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Based on interview and record review, the facility failed to ensure 4 staff members (F, G, H, and Q) were current with their ACLS certifications; failed to ensure 3 staff members (R, S and V) were current with their BLS certifications, and 2 staff member (G and P) of 21 sampled staff members were current with their PALS certifications. This deficient practice had the potential to affect all patients who received care in the emergency department and on the swing bed side of the facility. Findings include:

1. ACLS Certifications

Review of staff members' F, G, H, and Q personnel files, showed the following ACLS certifications were either not on file, or were expired:

- staff member F's ACLS expired on 1/18,
- staff member G's ACLS was not on file,
- staff member H's ACLS expired on 10/18,
- staff member Q's ACLS was not on file.

2. BLS Certifications

Review of staff members' R, S, and V personnel files, showed the following BLS certifications were expired:

- staff member R's BLS expired on 7/2019,
- staff member S's BLS expired on 4/2019,
- staff member B's BLS expired on 11/18.

3. PALS Certification

Review of staff members' G and P personnel files, showed the following PALS certifications were either not on file or were expired:

- staff member G's PALS was not on file,
- staff member P's PALS was not on file.

During an interview on 8/7/19 at 10:45 a.m., staff member C stated she believed staff member G had updated copies of the staffs' ACLS, BLS, and PALS certifications.

During a phone interview on 8/7/19 at 1:00 p.m., staff member G stated she expected staff who worked in the emergency department or the skilled nursing side of the facility to have ACLS, BLS, and PALS certifications. She believed she had several of the staff member's certifications in her office and would have staff member C check.

Staff member C provided the remaining available certifications, and there were no updated certifications for the listed personnel provided by the end of the survey.

A review the facility's policy and procedure titled, Licensure, Certification and Registration, dated 12/11/8, showed, "B. Renewals 1. Licensed, certified, or registered employees are responsible for maintaining current license, certification or registered status (including continuing education requirements) per state and federal regulations or as required by [Hospital]. a. [Hospital] performance expectations are that employees will initiate the renewal process at least 30 days in advance of the license, certification or registration expiration date in order to avoid processing delays by issuing agencies and to ensure appropriate staffing levels... b. Primary source verification from the issuing agency of renewed licensure, certification or registration must be available no later than two (2) weeks prior to the expiration date of the current license, certification or registration in order to ensure appropriate staffing. If primary source verification cannot be completed two (2) weeks in advance of the expiration date, a written disciplinary action will be given to the employee for failure to renew timely. 2. Human Resources will perform primary source verification two (2) weeks prior to the expiration date of all licenses, certification, and registrations. Human Resources will notify Department Managers of any staff who do not show evidence of renewal...."

Based on observation, interview, and record review, facility staff failed to ensure essential patient-care equipment, an ultrasound machine, had been routinely inspected and tested for performance and safety. Findings include:

During an observation on 8/5/19 at 2:00 p.m., a Toshiba Xaria-200-XG ultrasound machine, had a bright pink PMed sticker which showed the last PMed was completed 9/17.

During an interview on 8/5/19 at 2:00 p.m., staff member K confirmed the ultrasound sound machine was in use for patients. She stated she was not sure when it was last PMed. She said she would need to follow up with the ultrasound technician.

During a phone interview on 8/6/19 at 8:30 a.m., staff member O stated when she started working at the facility in January of 2019, she noticed the same pink sticker, which showed the last PMed was 9/17. She stated she was not able to locate any other records for when the ultrasound machine was last maintenance, so she contacted the imaging company and scheduled a PMed of the machine. She believed the PMed was completed by the company in March but could not recall. She said there should be a record of the last PMed in a policy and procedure book in the imaging department. Staff member O stated she believed the machine was on a biannual PMed schedule.

During an interview on 8/6/19 at 9:44 a.m., staff member J stated she was not sure when the ultrasound machine had last been PMed. She stated she would follow up when the last PMed was completed for the ultrasound machine. She stated there was no official ongoing method for maintaining the PMed of the radiology departments critical equipment. She stated she took personal initiative to ensure the CT and XR machines were routinely PMed. She said since she was not qualified to do ultrasounds, she did not ensure that machine was PMed.

During an interview on 8/6/19 at 1:55 p.m., staff member M stated she supervised the PMed of critical equipment for the facility but did not manage the PMed for the critical equipment in radiology. She stated she believed that would be staff member K.

