HospitalInspections.org

Based on interview, documentation in 3 of 3 inpatient medical records of Medicare beneficiaries reviewed for the "Important Message from Medicare" (Patients 14, 16, and 17), review of CFRs applicable to hospital patients, and review of the CMS website, it was determined the hospital failed to ensure it complied with applicable Federal regulations as all Medicare beneficiaries had not been informed of their discharge appeal rights and provided with the "Important Message from Medicare" (IM) form in accordance with 42 CFR 489.27(a), which cross references the regulation at 42 CFR 405.1205.

Findings include:

1.a. CFR 489.27(a), "Beneficiary notice of discharge rights", requires: "(a) A hospital that participates in the Medicare program must furnish each Medicare beneficiary or enrollee, (or an individual acting on his or her behalf), timely notice as required by section 1866(A)(1)(M) of the Act and in accordance with [CFR] 405.1205 and [CFR] 422.620. The hospital must be able to demonstrate compliance with this requirement."

1.b. CFR 405.1205, "Notifying beneficiaries of hospital discharge appeal rights," includes the following requirements:
"(a) Applicability and scope.
(1) For purposes of [CFRs] 405.1204, 405.1205, 405.1206, and 405.1208, the term "hospital" is defined as any facility providing care at the inpatient hospital level, whether that care is short term or long term, acute or non acute, paid through a prospective payment system or other reimbursement basis, limited to specialty care or providing a broader spectrum of services. This definition includes critical access hospitals.
(2) For purposes of [CFRs] 405.1204, 405.1205, 405.1206, and 405.1208, a discharge is a formal release of a beneficiary from an inpatient hospital."
(b) Advance written notice of hospital discharge rights. For all Medicare beneficiaries, hospitals must deliver valid, written notice of a beneficiary's rights as a hospital inpatient, including discharge appeal rights. The hospital must use a standardized notice, as specified by CMS, in accordance with the following procedures:
(1) Timing of notice. The hospital must provide the notice at or near admission, but no later than 2 calendar days following the beneficiary's admission to the hospital ...
(2) Content of the notice ...
(3) When delivery of the notice is valid. Delivery of the written notice of rights described in this section is valid if -
(i) The beneficiary (or the beneficiary's representative) has signed and dated the notice to indicate that he or she has received the notice and can comprehend its contents, except as provided in paragraph (b)(4) of this section; and
(ii) The notice is delivered in accordance with paragraph (b)(1) of this section and contains all the elements described in paragraph (b)(2) of this section ...
(c) Follow up notification.
(1) The hospital must present a copy of the signed notice described in paragraph (b)(2) of this section to the beneficiary (or beneficiary's representative) prior to discharge. The notice should be given as far in advance of discharge as possible, but not more than 2 calendar days before discharge.
(2) Follow up notification is not required if the notice required under [CFR] 405.1205(b) is delivered within 2 calendar days of discharge."

1.c. The CMS webpage titled "Notices and Forms" was dated as "Page Last Modified: 09/06/2023 04:51 PM" and included the following information:
"Hospital Discharge Notices - As under original Medicare, a hospital must issue to plan enrollees, within two days of admission, a notice describing their rights in an inpatient hospital setting, including the right to an expedited Quality Improvement Organization (QIO) review at their discharge. (In most cases, a hospital also issues a follow-up copy of this notice a day or two before discharge.) If an enrollee files an appeal, then the plan must deliver a detailed notice stating why services should end. The two notices used for this purpose are:
- An Important Message From Medicare About Your Rights (IM) Form [CMS-10065], and the
- Detailed Notice of Discharge (DND) Form CMS-10066.
These forms and their instructions can be accessed on the webpage 'Hospital Discharge Appeal Notice' at: /Medicare/Medicare-General-Information/BNI/HospitalDischargeAppealNotices"

1.d. The "Hospital Discharge Appeal Notice" webpage referenced above in Finding 1.c. included the IM form and the instructions for completion of the IM form. The instructions included the following:
* "Signature line: Have the beneficiary/enrollee or representative sign the notice to indicate that he or she has received it and understands its contents."
* "Date/Time: Have the beneficiary/enrollee or representative write the date and time that he or she signed the notice. If the document is delivered, but the enrollee or the representative refuses to sign on the delivery date, annotate the IM to indicate the date and time that the notice was delivered."

2. The review of Patient 14's medical record reflected they were a Medicare beneficiary, were admitted to the hospital as an inpatient on 03/05/2024 at 1636, and discharged from inpatient services on 03/11/2024. The medical record contained one copy of an IM form. The form was signed by Patient 14. However, the date and time the patient signed the form were not documented to indicate their receipt and understanding of the information within the required timeframe of not later than two (2) days following admission. Including that there was no space on the form to record the date and time as reflected on required Form CMS-10065. In addition, although the patient was hospitalized as an inpatient for six (6) days, there was no evidence that the patient received the required notice again not more than two (2) calendar days before discharge.

3. The review of Patient 16's medical record reflected they were a Medicare beneficiary, were admitted to the hospital as an inpatient on 03/19/2024 at 1247. They were hospitalized as an inpatient until 03/25/2024 when they expired. The medical record contained one copy of an IM form. The form was signed by Patient 16. However, the date and time the patient signed the form were not documented to indicate their receipt and understanding of the information within the required timeframe of not later than two (2) days following admission. Including that there was no space on the form to record the date and time as reflected on required Form CMS-10065.

4. The review of Patient 17's medical record reflected they were a Medicare beneficiary, were admitted to the hospital as an inpatient on 04/29/2024 at 1925, and discharged from inpatient services on 05/08/2024. The medical record contained one copy of an IM form. The form was signed by Patient 17. However, the date and time the patient signed the form were not documented to indicate their receipt and understanding of the information within the required timeframe of not later than two (2) days following admission. Including that there was no space on the form to record the date and time as reflected on required Form CMS-10065. In addition, although the patient was hospitalized as an inpatient for nine (9) days, there was no evidence that the patient received the required notice again not more than two (2) calendar days before discharge.







44104

Based on observations, interviews, review of CAH policies and procedures, review of SA licensing documents and records, and review of other documentation it was determined that the CAH failed to ensure it was in compliance with applicable State laws and rules related to hospital licensing and changes in the building and physical environment.

Hospital licensing OAR 333-500-0045 requires that a hospital submit building plans and specifications to the SA, the State of Oregon hospital licensing authority, for review and approval prior to building construction, alterations or additions. Impacted areas may not operate until building plans review licensing processes have been completed and approval for the project(s) is received from the SA FPS Unit. The CAH failed to comply as follows:
* The CAH converted an inpatient room into Outpatient Wound services without FPS Unit plans review and approval.
* The CAH converted an inpatient room into Outpatient Infusion services without FPS Unit plans review and approval.
* The CAH converted an inpatient room into Outpatient Respiratory Therapy services without FPS Unit plans review and approval.
* The CAH converted a Pulmonary Function Test room into a negative pressure room without FPS Unit plans review and approval.

Findings include:

1.a. An organizational chart that depicted the CAH's inpatient and outpatient departments and services dated "Updated February 28 2024" reflected that the CAH provided "O/P Nursing" services.

1.b. An undated "Outpatient Nursing Services" document reflected that "The Outpatient Nursing department at Lower Umpqua Hospital District provides prompt, safe and effective care for the patients in our community and surrounding areas. Services include IV infusions ... Hydration ... Blood transfusions ... Medication injections ... Port-a-cath care and lab draws ... Wound care ... Compression ... Arterial Brachial Index ... Ostomy care ... Urinary catheter management ... Gastrointestinal tube management ... Therapeutic phlebotomy ... Our department staff include [sic] two Wound Care Certified Registered Nurses ... The department is open Monday through Saturday ..."

1.c. Observations of the CAH's OP Wound services area, Room 114 on 06/26/2024 beginning at 1000 with the AC/ED NM and a Wound and Infusion RN, revealed it contained numerous wound and ostomy care supplies and items.

