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Based on observation and interview the Critical Access Hospital failed to comply with all federal and state laws. This deficiency is evidenced by failure to post required cautionary signage at the licensed healthcare facility.
Findings:

In accordance with R.S. 40:2199.11 through 2199.19,
"A. Each regulated entity shall display at its premises at least one sign that conforms with the specifications of Subsection B of this Section and indicates that abuse of or workplace violence against healthcare staff will not be tolerated and could result in a felony conviction under R.S. 14:38 or other applicable criminal laws.
B. Each sign displayed in accordance with the requirements of this Section shall conform with all of the following specifications:
(1) The sign shall be posted in a conspicuous location in a publicly accessible area of the regulated entity's facility.
(2) The sign shall be at least eighteen inches tall by eighteen inches wide and written in the English language with letters not less than one square inch in size."

Direct observation during the survey conducted on 12/19/2022 and 12/20/2022 failed to reveal the required cautionary signage.

In interview on 12/20 /2022 at 2:00 p.m., S2DON verified the sign was not posted.


44495

Based on observation and staff interview, the Critical Access Hospital (CAH) failed to ensure all patient care equipment was maintained in safe operating condition as evidenced by failing to ensure the functionality of a nurse call button located on the handrails of the beds, on the wall behind the patient's bed and patient bathrooms on the in-patient unit.

Findings:

On 12/19/2022 from 11:25 a.m. to 12:45 p.m. an observation was made of the inpatient unit with S2DON. A nurse call button was noted to be on the handrail of the beds, the wall behind the patient's beds and in the patient's bathroom in patient room's a-p. The buttons were noted to be non- functional as they only activated a light just outside of the patient's room. S2DON was interviewed at the time of the observation and confirmed the nurse call buttons were not functioning when pressed properly. S2DON indicated that they have a nurse call system which included a cord with a portable button and reported that patients are instructed to use this call system. When asked if it would be possible for a patient who may be confused or sedated to press the nurse call button on the handrail of the bed, the wall mounted call bell or the call bell in the bathroom thinking they are calling for assistance without the nursing staffs' knowledge due to the call button not working, S2DON confirmed that was possible.

In an interview on 12/19/2022 at 12:45 p.m., S5ADON verified the call bells on the bed rails, wall behind the patient's beds and in the patient bathrooms were non- functioning and could create confusion for the patients and delay care and or assistance.

Based on observation and interview the facility failed to ensure prompt disposal of trash.
Findings:

During tour of the facility on 12/19/2022 between 11:20 a.m. and 12:20 p.m. direct observation revealed 2 overflowing trash cans in the temporary medication room.

During the tour at 11:50 a.m. S2DON verified the trash had not been emptied. S2DON verified the medication room is always locked and housekeeping does not have access, it is the responsibility of the nursing staff to carry the waste out of the room.

During tour of the Rehabilitation Department on 12/19/2022 between 12:04 p.m. and 12:50 p.m. direct observation revealed an overflowing trash can in the hallway.

During the tour at 12:05 p.m., S6OT verified the trash can was overly full.

Based on observation and interview the facility failed to ensure the premises were clean and orderly. This deficiency is evidenced by 1) worn and rusted furnishings in patient rooms; 2) rust on a cart in the medication room; 3) dirty and corroded sinks; and 4) rust and dust in the kitchen.

Tour of the facility on 12/19/2022 between 11:20 p.m. and 12:20 p.m. revealed the following:

1. Worn and rusted furnishings in patient rooms.
a. Room "g" - Chipped and peeling paint on the walls and
b. Room "i"- Chipped and peeling paint on walls, rust on door hinges, rusted and uncovered toilet bolts, rust on the patient bed.
c. Room "k"- Chipped and peeling paint on walls, rust on door hinges, rusted and uncovered toilet bolts, and splintered wood on the wall.
d. Room "m"- Chipped and peeling paint, rust on electrical outlets, unpainted wood in the closet, chairs with worn unsealed wood on the arms.

2. Rust on a mobile cart in Room"A".
During tour of Room "A" a moble cart with various medical supplies was noted to have chipped paint and was rusted.

3. Dirty and corroded sinks.
a. Room "A" sink had corrosion on the handles and debris in sink.
b. Room "B" sink with pink substance at base of faucet.

The findings listed above for the patient rooms "g", "i", "k", "m", and Room "A" were verified during the tour by S2DON between 11:20 a.m. and 12:20 p.m.

The findings in Room "B" were verified at 12:20 p.m. during the tour by S6OT.