During an interview on 6/7/19 at 11:00 a.m., staff member J stated she could not find any documentation for when the ultrasound machine had last been PMed. She stated she contacted the imaging company and they could not validate when the last PMed had been completed by them. They had a record which showed a possible PMed occurred in May 2019, but they were not sure if the technician who came out did not complete the documentation for the PMed, or if it had even been done.

Review of the facility's PM report for the Toshiba Xario 200-XG, showed the last PM was completed on 6/12/18. The manufacturer recommendations for PM was biannually. The facility's records indicated the ultrasound machine had not been PMed for over a year.

A policy and procedure was requested for the PMed of critical care equipment, one was not provided by the end of survey.

Based on observation, interview and record review, the facility failed to ensure dry-goods stored in bins, outside of their original packaging, were labeled and dated with a UBD; measuring scoops used for powdered drinks were stored outside of the packages; and failed to ensure seasoning shakers were cleaned routinely. This deficient practice had the potential to affect all patients who consumed food from the kitchen. Findings include:

1. During an observation on 8/5/19 at 10:53 a.m., there was one bin which contained a white powder, one bin with a light brown powder, and one bin with a granulated white powder, which were not labeled or dated with a UBD or an opened date.

During an interview on 8/5/19 at 10:53 a.m., staff member D stated she believed the white powder was unbleached flour, the brown powder to be whole wheat flour, and the granulated powder to be sugar. She stated she was not sure how long they had been in each bin. She stated she was not aware they needed to label and date the bins with the flour and sugar. She said she believed they emptied each bin at the beginning of every month and then refilled them.

During a record review and interview on 8/7/19 at 1:00 p.m., staff member B stated the facility did not have a current policy and procedure for food storage. He stated they had an "outdated" policy from 12/22/03, which did not address the storage of dry-goods outside of their original packaging. A request for the facility's policy and procedure for food storage was requested. A policy dated 12/22/03 was provided, which did not address food storage of dry-goods stored in separate bins, outside of their original packaging.

2. During an observation on 8/5/19 at 10:53 a.m., there was one container with fruit punch concentrated juice powder, one with raspberry concentrated juice powder, and one with lemonade flavored powder; each container had a scoop which was stored inside the container.
The scoop inside the raspberry flavored juice concentrate was visibly soiled on the handle.

During an interview on 8/5/19 at 10:53 a.m., staff member E stated the scoops should be stored outside of the containers.

The facility did not have a policy and procedure which addressed the sanitary storage of scoops in multi-use containers.

3. During an observation on 8/5/19 at 10:53 a.m., there were seasoning shakers which were sticky on the sides, and the rubber top had brown/black sticky buildup on the side and on top of the lid.

During an interview on 8/5/19 at 10:53 a.m., staff member D stated she did not know how often they cleaned the seasoning shakers.

During an interview on 8/7/19 at 10:00 a.m., staff member B stated the dietary staff did not have a cleaning schedule for the seasoning shakers but have added it to their monthly cleaning schedule.

Review of the facility's policy and procedure titled, Dietary Sanitation, dated 6/27/19, showed, "The food service area shall be maintained in a clean and sanitary manner...3. All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions".

Based on observation, interview, and record review, the facility failed to ensure a patient's catheter drainage bag was not kept on the floor for 1 (#12); and failed to ensure a patient's urinal was labeled with a patient identifier and dated, and was not stored on the over-the-bed table for 1 (#16) of 20 sampled patients. Findings include:

1. During an observation on 8/6/19 at 9:44 a.m., patient #12 was lying in his bed, his catheter bag was laying uncovered on the floor under his bed. Staff member I entered the patient's room, assessed the patient's need, then left the room. The staff member did not address the urine bag on the floor.

During an interview on 8/6/19 at 9:45 a.m., staff member I stated urine bags should be stored on the side of the patient's bed, and not on the floor.

During an interview on 8/6/19 at 1:55 p.m., staff member F stated it was the expectation that urine drainage bags were kept off the floor to reduce the spread of infection.

A review of the facility's procedure from Lippincott, for storing urine drainage bags, showed, "Don't place the drainage bag on the floor, to reduce the risk of contamination and subsequent CAUTI."