1.d. Observations of the CAH's OP Infusion services area, Room 115 on 06/26/2024 beginning at 1055 revealed it contained numerous infusion equipment and supplies.

1.e. During interview on 06/26/2024 at 1040 with the AC/ED NM and the Wound and Infusion RN, the following information was provided:
* Before OP Wound and OP Infusion services were provided in Rooms 114 and 115, respectively they were both provided in one room, inpatient Room 111.
* Before OP Wound and OP Infusion services were provided in inpatient Room 111, they were provided "all over the place".

1.f. In a text message from the AC/ED NM on 06/26/2024 at 1608, the response regarding whether the hospital had notified the SA FPS Unit of the changes to the OP Wound and OP Infusion services area, was "We did not notify FPS ..."

1.g. During interview on 08/16/2024 at 1105 the SA FPS Unit Manager reviewed SA licensing records and confirmed that the hospital had not submitted plans for approval of the change of Room 114 to OP Wound services or the change of Room 115 to OP Infusion services.

2.a. An organizational chart that depicted the CAH's inpatient and outpatient departments and services dated "Updated February 28 2024" reflected that the CAH provided "Respiratory Therapy".

2.b. Observations in the CAH's OP RT services area, Room 113 on 06/27/2024 beginning at 1110 with the Respiratory Therapy Manager, revealed it contained numerous RT equipment and supplies.

2.c. The following P&Ps were provided by the Respiratory Therapy Manager in response to a request for OP RT P&Ps:
* The P&P titled "Nocturnal Oximetry - Outpatient," dated last revised 10/18/2017. It included details and steps regarding "... the procedure for setting up a physician-ordered overnight Oximetry study ... Prior to starting the test ... Steps for preparing Nonin Model 2500 Oximeter ... Prepare Patient for test ... Conclude test ... Printing the Reports ..."
* The P&P titled "Cardiac Stress Testing - Standard, Cariolite & Lexiscan," dated last revised 08/24/2010. It included: "... Cardiac Stress Testing is the recording of the heart's electrical activity and blood pressure while the heart is under the stress of increased physical demand. This is also known as exercise tolerance test ..."
* The P&P titled "Pulmonary Function Testing," dated last revised 08/16/2010. It included: "When prescribed by a physician, pulmonary function testing (PFT) will be performed by a qualified respiratory therapist to determine if a patient has a pulmonary obstructive, restrictive or diffusion defect ..."
* The P&P titled "Event Monitor Setup," dated last revised "6/07".

2.d. During interview on 06/26/2024 at 1350 with the Respiratory Therapy Manager, the following information was provided:
* Inpatient Med/Surg Unit Room 113 was converted to OP RT services in approximately "July 2023".
* OP RT services included pulmonary function tests, overnight oximetry, and occasional stress tests.
* OP RT hours of operation were 0800 to 1700, Monday through Friday.
* OP RT was staffed with one full-time RT and one part-time RT.

2.e. In a text message from the AC/ED NM on 06/26/2024 at 1608, the response regarding whether the hospital had notified the SA FPS Unit of the changes to the OP RT services area, was "We did not notify FPS ..."

2.f. During interview on 08/16/2024 at 1105 the SA FPS Unit Manager reviewed SA licensing records and confirmed that the hospital had not submitted plans for approval of the change of an inpatient room to OP RT services.

3.a. Observations in the CAH's negative pressure room, ED Exam Room 4 on 06/26/2024 beginning at 0935 with the AC/ED NM, revealed it contained numerous patient equipment, supplies and items including lab specimen collection supplies, patient gurney, transfer/repositioning device, mayo instrument stand, infusion pumps, and patient monitoring equipment.

3.b. During interview on 06/26/2024 at 0940 with the AC/ED NM the following information was provided:
* The pulmonary function test room was converted to a negative pressure room, ED Exam Room 4 "at the end of July 2023". Alterations to the room included "running cables and oxygen".
* The CAH had not notified the SA FPS Unit of the changes to the pulmonary function test room.

3.c. During interview on 08/16/2024 at 1105 the SA FPS Unit Manager reviewed SA licensing records and confirmed that the hospital had not submitted plans for approval of the change of the pulmonary function test room to a negative pressure room.

4. In an email from CSC dated 07/05/2024 at 1132 the response to a request for "Policy and procedures that address submitting building construction, renovation, alterations and/or change of use projects for review and approval to the State Agency Facilities, Planning and Safety (FPS) prior to operation" was "NO POLICY".




44104

29708


Based on observations, interviews, review of CAH policies and procedures, review of SA licensing documents and records, and review of other documentation it was determined that the CAH failed to ensure that the physical environment was constructed, arranged, and maintained for patient safety and to provide adequate space for the provision of services:
* Building construction/alterations had been made for Outpatient Wound services, Outpatient Infusion services, Outpatient Respiratory Therapy services, and a negative pressure room without the required approval of the SA.
* Areas in the CAH, including where patient services were provided, had not been maintained in good repair and were not arranged to provide adequate space for services.

Findings include:

1. Refer to Findings 1-4 under Tag C-816 that reflects building construction/alterations had been made without the required approval of the SA.

2. During tour of the Outpatient Rehabilitation Department on 06/25/2024 beginning at 1030 observations included:
* The cabinet under the sink in the Rehabilitation Department wound care room was cluttered with a variety of items and solutions. The surface on the cabinet floor had areas that were peeled and chipped away and exposed the under-lying pressboard or particle board. Those conditions rendered the space not readily cleanable.

3. During tour of the Respiratory Therapy Department on 06/25/2024 beginning at 1220 observations included:
* The floor in a closet outside of the department where ventilators, BiPAP/CPAP machines, and other respiratory therapy equipment was stored had low-pile carpet over a portion of the floor. Where the floor was not covered it was observed to be of an unfinished and rough material, was severely marred, and was covered with dirt and debris. In addition, there was no baseboard or other material to cover open spaces or gaps evident between the floor surface and the walls. A series of built in shelves on one wall in the room were made of unfinished wood and had rough and splintered surfaces. Boxes of supplies were stored on some of the shelves. Those conditions rendered those surfaces not readily cleanable.

4. During tour of the Laboratory Department on 06/25/2024 beginning at 1435 observations included:
* The floor surface of the cabinet under the sink in the Laboratory Department was made from an unfinished pressboard or particle board material and was covered with numerous jars, jugs, containers of various solutions, and cardboard boxes of other supplies and materials. The cabinet floor surface had a series of large, drilled holes in it that clearly exposed the roughness of the pressboard or particle board composition. Further, the floor was severely stained and the surface marred by dried solution spills of various colors. Those conditions rendered the space not readily cleanable.
* A large portion of the back wall of the cabinet under the sink, behind the sink plumbing fixtures, was missing. The shape of the missing cabinet wall was irregular and appeared to have been cut out after the cabinet wall was originally installed. The main plumbing pipe in the wall, to which the sink pipe was attached, was significantly exposed as were the rough surfaces of the building wall and the building ground that could be observed because the cabinet wall was not intact and closed. There may have been potential for entry of insects and rodents into the lab through that unfinished and unsealed opening.
* On the wall to the left upon entry into the Laboratory Department, a black metal pipe was observed running up the outside of the wall next to a counter. At ~ counter level the pipe curved ~ 90 degrees and entered a roughly cut hole in the wall. The pipe was observed to connect to piping inside the wall. The large, roughly cut hole in the wall around where the pipes were joined was unfinished and unsealed. Broken and peeling plaster and wall materials and the interior space inside the wall were observed.

5. During tour of the Imaging Department on 06/25/2024 beginning at 1510 observations included:
* Significant areas of a light bluish paint on the frame around the observation window from which the X-Ray Technician operates the X-Ray machine were observed to have peeled and chipped away to reveal an underlying coat of beige paint. There were additionally areas where the chipped or peeled paint exposed wood type material. Those conditions rendered those surfaces not readily cleanable.

