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Based on observation and interview, the facility failed to maintain a free and accessible handwashing sink in the Bone Density Room and a functional emergency shower at ambulance entrance to the Emergency Department resulting in the potential to spread infectious agents and unsafe environment to all patients and staff utilizing each of the spaces. Findings include:

During the initial tour of the facility on 5/17/2022 at 1515, the Bone Density Room serving the Radiology Suite, the original Bone Density Machine been relocated and replaced with a larger one leading to a complete blockage of the access to the available handwashing sink. Therefore, preventing the assigned staff from being able to wash hands as required before and after coming in contact with the patient. Also, leading for a water stagnation concept and potential for bacteria growth and;

On 5/17/2022 at 1535, the emergency shower located at the ambulance entrance to the emergency department of the hospital has been impeded with furnishings, very short shower curtain, and the floor sloping away from the available floor drain leading to unsanitary and unsafe environment with a potential for cross contamination and slip and fall for anyone accessing the entrance.

Both findings above were confirmed by accompanying staff A, D, and E at the time of observation.

Based upon observation and interview the facility failed to provide and maintain adequate physical facilities for the safety and needs of all patients and was found not in compliance with the requirements for participation in Medicare and/or Medicaid at 42 CFR Subpart 485.62(c), Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care, resulting in the potential for negative outcomes up to and including death in the event of a fire. Findings include

See the individually and below cited K-tags dated May 18, 2022.
K-0324
K-0363
K-0372

Based on observation and interview, the facility failed to ensure a clean and sanitary environment resulting in the potential to spread infectious agents to all patients. Findings include:

During the initial tour of the facility on 5/17/2022 at 1410, Room A-104 was entered and was identified by Staff C as being a patient-ready room. On the windowsill, it was observed there were many dead gnats present-too numerous to count. This was confirmed by Staff C at the time of discovery. Staff C was queried as to when the room had last been used to which she stated she did not know. Staff C also was unable to recall when the room had last been cleaned; however, agreed the dead insects should not be present.

On 5/17/2022 at 1413, Room A-103 was entered and was identified as being a patient-ready room. On the windowsill there were many dead gnats present. This was confirmed by Staff C at the time of discovery. Staff C stated she would notify maintenance to "take care of the bugs."

On 5/17/2022 at 1415, Room A-102 was entered and was identified as being a patient-ready room. On the windowsill, there were many dead gnats present. This was confirmed by Staff C at the time of discovery.

On 5/17/2022 at 1446, Room A-101 was entered and infusion therapy patient #1 was present. Upon walking to the window, 2 dead gnats were visualized on the windowsill.



28042

On 5/19/2022 at 0805 while on tour with Staff S, a sharps box mounted on an anesthesia cart in the "eye operating room" was observed to be full with the protective flap up. The surveyor looked into the box to ensure the box was full and observed needles and syringes up to the top of the container. Staff S was observed pulling down on the protective flap, looking into the container and stated that the container was full. Staff S stated she wasn't sure, but thought Environmental Services were supposed to empty the containers.

On 5/19/2022 at 0850 while on tour with Staff S, a sharps box mounted on the wall in the Post Anesthesia Care unit was observed to be full with the protective flap up. The surveyor looked into the box to ensure the box was full and observed needles and syringes up to the top of the container. Staff S stated she had found out that nursing staff were responsible for emptying the sharps containers.

Based on interview and record review the facility failed to provide failed to provide an nutritional services for 3 of 5 swing bed patients (#4, 11, and 27), out of a total sample of 28 patients, resulting in the potential for poor nutritional status, affecting the physical, mental and psychosocial well-being of each patient. Findings include:

During record review on 05/18/22 at 1330, the following information was revealed:

Patient #4

A face sheet indicated Patient (Pt) #4 was admitted to a swing bed on 11/12/2021 and discharged on 12/9/2021. Additional review of this closed record revealed no evidence that any nutritional assessment was completed, or nutritional services were offered or provided during course of stay in the swing bed.


Patient #11

A face sheet indicated Pt #11 was admitted to a swing bed on 07/27/2021 and discharged on 8/07/2021. Additional review of this closed record revealed no evidence that any nutritional assessment was completed, or nutritional services were offered or provided during course of stay in the swing bed.

Patient #27

A face sheet indicated Pt #27 was admitted to a swing bed on 01/14/2022 and discharged on 2/18/2022. Additional review of this closed record revealed no evidence that any nutritional assessment was completed, or nutritional services were offered or provided during course of stay in the swing bed.

During an interview with Staff W on 05/18/2022 at 1515, Staff W said she recently started as the registered dietician and could not speak to why there was no documentation for nutritional services for swing bed patients #4 or #11. Staff W stated she did not see Patient #27 because nursing did not inform her that Patient #27 was admitted as a swing bed patient.