HospitalInspections.org

Based on observation, interview and record review, the Facility's Governing Body failed to ensure medical staff contracted emergency room physicians, are provided orientation to the facility, prior to assuming their roles as staff physicians in 2 of 3 physicians' credentialing files reviewed from 11 sampled staff. Physician#s 57 and 58

Findings:

Physician #57
On 2/08/2022 at 10:00 a.m. Physician # 57 was observed providing care and services in the facility's emergency room.

Review on 02/10/2022 of Physician #57's personnel and credentialing records revealed, she was granted privilege and appointed to work as an emergency room physician on November 19, 2021 - November 30 2023.
Review of the record revealed no evidence that the Physician completed orientation to the facility.

Physician #58
Review on 02/10/2022 of Physician #58's personnel and credentialing record revealed, he was granted privilege and re- appointed to work as an emergency room staff physician on January 21, 2022 - January 30th, 2023.
Review of the record revealed no evidence of the Physician completed orientation to the facility.

Interview on 02/10/2022 at 9:00 a.m. with the Facility's Quality Assessment Performance Improvement Director revealed, the physicians are contracted and the contract company is responsible for providing orientation to the physicians and a packet on orientation is given to the Physician.

The Quality Assessment Performance Improvement Director provide a packet which was not included in the Physician's records. The Orientation packet was blank and their was no acknowledgement by the physicians that they were orientated to the facility.

Review of the Facility's current Policy and Procedure on, Orientation New Employees Policy # ALL 301, revised 10/21 direct staff as follows: "Orientation of New employee will take place prior to the performance of job duties when feasible but will occur no later than thirty days after employment. "

Based on observation and interview, the facility failed to ensure laundry staff followed manufacture's direction for use, to clean filters on the laundry system daily in 2 of 2 washing machines observed in the facility's laundry room.

Findings

Observation on 02/08/2022 at 11:00 a.m. revealed two laundry washing machines ( Scott equipment Inc Laundry System) in use in the facility's laundry room. Observation of the machines revealed two black filters on the sides of each machine.

Instruction on the side of the machines directed users of the Laundry system to "clean filters daily."

Interview with Housekeeping and Laundry Personnel who toured with the Surveyor during the observation revealed, the Surveyor asked her who was responsible for cleaning the filters and when where they cleaned?
She stated " I do not mess that."

After the Surveyor notified Facility's Environmental Supervisor of the presence of the filters, he removed them and washed them under the tap with running water in the laundry room sink. Discolored residue was observed coming from the water used to clean the filters.

Interview with the Facility's Environmental Supervisor who was present during the observation, revealed he has no record of the filters being cleaned.

Based on observation and interview the facility failed to ensure the environment was clean.

Findings Include:

Record review of facility policy Housekeeping, reviewed 11/19, stated to maintain clean, antiseptic and attractive surroundings without disrupting patient care. Daily cleaning: clean televisions (TV), furniture, and fixtures- top, sides, and front.

Observation 02/07/2022 at 1015 of the patient units with the CNO (ID#51) revealed heavy dust on figures on suction machine, light, TV, table in 121 and 132.

Observation during the tour on 02/07/2022 at 1015 of the physical therapy unit, revealed seven (7) overhead trapeze were found on the floor. The Physical therapy tech (ID #63) verified that the trapeze were for patient use and were being stored on the floor

Interview during observation on 02/07/2022 with the CNO (ID#52) verified the findings for both areas.

Based on record review and interview the facility failed to update pertinent emergency risk preparedness data for to the facility.

Findings Include:

Record review of the facility policy "Emergency Preparedness Plan", reviewed 08/2018 stated the purpose is to establish, support, and maintain a plan ... to better serve our community in the time of disaster.

Record review of the facility's Emergency Preparedness Risk Assessment revealed the plan was updated 02/2021 but the facility were missing key elements, that included facility tabletop drills, and updated phones numbers of staff including physicians.

Record review on 02/10/2022 of the Incident Command Structure, revealed the document had not updated since 08/18. The document revealed that the Quality Director (ID#51) was not the Planning Section Chief and was not the person listed on the form.

Interview on 02/10/2022 at 11:45 with the Quality Director at (ID # 51) who validated the facility did not update the Incident Command Structure form.