6. During tour of the Nuclear Medicine Department on 06/25/2024 beginning at ~ 1600 observations included:
* In addition to the nuclear medicine machine and equipment in the room, the space was crowded with the storage of patient care equipment that created difficult mobility and navigation through the room, inability to access or inspect the nuclear medicine equipment and the other patient care equipment stored in the space, and rendered the space not readily cleanable. Equipment stored in the room included, three patient beds, a large commode or shower chair type device, and two ventilator machines (one of which had a sticker with "Inspection Due" date of "10/23").

7. Refer to Findings at Tag C-1208 that include other examples of areas not maintained or in disrepair throughout the hospital. For example:
* Finding 12 reflects that scrub sinks in the surgical suite were stained, a housekeeping closet had a large hole with visible electrical wires near an operational sink, there was drywall damage in the anesthesia room and the endoscope storage room, and unmarked "clean" patient equipment was stored with sterilized instruments.
* Finding 13 reflects that the EVS linen storage room contained open areas in the ceiling and walls and discoloration that was suspicious for mold and/or water damage, electrical wires protruded from ceiling, and the floor sink in housekeeping closet on a patient care unit was stained.
* Finding 23 reflects that kitchen ovens in Dietary & Nutrition Services had visible and palpable layers of grease and grit, and water temperatures documented for the dishwasher were out of optimal range.




44104

29708

Based on observation, interview, and review of equipment PM documentation, it was determined that the CAH failed to fully develop and implement systems and policies and procedures to ensure that all electrical and bio-medical patient care equipment had been maintained to ensure an acceptable level of safety and quality:
* Documentation did not reflect a complete inventory of all patient care equipment had been developed.
* Documentation did not reflect initial PM inspections on all equipment prior to being put into service for patient use.
* Documentation did not reflect timely PM inspections had been conducted for all patient care equipment that was in use or was available for use; and
* Not all electrical and patient care items had an electrical or up to date PM, and electrical checks of items were inconsistent.

Findings include:

1. During tour of the Respiratory Therapy Department on 06/25/2024 beginning at 1220 observations included:
* A Phillips Respironics V200 Ventilator was observed in a storage closet, available for patient use along with other ventilators and BiPAP/CPAP machines in the room. A "Cascade Biomedical Services" sticker was attached to the back of the machine. Writing on the sticker showed an "Inspection Date" of "10/22" and "Inspection Due" date of "10/23." During interview with the Respiratory Therapy Director at the time of the observation, about the inspection due date that had passed, they stated that the hospital was not using that ventilator and was trying to sell it. There was no signage or other indicator on the machine to reflect the ventilator was taken out of service, or to convey to staff that they do not use that ventilator that was overdue for inspection.

2. During tour of the Nuclear Medicine Department on 06/25/2024 beginning at ~ 1600 observations included:
* Equipment stored in the nuclear medicine room and that was available for patient use included a Phillips Respironics V200 ventilator machine that had a "Cascade Biomedical Services" sticker on it with "Inspection Due" date of "10/23".

3. During tour of the outpatient Reedsport Medical Clinic on 06/25/2024 beginning at 1130 with CM and MA, observations included:
* In the medication room, a Philips Burton electric hand held UV light was available for use. There was no evidence of inventory tracking, initial or ongoing PM, electrical check or other safety checks observed.
* In the staff break room, a toaster, a portable ice maker, and a microwave were observed with no evidence of inventory tracking, initial electrical or other safety checks observed. In the same break room, a single-serve coffee maker was observed with evidence of an initial electrical safety check completed by "Bio/Med" on 02/09/2023. It was not clear why all electrical appliances were not evaluated consistently for initial electrical and safety check. These findings were confirmed with the CM at the time of the observations.

4. During tour of the ED on 06/25/2024 beginning at 1525 with the AC/ED NM, a SECA infant scale was observed in a treatment room available for use with no evidence of inventory tracking and a sticker that lacked evidence of current PM. The sticker reflected:
"Equipment Check Date 1/31/20 Initials [initials]
"Reinsp 1/31/21 Service P.M." These findings were confirmed with the AC/ED NM at the time of the observations.

5. During a tour of Surgical Services with the SSM on 06/26/2024 beginning at 0910 a wet/dry shaver was observed with no evidence of inventory tracking, or initial or ongoing PM.

6. During tour of the Med/Surg Unit on 06/26/2024 beginning at 1330 with the AC/ED NM, observation of an upright Frigidaire refrigerator/freezer in the medication room containing patient food and beverages revealed no evidence of inventory tracking, initial electrical or other safety checks. These findings were confirmed with the AC/ED NM at the time of the observations.

7.a. During interview with POM on 06/24/2024 during the entrance conference they provided the following description regarding the CAH's system used to track patient care equipment and PM:
* Biomed puts inventory and asset numbers on each piece of equipment.
* Biomed does an electrical check on all equipment before it is put into service.

7.b. During interview and review of equipment inventory and PM records on 06/27/2024 at 0900, the following information was provided and confirmed with the POM and BT:
* The Biomedical Department has a master equipment inventory list of equipment organized by department and a calendar for tracking equipment PMs that are due and those that have been completed.
* New equipment arrives in the materials management area where a new intake is generated. Materials management informs the Biomedical Department when the equipment has arrived or brings the equipment to the Biomedical Department. The Biomedical Department does an initial equipment check and ongoing PM thereafter.
* Regarding the UV light, toaster, portable ice maker, and microwave in the outpatient Reedsport Medical Clinic in Finding 3, they confirmed there was no documentation of inventory tracking, PM, initial electrical or other safety checks.
* Regarding the SECA infant scale in ED in Finding 4, a reinspection was due 01/31/2021 and that inspection had been missed.
* Regarding the wet/dry shaver in SPD in Finding 5, they confirmed there was no documentation of inventory tracking, PM, initial electrical or other safety checks.
* Regarding refrigerator/freezer in Med/Surg Unit that contained patient food and beverages in Finding 6, they confirmed there was no documentation of inventory tracking, PM, initial electrical or other safety checks.
* The "Medical Equipment Management Plan 2024" in Finding 7.c. was provided. The BT stated that aside from that plan, the CAH had no PM P&Ps.

7.c. Review of the "Medical Equipment Management Plan 2024" reflected:
* "This plan covers activities performed in the various locations of the organization, including ... Hospital campus ... Reedsport Medical Clinic ..."
* "Assessment of needs for continuing technical support of medical equipment and design of appropriate calibration, inspection, maintenance, and repair services is an essential part of assuring that medical equipment is safe and reliable ... Assessment of needs for continuing technical support of medical equipment and design of appropriate calibration, inspection, maintenance, and repair services is an essential part of assuring that medical equipment is safe and reliable."
* "The organization maintains a written inventory for the inspection, testing, and maintenance of all the medical equipment used for the treatment, care, diagnosis, or therapy of the patients. The [Biomedical Department] maintains the inventory and updates it as appropriate based on risks identified. The inventory includes medical equipment maintained by the [Biomedical Department] and equipment maintained by vendors."
* "Identifying high-risk medical equipment ... The hospital identifies high-risk medical equipment on the inventory for which there is a risk for serious harm or death to a patient or staff member should the component fail. The high-risk medical equipment includes life-support equipment."
* "Identifying activities and frequencies ... A computerized maintenance management system is used to schedule and track timely completion of scheduled maintenance and service activities. The [Biomedical Department] is responsible for assuring that the rate of timely completion of schedule maintenance and other service activities meets regulatory and accreditation requirements."
* "Maintaining specific medical equipment ... The organization's activities and frequencies for inspecting, testing, and maintaining the following items are conducted in accordance with manufacturers' recommendations ... Medical equipment subject to federal or state law or Medicare Conditions of Participation in which inspecting, testing, and maintaining be in accordance with the manufacturers' recommendations, or otherwise establishes more stringent maintenance requirements ... Medical laser devices ... Imaging and radiologic equipment ... New medical equipment with insufficient maintenance history to support the use of alternative maintenance strategies ..."
* "Equipment inventory and initial testing ... Prior to the initial use of medical equipment on patients or after major repairs or upgrades, the appropriate safety, operational, and functional tests are performed. This includes equipment owned by the organization, leased, demonstration, and rented equipment, and personally owned equipment used for the diagnosis, treatment, and monitoring of patient care needs."
* "Testing of high-risk medical equipment ... The organization assures that scheduled inspection, maintenance and testing of all high-risk equipment, including life support equipment, is performed in a timely manner ..."
* "Testing of non-high-risk medical equipment ... The Organization assures that scheduled inspection, maintenance and testing of all non-high-risk equipment, including life support equipment, is performed in a timely manner."