4. Rust and dust in the kitchen.

Tour of the kitchen on 12/19/2022 between 3:30 p.m. and 4:00 p.m. revealed the following:
a. Rust on the metal cabinet doors above the prep counter.
b. Rust on the doors of the double door freezer.
c. Three dirty ceiling vents in the kitchen.
d. Dust on the fan in the room with the dishwasher and splatters of dark substance on the walls.
e. Dust and particles on the windows and window frames.
f. Rust on the spice rack.
g. Rust on lower shelf of prep table with food supplies stored on the shelf.

The findings listed above were verified by S5DM during the tour.

Based on observation and interview, the hospital failed to ensure patients received care in a safe setting as evidenced by full and empty portable oxygen cylinders not separated and the storage area. Findings:

Review of the Life Safety Codes revealed in part:

NFPA 99:11.6.5.2 If empty and full cylinders are stored within the same enclosure, empty cylinders shall be segregated from full cylinders.
NFPA 99:11.6.5.3 Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed in a rapid manner.

Tour of the Rehabilitation Department on 12/19/2022 between 12:04 p.m. and 12:20 p.m. revealed a small closet with 3 portable oxygen tanks. The pressure gauges indicated that 2 were full and one was empty. There were no markings or tags to identify the empty tank.

In interview on 12/19/2022 at 12:15 p.m., S6OT verified that the pressure gauge indicated that one of the tanks in the closet was empty. She was not aware that full and empty tanks needed to be separated and did not know if the facility has a process for marking the tanks for easy identification.

Based on observation and interview the hospital failed to ensure the drug storage area was designed according to accepted standards. This deficiency is evidenced by lack of access to a sink in Room "A."
Findings:

Tour of the facility on 12/19/2022 between 11:20 a.m. and 12:20 p.m. revealed the nurses station was under construction and the automated medication dispense machine had been relocated to Room "A." Direct observation revealed many items stored in this room in addition to the automated medication dispense machine and access to the only sink in the room was blocked.

During the tour on 12/19/2022 at 11:50 S2DON verified access to the sink was blocked and prohibited use of the sink for hand hygiene before and after handling of medication.

Based on record review and interview the hospital failed to include all services in the Quality Assessment and Performance Improvement Program (QAPI). This deficiency is evidenced by failure of the hospital to include the transportation services provided by the hospital in the QAPI program.
Findings:

Record review on 12/20/2022 at 12:00 p.m. S4CM verified the hospital provided transport for swing bed patients to dialysis in a hospital owned vehicle.

In interview on 12/20/2022 at 2:00 p.m. S1CEO verified the vehicle was considered a part of the maintenance department and transportation in the vehicle was not included in QAPI.

47397

Based on records review and interview, the Critical Access Hospital failed to document the date of the initial comprehensive nursing care plan and failed to document the date of the updates to the comprehensive nursing care plan for 5/5 (Patients #1, #2, #3, #4, and #5) Swing Bed patients sampled from a total patient sample of 20.
Findings:

Review of the facility Multidisciplinary Plan of Care policy revealed, in part:
Purpose: To ensure that every patient in the Swing Bed Program has a timely and need driven plan of care that promotes maximizing the patient's healing.
Policy: The multidisciplinary plan of care is the responsibility of the multidisciplinary team. The initial care plan will be developed within 72 hours of admission and reflect all current needs of the patient and the team-based plan for addressing those need. Each member of the multidisciplinary team will be responsible for monitoring and updating his or her piece of the plan as patient needs change. The team will meet weekly to review the plan and patient progress within the plan. During this meeting, the team will reapprove the plan or make modifications as appropriate to benefit the patient. The patient and family members will be offered the opportunity to participate in these multidisciplinary team meetings.

Review of medical records for Swing Bed Patients #1, #2, #3, #4, and #5 on 12/20/2022 at 12:15 p.m., revealed the omission of the date of the initial comprehensive nursing care plan. Further review revealed the omission of the date of updates to the comprehensive nursing care plan.

In an interview on 12/20/2022 at 12:30 p.m., S2DON confirmed the care plans were not dated. S2DON also confirmed all initial care plans should be dated and all updates to care plans should be dated.

Based on record review and interview the Critical Access Hospital failed perform required emergency preparedness exercises.
Findings:

Review of the Emergency Preparedness binder revealed the Critical Access Hospital documented and analyzed the facility's response performance for two actual events in 2021. The dates of the events were 02/21/2021 and 08/28/2021. There were no documented exercises performed in 2022.

In interview on 12/20/2022 at 10:14 a.m. S2DON verified there were no exercises performed in 2022 and no exercises planned at the time of the survey on 12/20/2022.