surgery unit at 0725 on 03/21/2017. Patient 21 was scheduled to have a colonoscopy. Additional review of documentation in the medical record revealed that at 1236 on 03/21/2017 Patient 21 was admitted to the hospital for an "emergent splenectomy post colonoscopy."

Documentation in the medical record failed to reflect that a signed consent form had been obtained for the splenectomy procedure.

Review of the undated policy titled "Consent-Informed and Implied," included "...Obtaining Informed Consent...It is the responsibility of the practioner(s) responsible for the surgery/procedure to obtain the Informed Consent...Only the performing practitioner and/or anesthetist can provide the information...Documentation must clearly indicate that the patient or legal guardian has the opportunity to ask any questions he/she may have about the proposed anesthesia and/or procedure...The original copy of the Informed Consent must be in the patient's medical record Prior [sic] to surgery...Any special circumstance(s) must be documented on the Informed Consent...The healthcare professional witnessing the signature of the patient signs as a witness...When witnessing an oral signature, interpreted consent discussion or mark substitute for signature, the witnesses will briefly describe the circumstances and date, time and sign the Consent Form. In most circumstances, two (2) witnesses are requested in these circumstances an generally, they are hospital employees."

During an interview with the CNO at 1500 on 03/29/2017 he/she stated that a consent form for the splenectomy was not obtained because the MD had talked to Patient 21's spouse and had received a verbal consent from the spouse for the procedure and the MD "did not take the time to get it in writing."

Based on interview and review of documentation, it was determined the hospital had failed to conduct timely, complete and accurate evaluations of its total program at least annually.

Findings:

Review of documentation included the "Annual Critical Access Hospital Evaluation for fiscal year 2016/2016". This document was not complete, signed or dated and included the following sections:

- Payor Mix
- Volume and Utilization of Services
- Average Length of Stay
- Medical Necessity Reviews
- Medical Record Review
- Peer Review
- Policy and Procedure Review
- Survey Readiness

Documentation in the section titled "Peer Review" included the following statement: "The hospital has an agreement with CIMRO for external peer review...The goal is to submit 10% of records for review...Although we have not met this thresh-hold [sic] yet, we are working on meeting the target...The medical staff reviews [sic] also reviews records."

Documentation failed to reflect a description of the actual peer reviews that had been completed or a summary of the peer review findings for the fiscal year 2015/1026.

Documentation in the section titled "Medical Necessity Reviews" included the following statement: "Utilization Review or the admitting nurse screens inpatients, swing bed and observation patients based on Interqual criteria for medical necessity...Continued stay reviews are completed daily Monday - Friday...Any issues or questions are discussed with the attending provider."

Documentation failed to reflect a description of the findings related to any Medical Necessity Reviews that had been completed for the fiscal year 2015/2016.

Documentation in the section titled "Medical Record Review" included the following statement: "100% of records are reviewed for complete documentation including: H&P, Discharge Summary, Progress Notes, Signatures for Orders and Transcription...In addition, records are reviewed for other quality measures including: Clinic PQRS measures, MBQIP, [and] Meaningful Use...Reports are submitted to committees for review and discussion and a summary is provided to the Governing Board."

Documentation failed to reflect a summary report of the findings for any Medical Record Reviews completed for the fiscal year 2015/2016.

Documentation presented for review failed to reflect that the hospital had completed an evaluation of its total program for the fiscal year 07/012012 to 6/30/2013.

During interview at 0830 on 03/28/2017 with the CNO he/she indicated "The only CAH evaluations I could find were for fiscal year July 1, 2013 to June 30, 2014 and July 1, 2015 to June 30, 2016."