44104

Based on observations, interviews, and review of fire safety and emergency preparedness policies and procedures and documentation, it was determined that the CAH failed to fully develop and implement policies and procedures to ensure compliance with all Life Safety from Fire and Emergency Preparedness requirements.

Findings include:

1. Refer to the findings on the Life Safety from Fire CMS 2567 SOD reports for hospital Building-01 and Building-02, and the Emergency Preparedness CMS 2567 SOD.



44104

Based on interview and review of the CAH's lists of services furnished under contract, arrangement or agreement it was determined that the current list of services furnished under contract, arrangement or agreement had not been maintained prior to the survey, and was not complete as it did not include all such services.

Findings included:

1. An undated document titled "Service Contracts" was reviewed. It contained a list of entities and organizations with a brief description of the service. The list did not reflect all services provided to the hospital under contract, arrangement or agreement. Examples included, but were not limited to:
* During tour of the Rehabilitation Department on 06/25/2024 beginning at 1030 the Rehabilitation Director stated that the hospital used the services of the Highland public swimming pool in the community for the provision of outpatient physical therapy services. That company was not on the "Service Contracts" list.
* During tour of the Laboratory Department on 06/25/2024 beginning at 1435 the Laboratory Director stated that the hospital used the services of Pacific Micro for inspection and maintenance of laboratory microscopes. That company was not on the "Service Contracts" list.
* During tour of the Imaging Department on 06/25/2024 beginning at 1510 the Imaging Director stated that the hospital used the services of Health Physics NW for evaluation and calibration of radiology equipment. However, that company was not on the "Service Contracts" list.

2. During interview at the time of the contracted services review on 06/27/2024 beginning at 1015, with staff that included the CEO, CNO, and DQRM, the CEO indicated that the list of services furnished under contract, arrangement or agreement had been generated for the survey and confirmed that it did not contain all applicable services including those examples described under Finding 1 above in this Tag. During the review, staff additionally identified other services not on the list that included, but were not limited to:
* Compass Behavioral Health Services for QMHP services
* Adapt Integrated Health Care for QMHP services
* Iron Mountain for confidential record destruction
* Vend West Services for water dispensing services
* Stericycle for management, transportation, and disposal of medical waste





44104

29708


Based on interview and review of medical record documentation for 3 of 3 patients reviewed for nursing care plans (Patients 8, 9, and 18), it was determined the CAH failed to ensure a nursing care plan was developed, implemented and kept current for each patient based on assessment of the patient's individualized needs.

Findings include:

1.a. Review of medical record documentation for Patient 8 reflected the patient was admitted to the CAH on 06/23/2024 with diagnoses that included large bowel obstruction. The record included:
* The patient underwent a surgical procedure and had multiple nursing care needs including but not limited to those related to post-operative care, abdominal surgical care, NG tube management, colonostomy care, urinary catheter care, pain management, and IV fluid management. Examples included:
* An RN note dated 06/23/2024 at 0745 reflected "0725 hrs - [physician] with pt ... has ng tube in L nare with green/brown fluid in suction canister ... 0840 hrs - OR consent signed ... 1010 hrs - Pt to OR with [RN] ..."
* A physician operative note dated 06/23/2024 at 1437 reflected the patient underwent a sigmoid colectomy with partial cystectomy and descending colostomy procedure on 06/23/2024.
* An RN note dated 06/23/2024 at 1612 reflected that the patient arrived from recovery and complained of reflux "that is getting worse." The physician was consulted and gave orders for pantoprozole 40 mg IV.
* An RN note dated 06/24/2024 at 0642 reflected the patient had "[hiccups] all night that was causing [them] pain" and their "NG tube got clogged and [they stated they] felt sick from this". The note reflected the patient was administered "pain medication a few times that seemed to help". The note further reflected the patient had an abdominal dressing, a urinary catheter, wore SCDs and IV fluids were "infusing".

1.b. Review of Patient 8's medical record reflected there was no nursing care plan, including no goals and no interventions based on an assessment of the patient's individualized needs.

1.c. During an interview and review of the medical record with the AC/ED NM on 06/26/2024 at 1515 they confirmed Findings 1.a. and 1.b. The AC/ED NM acknowledged the patient had multiple nursing care needs and confirmed the medical record contained no nursing care plan that addressed those.

2.a. Review of medical record documentation for Patient 9 reflected the patient was admitted to the CAH on 06/22/2024 with diagnoses that included failure to thrive and hypotension.
* A physician order dated 06/22/2024 at 0731 reflected the patient was admitted to the Med/Surg Unit. The "Reason for Admission" was hypotension and the patient's "Condition on Admission" was "Guarded".
Flowsheet documentation reflected:
- On 06/22/2024 at 0615, the patient's BP was 86/66 and "Pulse Oximetry" was "100" on room air.
- On 06/22/2024 at 0647, the patient's BP was 98/62 and "Pulse Oximetry" was "100" and unclearly reflected the patient was on room air with oxygen flow rate "2" Liters.
- On 06/22/2024 at 0911, the patient's BP was 109/68 and "Pulse Oximetry" was "99" on room air.
* On 06/22/2024 at 1539, the patient's "Pulse Oximetry" was "95" on room air.
* On 06/23/2024 at 0927, the patient's BP was 112/68 and "Pulse Oximetry" was "97" and unclearly reflected the patient was on room air with oxygen flow rate "2" Liters.
* On 06/23/2024 at 1132 and 1448, the patient's BP and "Pulse Oximetry" had decreased and were BP 94/65 and pulse oximetry "92 [low]" on room air.
* On 06/25/2024 at 2034, the patient's "Pulse Oximetry" was "91 [low]" on 2 Liters oxygen by nasal canula.

2.b. Review of Patient 9's medical record reflected there was no nursing care plan, including no goals and no interventions including those related to the patient's guarded condition, oxygen needs, nor diagnoses of failure to thrive and hypotension.

2.c. During an interview and review of the medical record with the AC/ED NM on 06/26/2024 at 1535 they confirmed Findings 2.a. and 2.b. The AC/ED NM stated the medical record contained no nursing care plan.

3.a. Review of the medical record for Patient 18 reflected that on 10/20/2022 they were brought to the ED by ambulance from a hotel/motel where they were living and were in observation status unit 10/24/2022 on which day they were admitted as an inpatient. They had a primary diagnosis of Failure to Thrive and were discharged to a shelter on 10/28/2022. There was no evidence in the medical record to reflect that a nursing care plan had been initiated or developed to address the problems and needs identified in the medical record for Patient 18. Those included: UTI, skin excoriation, mobility and transfer dependency, lack of social support system and reliable housing, and discharge plan challenges.

3.b. During interview at the time of the medical record review, with staff that included the DQRM, NM, and DP on 07/01/2024 beginning at 1400, staff stated that a nursing care plan for Patient 18 had not been initiated or developed for Patient 18.



44104

Based on observations, interviews, and review of documents and employee health records it was determined that the CAH failed to develop and implement an active facility-wide program for the surveillance, prevention, and control of HAIs and other infectious diseases. The hospital failed to demonstrate adherence to nationally recognized infection prevention and control guidelines for reducing the development and transmission of HAIs and antibiotic-resistant organisms.