2. During an observation on 8/6/19 at 9:30 a.m., patient #16 was laying in his bed, there was a urinal with approximately 300 ml of light yellow urine sitting on the patient's over-the-bed table. The urinal was not capped. The urinal did not have a patient identifier or a date of use.

During an interview on 8/6/19 at 9:45 a.m., staff member I stated urinals should be dated with a patient identifier and the date they were provided to the patient. He stated they should not be stored on the over-the-bed tables because patient's eat off those tables. He stated if he noticed the urinal was on the over-the-bed side table he would move it and disinfect the table.

During an interview on 8/6/19 at 1:55 p.m., staff member F stated it was the expectation urinals were dated, and not stored on the patient's over-the-bed table, to prevent cross-contamination or the spread of infection. She stated urinals should be dated and a patient identifier should be noted on the urinal.

Based on observation, interview, and record review, the facility failed to ensure an assessment and physician order were obtained prior to self-administration of medication for 1 (#21) of 21 sampled patients. Findings include:

During an observation of medication pass on 8/6/19 at 9:40 a.m., staff member W placed patient #21's medications in a small plastic cup. Staff member W walked over to where patient #21 was seated and placed the cup with the medications on the table and walked away back to the medication cart. Staff member W stated she stays in the dining room until all the patients have finished eating.

A request was made on 8/6/19 at 1:00 p.m. for a policy for self-administration of medications.

During an interview on 8/6/19 at 2:10 p.m., staff member B stated a self-administration assessment and physician order could not be located for patient #21. Staff member B stated a self-administration of medication policy could not be located.

Based on record review and interview, the facility failed to complete background checks for 1 (staff member T); and failed to ensure a background check was completed before an employee provide patient care for 1 (staff member N) of 21 sampled staff members. Findings include:

1. Review of staff member T's personnel file did not include a background check, which would indicate no criminal activity or actions against the staff member's license that would preclude them from being employed.

During an interview on 8/7/19 at 9:30 a.m., staff member C stated staff member T was a locum, and she did not realize that she needed to have a background check completed before he started.

2. Review of staff member N's personnel file, showed, the staff member began his employment at the facility on 4/27/19. A review of the staff member's background check showed it was not requested and completed until 5/16/19.

During an interview on 8/7/19 at 9:30 a.m., staff member C stated she had started doing background checks for two different providers, but did not realize they needed to be completed before they started working. She stated without the background check, there is no way to ensure the staff members had not been found guilty of abuse.

A review of the facility's policy and procedure titled, Preventing Resident Abuse, dated 5/28/19, showed, "k. Conducting background investigations to avoid hiring persons or admitting new resident/patients who have been found guilty (by a court of law) of abusing, neglecting, or mistreating individuals or those who have had a finding of such action entered into the state license registry."

Based on interview and record review, the facility failed to ensure a comprehensive assessment was completed within 14 days of admission for 6 (#s 1, 2, 3, 4, 6 and 10) and failed to ensure a comprehensive assessment was completed yearly for 2 (#s 3 and 10) of 21 sampled patients. Findings include:

1. Patient #1 was admitted on 9/22/18.

Review of patient #1's medical record failed to show a comprehensive assessment was completed 14 days following admission.

2. Patient #2 was admitted on 12/10/18.

Review of patient #2's medical record failed to show a comprehensive assessment was completed 14 days following admission.

3. Patient #3 was admitted on 7/1/15.

Review of patient #3's medical record failed to show a comprehensive assessment was completed on admission and failed to show a comprehensive assessment was completed yearly thereafter.

4. Patient #4 was admitted on 5/28/19.

Review of patient #4's medical record failed to show a comprehensive assessment was completed within 14 days following admission.

5. Patient #6 was admitted on 3/8/19.

Review of patient #6's medical record failed to show a comprehensive assessment was completed within 14 days following admission.

6. Patient #10 was admitted on 8/15/16.

Review of patient #10's medical record failed to show a comprehensive assessment was completed within 14 days following admission and failed to show a comprehensive assessment was completed yearly.

During an interview on 8/7/19 at 2:25 p.m., staff member F stated the facility had identified the need for collecting data for a comprehensive assessment but had not begun to complete a comprehensive assessment yet. Staff member F stated every patient received a physical assessment on admission and weekly with their bath.