The findings identified during the survey reflect the CAH's limited capacity to provide care and services and represent a Condition-level deficiency of CFR 485.640 Condition of Participation: Infection Prevention and Control and Antibiotic Stewardship Programs.

Findings included:

1. Refer to the Findings at Tag C-1204, CFR 485.640(a) Standard: Infection prevention and control program organization and policies. The hospital's governing body failed to appoint an infection control professional based on medical and nursing leadership recommendations.

2. Refer to the Findings at Tag C-1206, CFR 485.640(a)(2) The infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the CAH and between the CAH and other healthcare settings. The hospital failed to fully develop and implement infection control policies for preventing and controlling the transmission of infections within the CAH.

3. Refer to the Findings at Tag C-1208, CFR 485.640(a)(3) The infection prevention and control includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and that the program also addresses any infection control issues identified by public health authorities. The hospital failed to fully develop, implement and monitor compliance with infection control policies for preventing and controlling the transmission of infections within the CAH.

4. Refer to the Findings at Tag C-1231, CFR 485.640(c) Standard: Leadership responsibilities (2) The infection prevention and control professional(s) is responsible for: (i) The development and implementation of facility-wide infection surveillance, prevention, and control policies and procedures that adhere to nationally recognized guidelines. The hospital failed to fully develop and implement infection prevention policies that adhered to nationally recognized standards for reducing the development and transmission of HAIs.

Based on interview and lack of documentation, the hospital's governing body failed to appoint an individual, as the infection preventionist(s)/infection control professional(s) responsible for the infection prevention and control program based on the recommendations of medical staff leadership and nursing leadership.

Findings included:

1. During an interview with the IPD and the DQ on 06/26/2024 beginning at 1400, they were asked whether the IPD had been appointed by the governing body, or responsible individual, as the infection control professional responsible for the hospital's infection prevention and control program, and whether their appointment had been based on the recommendations of medical staff leadership and nursing leadership. Both the IPD and the DQ responded that they were unsure. The DQ stated they would verify whether that had occurred. As of the exit date of the survey, no documentation was provided reflecting that the IPD had been recommended to their position by medical staff or nursing staff leadership, or that the IPD had been appointed by the governing body.

Based on observations, interview, documentation in 3 of 5 employee TB screening records (Employees 2, 3 & 4), review of infection control P&Ps, and other documentation, it was determined that the CAH failed to ensure that infection prevention policies and procedures had been fully developed and implemented for preventing and controlling the transmission of infections within the CAH and between the CAH and other healthcare facilities.

Findings included:

1. Refer to the findings under Tag C-1208 related to:
* Annual IC Risk Assessments had not been conducted and risks were not thoroughly evaluated hospital-wide.
* Annual IC Plan and Program evaluation was not fully developed or implemented.
* Annual TB Risk Assessment was not complete and risks were not thoroughly evaluated.
* A TB Exposure and Control Plan had not been developed or implemented; TB screening for employees and contracted staff were not complete or timely in accordance with hospital P&Ps and CDC recommendations.
* A healthcare Water Management Program had not been developed or implemented.
* Hospital wide IC P&Ps were not fully developed and implemented to address infection prevention and control issues. Policies were unclear, inconsistent, and were not in accordance with manufacturer's instructions or nationally recognized standards.
* The hospital did not fully implement IC policies to maintain a clean and sanitary environment.
* Cleaning products, hand hygiene products, and patient care supplies and equipment were expired, unlabeled, in secondary containers with incomplete labels, or were not maintained in a clean or sanitary manner.
* Food handling and storage was not in accordance with clear or complete P&Ps to ensure prevention of food-borne illness.
* Single-dose and multi-dose medication vials were not managed in accordance with P&Ps.
* Services provided under contract, agreement, or arrangement were not evaluated for adherence to the hospital's IC P&Ps and standards.

2. Refer to the findings under Tag C-1231 related to:
* Nutrition Services policy regarding the storage of patient food were not fully developed or implemented.
* Policies regarding animals in the hospital did not align with each other and were not fully developed or implemented.
* Hospital wide policies regarding the labeling of refilled chemical bottles were not clearly written.
* TB Exposure and Control policies were not fully developed or implemented and were unclear.
* Surgical Services policies regarding the disinfection of endoscopes and continuing education were not fully developed or implemented and were unclear.

29708








44104


Based on observations, interview, documentation in 3 of 5 employee TB screening records (Employees 2, 3 & 4), review of infection control P&Ps, and other documentation, it was determined that the CAH failed to ensure that infection prevention policies and procedures had been fully developed and implemented, and provisions for ongoing assessment and evaluation of those put into place. Procedures and processes based on nationally recognized standards to prevent cross-contamination, HAIs, and to ensure infection prevention had not been fully developed and enforced in the following areas:
* Annual IC Risk Assessments had not been conducted and risks were not thoroughly evaluated hospital-wide.
* Annual IC Plan and Program evaluation was not fully developed or implemented.
* Annual TB Risk Assessment was not complete and risks were not thoroughly evaluated.
* A TB Exposure and Control Plan had not been developed or implemented; TB screening for employees and contracted staff were not complete or timely in accordance with hospital P&Ps and CDC recommendations.
* A healthcare Water Management Program had not been developed or implemented.
* Hospital wide IC P&Ps were not fully developed and implemented to address infection prevention and control issues. Policies were unclear, inconsistent, and were not in accordance with manufacturer's instructions or nationally recognized standards.
* The hospital did not fully implement IC policies to maintain a clean and sanitary environment.
* Cleaning products, hand hygiene products, and patient care supplies and equipment were expired, unlabeled, in secondary containers with incomplete labels, or were not maintained in a clean or sanitary manner.
* Food handling and storage was not in accordance with clear or complete P&Ps to ensure prevention of food-borne illness.
* Single-dose and multi-dose medication vials were not managed in accordance with P&Ps.
* Services provided under contract, agreement, or arrangement were not evaluated for adherence to the hospital's IC P&Ps and standards.

Findings included:

1.a. An untitled document dated "25 June 2024" was provided by the hospital regarding the hospital's annual Infection Control Risk Assessments. It was reviewed and reflected:
* "The Infection Control Nurse at Lower Umpqua Hospital District has been employed by the district for three years."
* " ... there has not been a comprehensive annual Infection Control Risk Assessment completed."
* "The requirements for an annual Infection Control Risk Assessment were brought to [their] attention in 2023, and the plan to initiate this is reflected in the Infection Control Plan ... "
* "The Infection Control Nurse had an initial consultation with [the state HAI/IP team representative] in March of 2023 ... for improvement practices ..."
* "There was an on-site visit April 15th, 2024, to tour the facility ... "
* "The district's Infection Control Nurse will be collaborating with the [the state HAI/IP team representative] ... to perform and document an annual Infection Control Risk Assessment in January 2025."
* The document closed with an unsigned signature block reflecting the IPD name, credentials and title.

The hospital failed to conduct an annual Infection Control Risk Assessment per hospital policy, CDC recommendations, and nationally recognized standards. The document provided by the IPD confirmed that an Annual Infection Control Risk Assessment had not been conducted for approximately 3 years and that the hospital had no plans to correct the oversight until January of 2025, approximately 1 year and 10 months after identifying that an Infection Control Risk Assessment was required.

1.b. During an interview with the IPD and the DQ on 06/26/2024 beginning at 1400, the IPD was asked for documentation of the hospital's annual hospital-wide Risk Assessments. The IPD stated that they had not conducted a Risk Assessment since assuming the role of IPD on 12/20/2020. For clarification, the IPD was asked whether a Risk Assessment had been conducted for 2021. The IPD responded, "No." The IPD was asked whether a Risk Assessment had been conducted for 2022, 2023, and 2024. The IPD responded "No" for each year. The IPD was asked whether they had evaluated the hospital's contracted patient care services for adherence to IC practices such as: conducting an on-site Risk Assessment, or by reviewing contracts. The IPD responded:
* Regarding contracted services for patient laundry/linen: The IPD stated "No," they had not reviewed the contract nor conducted an on-site Risk Assessment.
* Regarding the MRI mobile unit, the IPD stated, "Yes," they had conducted an on-site review and evaluation. When asked when that evaluation occurred, the IPD stated, "Perhaps early 2023?" They further acknowledged that they had not reviewed the contract and that no documentation of the evaluation was available.
* Regarding the public swimming pool used by the hospital's Rehabilitation patients: The IPD stated "No," they had not reviewed the agreement nor conducted an on-site Risk Assessment.
Additionally, the IPD confirmed:
* Neither an IC Risk Assessment nor an IC evaluation of the outpatient Wound Care Clinic had been conducted.
* Neither an IC Risk Assessment nor an IC evaluation of the outpatient Reedsport Medical Clinic had been conducted.

2.a. A document titled "Infection Control Plan" with "Effective Date: 10/11/2017" and "Revised: 06/072021; 03/28/2024" was reviewed and reflected:
* "The program goals are achieved through the following objectives ... Priority-directed, targeted surveillance based on the risk assessment."
* "Infection Control will develop a risk assessment at least annually or whenever significant changes occur ... "
* "Factors that are addressed in the risk assessment include, but are not limited to the following ... Geographic location and Community Environment ... Population Served ... Scope of Services provided ... Results of Analysis of Surveillance Data Collected ... Employee Health ... Emergency Preparedness ... "
* "Based on the Risk Assessment and goal prioritization, strategies are developed to address and implement actions of the Infection Control Plan."
* "Evaluation of Plan ... The Infection Control Nurse monitors the Infection Control Program, allowing the hospital to determine if procedures are working well or require revision ... The evaluation addresses changes in the scope of the program, changes in the results of the program risk analysis, emerging and re-emerging problems in the ... community that potentially affect the hospital, assessment of the success or failure of interventions for preventing and controlling infection, and responses to concerns raised by leadership and others... Documentation of program evaluation is located in the CQC meeting minutes and in the Infection Control department."

The hospital failed to fully develop and implement its Infection Control Plan and failed to thoroughly evaluate that plan at least annually, or when significant changes occurred, per hospital policy and nationally recognized standards. For example, the Infection Control Plan stated that program goals were achieved by conducting "Priority-directed, targeted surveillance based on the risk assessment". It was unclear how the "strategies ... developed to address and implement actions of the Infection Control Plan" based on the "Risk Assessment" were determined as no risk assessment had been conducted for the past 3 years, refer to Findings 1.a. and 1.b., IPD confirmation that Infection Control Risk Assessments had not been conducted. Further, the plan reflected that "changes in the results of the program risk analysis" would be considered when evaluating the plan. However, since no IC risk assessments were conducted, it was unclear on what the hospital based its IC program evaluations for those years in which a risk assessment had not been conducted. The IC Plan reflected "The Infection Control Nurse monitors the Infection Control Program, allowing the hospital to determine if procedures are working well or require revision ..." The plan was not clear on whether it met state OAR requirements that the infection control program be managed by a qualified individual and overseen by a multidisciplinary committee with responsibility for investigating, controlling and preventing infections in the facility. The IC Plan did not describe the existence of a multidisciplinary committee that included representation from major departments and services or whether that committee's role included provision of consultation and oversight of all aspects of the infection control program.

2.b. A document titled "Lower Umpqua District Infection Control Committee Minutes" dated "March 15, 2024" was reviewed and reflected:
* "Attendance: (Name, Title, who representing (indicate chair) [sic]"
* "Approval of Minutes: 1st meeting".

The minutes reflected that this was the first meeting for the Infection Control Committee. No "chair" was identified in the attendance roster.

2.c. During an interview with the IPD and the DQ on 06/26/2024 beginning at 1400, the IPD confirmed Findings 2.a. and 2.b. The IPD confirmed that the hospital Infection Control Committee "began March 15, 2024."

3.a. A document titled "2023 Lower Umpqua Hospital District Tuberculosis Risk Assessment" was reviewed and reflected:
* The TB Assessment addressed 8 areas as follows:
* Introduction - "This risk assessment aims to evaluate the TB risk within Lower Umpqua Hospital District ... and outline measures to mitigate these risks effectively."
* Assessment Scope - "Physical Environment: Evaluate ventilation systems, room configurations, and patient flow ... Patient population: Assess demographics, prevalence of TB, and related risk factors ... Staff Training: Review training programs and awareness of TB Prevention measures ... Infection Control Practices: Examine protocols for screening, isolation, and treatment adherence."
* Risk Factors Identification - "Patient Population: High-risk demographics ... History of TB cases among patients ... Physical Environment: Ventilation adequacy in patient rooms, waiting areas, and procedural spaces ... Room configurations for isolation capabilities. Room 103 in Acute Care is identified as negative pressure. Other rooms in the Emergency Department, Acute Care ... have the capability of negative pressure via portable units."
* Current Mitigation Strategies - "Infection Control Policies: Screening Patients upon admission ... Isolation procedures for suspected or confirmed TB cases ... Staff Education and Training: TB awareness training for all healthcare personnel. Staff receive training in General Orientation and annual training ... Correct use of ... PPE ... The Respiratory Therapy Department conducts fit testing of newly hired workers and annual fit testing. Employee Health oversees PAPR training and processing.
* Assessment Findings - "TB Prevalence: Low/moderate/high based on historical data and current patient demographics ... There were zero cases of inpatients with TB in 2021, 2022 and 2023 ... Employee Health Screenings: Healthcare workers are screened for Tuberculosis prior to employment. All contracted workers are required to show proof of recent Tuberculosis testing (within six months) prior to employment. New employees are assessed through screening questions and testing. Lower Umpqua Hospital District utilizes the two-step PPD testing method or QuantiFERON [sic] Gold testing as part of the new hire process. There were zero cases of positive TB tests among healthcare workers in 2022 and 2023 ... Infrastructure: Adequate airborne infection control ... Compliance: Generally compliant with TB control guidelines."
* Conclusion - "This risk assessment identifies the current state of TB risk within Lower Umpqua Hospital District ... By implementing the recommended measures and continuously evaluating TB control strategies, the hospital can effectively minimize the risk of TB transmission among patients, visitors, and staff."
* Approval: "This risk assessment is approved by: [the IPD name and title]'.

The hospital failed to fully develop and implement a TB Risk Assessment per CDC recommendations and nationally recognized standards. For example, the TB Risk Assessment date lacked a month and day, and therefore it was unclear when the risk assessment was conducted. It was unclear how assessment findings were were determined. For example, under "Assessment Findings" the document reflected a determination of "Adequate airborne infection control." However, under "Physical Environment" the document described actions instead of findings, e.g., "Evaluate ventilation systems". Documentation of the ventilation system evaluation such as a description of type of ventilation system employed, e.g., single-pass, recirculated flow, variable air volume, etc., which air-cleaning methods were in use, e.g., HEPA filtration or UVGI, or whether air exchanges in various patient care areas adhered to nationally recognized standards were not noted. The physical environment evaluation also did not address findings on whether environmental controls were regularly checked and maintained, or whether a procedure existed for verifying the negative pressure in AII rooms when the rooms were in use, including those rooms where portable HEPA filter units were utilized. Additionally, it was unclear what was meant by "Generally compliant with TB control guidelines" and how that contributed to the overall risk of TB within the hospital environment. The "Assessment Findings" did not clearly state the hospital's overall risk of TB and instead reflected "Low/moderate/high based on historical data and current patient demographics ..." Finally, the assessment was approved by the author and did not reflect IC Committee members' or leadership review and approval.

3.b. During an interview with the IPD and the DQ on 06/26/2024 beginning at 1400, the IPD confirmed Finding 3.a.

4.a. A document titled "Tuberculosis Screening - Employees, Volunteers and Students" with "Effective Date: 5/3/2018" and last revised "06/05/2024" was reviewed and reflected:
* "Approved By ... Director Infection Control [and] ... Chief Nursing Officer"
* "Employees, volunteers and students shall be evaluated for Tuberculosis (TB) upon employment, annually thereafter if indicated by the annual Infection Control evaluation, and following exposures."
* "All new employees must have a TB symptom screening, risk assessment and two-step baseline TB skin test (TST) or single Interferon Gamma Release Assay (IGRA) ... or T-Spot within twelve (12) months of the date of hire, date of executed contract date or date of being granted hospital credentials. For those utilizing the two-step TST, the first step must be completed prior to the start of employment."
* "If an annual ... PPD ... is warranted per Lower Umpqua Hospital District's ... Tuberculosis Exposure Control Plan Risk Assessment, Infection Control will implement a plan to arrange for testing through Employee Health."

The policy was not fully developed and implemented. For example, key stakeholders, such as the Infection Control Committee, were not listed to ensure that the procedures had been evaluated for any unique infection control risks specific to the hospital's environment, or whether the policy had been evaluated by an interdisciplinary team responsible for the oversight of the infection control program. Although the references listed the "Centers for Disease Control and Prevention ... Guidelines for Preventing the Transmission of Mycobacterium tuberculosis [sic] in Health-Care Facilities", the hospital failed to thoroughly complete the CDC's recommended TB Risk Assessment, which lacked the hospital's determined TB risk; refer to Finding 3.a. Therefore, it was unclear how the hospital decided the frequency of HCW TB screening and testing without an accurate TB risk evaluation.

4.b. Employee TB testing records were reviewed for Employees 1-5, and reflected:
* The hospital could not provide the baseline TB symptom screening and risk assessment form for Employee 2 per hospital policy.
* The hospital could not provide the baseline TB symptom screening and risk assessment form for Employee 3 per hospital policy.
* The hospital could not provide the baseline TB symptom screening and risk assessment form for Employee 4 per hospital policy.

The hospital failed to develop and implement a Tuberculosis Exposure Control Plan as referenced in the hospital's "Tuberculosis Screening" policy, CDC recommendations, and nationally recognized standards. Employee TB screenings were incomplete and inconsistent with the hospital's TB screening policy and with the hospital's "Tuberculosis Risk Assessment". For example, 3 of 5 employee records (Employees 2, 3, 4) lacked a completed TB symptom screening and risk assessment form as required by the TB screening policy. Documentation of Employees 2, 3, and 4 being "assessed through screening questions", as described in the TB Risk Assessment were not provided.

4.c. During an interview with the IPD and the DQ on 06/26/2024 beginning at 1400, the IPD confirmed Finding 4.b. The IPD stated that an OSHA form titled "OSHA Respirator Medical Evaluation Questionnaire (Mandatory) Appendix C to Sec. 1910.134" served the same purpose as the hospital's TB symptom screening and risk assessment form. When the IPD was asked whether symptoms of TB, such as night sweats were included on the OSHA Respirator Medical Evaluation Form, the IPD stated, "No, but I ask them if they are free from infectious diseases." When asked whether the policy reflected that the OSHA Respirator Medical Evaluation Form and the TB symptom screening form could be used interchangeably, the IPD stated, "No," and confirmed that it was not reflected in the policy. The IPD was asked whether the hospital had a Tuberculosis Exposure Control Plan. The IPD stated, "No."

5. An untitled, undated document provided by the hospital regarding the facility's Water Management Program was reviewed and reflected:
* "April 15th, 2024 OHA IP [the state HAI/IP team representative] visited the facility and provided the CDC resource, Developing a Water management [sic] Program to Reduce Legionella Growth and Spread in Buildings to assist us with a water management plan."
* "This plan is currently not completed."
* The document closed with a signature block reflecting the "Plant Operations" Assistant Manager's name and signature.

The hospital failed to develop and implement a Water Management Program as required by CMS, recommended by CDC and per nationally recognized standards. The hospital could not provide a hospital risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the hospital water system.

6. A policy titled "Central Service - Sterilization - Scope of Services Provided" with "Effective Date: 10/18/2003" and revised dates of "02/03/2022; 05/02/2023" was reviewed and reflected:
* "Approved By ... Director of Surgical Services ... Chief Nursing Officer [and] Medical Director DFHC"
* "Central Service is responsible for the processing, sterilization and quality control of all sterile supplies and equipment used in Lower Umpqua Hospital District."
* "Central Service personnel must also maintain all required quality assurance tests and documentation for each sterilizer load."
* "Personnel in each department are responsible for the initial cleaning of all items and processing as described for each department's specific procedure."
* Regarding outpatient Reedsport Medical Clinic, "Individual department will bring items to Central Service for processing. Items to be placed in Decontam container on counter or if door locked, place on floor."
* " ... services will be provided Monday through Friday per hospital department: *Instrument turnaround [sic] time is 48 hours for processing ... "
* "Surgical Services Department/Outpatient Surgery/GI Laboratory ... All instrument and basin sets and trays will be decontaminated, packaged and sterilized by Central Service ... Equipment ... Single packaged items ... Implants ... Other patient care items such as transducers and anesthesia supplies."
* "... Reedsport Medical Clinic ... All instruments, single packaged instruments and trays and other patient care items that must be sterilized prior to use, will be sterilized by Central Service ... Clinic staff will wipe gross debris off instruments at point of use with 4x4 gauze ... Staff should wear appropriate personal protective equipment ... including chemical resistant gloves and eye protection ... Clinic staff will spray dirty instruments with approved enzymatic spray 'RUHOF ... Prepzyme Forever Wet ... Instruments should remain moist until they are transported to Central Service for sterile processing ... Dirty instruments will be transported in a latch/lock labeled biohazard container. Lid should remain on container at all times during transport to prevent cross contamination ... Once dirty instruments are out of biohazard container, Central Services staff will clean the container with approved low-level disinfectants such as Meritz plus, Sani-Cloth, bleach wipes, or Dispatch ... A label indicating 'Clean' will be affixed to the container and sterilized instruments will be returned in the cleaned container."
* "Emergency Department and Patient Care Units ... Sterile instrument sets, single packaged instruments and trays for treatment or diagnostic tests ... Other patient care items that require sterilization prior to use."
* "Radiology ... Patient care items that require sterilization prior to use."
* "Reference: Former policy ID #1004, Central Supply policy".

The policy was not fully developed or implemented and it was unclear whether the policy was based on nationally recognized standards. For example, the policy lacked professional references, such as CDC Guidelines for sterilization and disinfection, and did not reflect whether the hospital considered recommendations by other professional sources such as AORN, or APIC. Key stakeholders, such as the Infection Control Committee, were not listed to ensure that the procedures had been evaluated for any unique infection control risks specific to the hospital's environment, or whether the policy had been evaluated by an interdisciplinary team of personnel involved in the use and reprocessing of patient care equipment, such as personnel from the Reedsport Medical Clinic or other patient care units. Parameters for processes such as "Instruments should remain moist until they are transported to Central Service for sterile processing" were not well described. For example, it was unclear whether the manufacturer's IFUs for the enzymatic spray RUHOF Prepzyme Forever Wet meant that the instruments could remain in the "biohazard container" for greater that 24 hours, 48 hours, 72 hours, or "Forever" prior to processing. The policy did not specify when, after being used, instruments should be transported to Central Service for processing. It was unclear whether items in biohazard containers taken to Central Service for processing when the "door [was] locked" and placed "on floor" created other infection prevention or safety concerns as a designated area "on floor" was not specified.

7. A document titled "Olympus Reprocessing Manual ... Duodenovideoscope ... Type Q180v" with a revision history of "March 2015" was reviewed for the manufacturer's cleaning and reprocessing instructions for the hospital's endoscopes. It reflected:
* "Warning ... Improper handling, such as touching a reprocessed endoscope and/or accessories with contaminated gloves, placing a reprocessed device on a contaminated hanger or surface, allowing devices to touch the floor, etc., will recontaminate the device."
* "Patient debris and reprocessing chemicals are hazardous. To guard against contact with dangerous chemicals and potentially infectious material, wear appropriate personal protective equipment during cleaning, disinfection, and sterilization. Such protective equipment should include appropriate eyewear, face mask, cap, moisture-resistant clothing, shoe covers, and chemical-resistant gloves that fit properly and are long enough to prevent skin exposure."
* "All cloths used in reprocessing are recommended to be lint-free. Lint or cloth fibers shed into reprocessing fluids may be injected into the endoscope channels. There is the potential for lint or cloth fibers to lodge in channels or become trapped in the air/water nozzle. If gauze is used to reprocess the endoscope, ensure that fibers do not get caught on or remain trapped by protruding components like the air/water nozzle."
* "Insert the brush into the forceps elevator recess along the forceps elevator (insert the brush into the instrument channel) until the brush handle touches the distal end of the endoscope and pull the brush out of the forceps elevator recess. Repeat the insertion and pulling out three times."
* "Brush the distal end of the endoscope except the forceps elevator and the forceps elevator recess, using the single use channel-opening cleaning brush ... or the single use combination cleaning brush ... until no debris is observed upon inspection of the distal end of the endoscope ... 2. Insert the brush at a 45 [degree] angle into the opening located in the side wall of the suction cylinder. Using short strokes, feed the brush through the instrument channel until it emerges from the distal end of the endoscope's insertion section. 3. Inspect whether there is debris on the bristles when the brush emerges from the distal end. Clean the bristles in the detergent solution using your gloved fingertips to remove any debris. 4. Carefully pull the brush back through the channel and out of the suction cylinder. 5. Inspect whether there is debris on the bristles when the brush emerges from the suction cylinder. Clean the bristles in the detergent solution using your gloved fingertips to remove any debris. 6. Repeat Step 2 through 5 until no debris is observed upon inspection of the brush."
* "Dry the external surfaces of the endoscope, the channel plug, and the injection tube by wiping with a clean, lint-free cloth(s)."
* "Proper storage procedures are as important as proper reprocessing procedures in maintaining good infection control practices. Be sure that the endoscope storage cabinet is properly maintained, clean, dry, and well ventilated. All equipment must be thoroughly dried prior to storage. Microorganisms proliferate in wet/moist environments. Keep the cabinet doors closed to protect the equipment from environmental contaminants and accidental contact."

8.a. A policy titled "Endoscopes - High Level Disinfection" with "Effective Date: 04/21/2006" and a revised date of "07/28/2017" was reviewed and reflected:
* "Approved By ... Director of Surgical Services [and] ... Chief Nursing Officer"
* "This is an abbreviated procedure. Please refer to Olympus manuals for all specifics on endoscope sterilization procedure."
* "All endoscopes shall receive mechanical cleaning prior to sterilization or disinfection."
* "Flexible endoscopes shall be cleaned with a manufacturer-approved enzymatic cleaner immediately following use."
* "The channels will be irrigated and brushed, if accessible."
* "Rinse all immersible parts of the endoscope with water."
* "Discard all detergent solutions after each use. Use single-use disposable brushes for cleaning the channels or clean and sterilize."
* "Conduct leak testing on flexible endoscopes prior to immersion. Remove endoscope from service, if it leaks, before it is cleaned and contact the manufacturer. See policy and procedure."
* "Following chemical disinfection, rinse the endoscope with sterile water."
* "Thoroughly air dry the endoscope while in the hanging position."
* "Do not store the endoscope coiled. Store endoscopes in the hanging position. Wipe the cabinet floors daily after endoscope cleaning."

8.b. The policy was not fully developed or implemented and it was unclear whether the policy was based on nationally recognized standards. For example, the policy lacked professional references, such as CDC Guidelines for sterilization and disinfection, and did not reflect whether the hospital considered recommendations by other professional sources such as AORN, or APIC. Key stakeholders, such as the Infection Control Committee, were not listed to ensure that the procedures had been evaluated for any unique infection control risks specific to the hospital's environment, or that the policy had been evaluated by an interdisciplinary team of personnel involved in the use and reprocessing of endoscopes. The mechanical cleaning processes for endoscopes were not well described. For example, it was unclear what was meant by "Use single-use disposable brushes for cleaning the channels or clean and sterilize."

9.a. A policy titled "Medivators Cer-2 Optima Scope Washer - Care and Operation" with "Effective Date: 07/17/2017" and a revised date of "4/8/2024" was reviewed and reflected, in it's entirety:
* "Approved By ... Director of Surgical Services [and] ... Chief Nursing Officer"
* "Purpose: High level disinfection of flexible endoscopes using rapicide."
* "Policy: All scopes must be leak tested, brushed and wiped prior to loading in the Medivators CER-2 Optima Scope Washer. Refer to manual for detailed instruction on proper maintenance and operation. In the event of scope washer failure, please refer to Olympus Reprocessing Manual for GIF and CF scopes, chapter 3 for manual reprocessing in the Endoscopy Manual book."

9.b. The policy was unclear and not fully developed. For example, the policy lacked references, such as CDC Guidelines for sterilization and disinfection, and therefore it was unclear whether the policy was based on nationally recognized standards. Key stakeholders, such as the Infection Control Committee, were not listed to ensure that the procedures had been evaluated for any unique infection control risks specific to the hospital's environment, or that the policy had been evaluated by an interdisciplinary team of personnel involved in the use and reprocessing of endoscopes.

10.a. A policy titled "Annual Training/Continuing Education" with "Effective Date: 11/15/2002" and a revised date of "08/03/2023" was reviewed and reflected:
* "Approved By ... Director of Surgical Services [and] ... Chief Nursing Officer"
* "Policy ... All members of the surgery department staff will complete annual Relias training ... All members of the surgery department staff will have current CPR certification ... All surgery registered nurses will have current ACLS certification ... All surgery technologists will have current certification or complete 16 hours of continuing education every two years ... All members of the surgery department staff will review the following skills/equipment annually: Adult Code Cart ... Difficult Intubation Cart ... Malignant Hypothermia Cart".
* "All records of certifications will be kept in Human Resources. All department skills reviews will be logged in the employee development book in the PACU."
* Attached to this policy was a copy of a 1-page, handwritten document dated "11-21-23" and titled "Anesthesia Inservice, difficult intubation, art line set-up, intubation skills w/ Dr. [doctor's name]. This was followed by 6 signatures, of which only 2 were legible. No other information that identified which staff attended the inservice was reflected.

10.b. The policy did not clearly state whether competencies for HLD or mechanical cleaning of endoscopes were required. The policy did not reflect whether staff performing HLD and mechanical cleaning of endoscopes were required to review processing steps periodically. Key stakeholders, such as the Infection Control Committee, were not listed to ensure that the procedures had been evaluated for any unique infection control risks specific to the hospital's environment, or that the policy had been evaluated by an interdisciplinary team of personnel involved in the use and reprocessing of endoscopes.

10.c. In an email received on 07/08/2024 at 0823 the CSC wrote that the hospital had "No Competencies or Annual training/records re: scope washing" for the last two years.

11.a. During a tour of Surgical Services with the SSM on 06/26/2024 beginning at 0910, the ST was observed during mechanical cleaning and reprocessing of an endoscope and stated the following:
* The water temperature wi

44104

Based on observations, interview, review of infection control P&Ps, and other documentation, it was determined that the CAH failed to fully develop and implement infection prevention P&Ps hospital wide. Policies did not adhere to manufacturer's instructions or nationally recognized standards in the following areas:
* Dietary and Nutrition Services policy regarding the storage of patient food.
* Policies regarding animals in the hospital were not fully developed or implemented and lacked key stakeholder input.
* Hospital wide policies regarding the labeling of refilled chemical bottles were not clearly written.
* TB Exposure and Control policies were not fully developed or implemented and were unclear.
* Surgical Services policies regarding the disinfection of endoscopes and continuing education were not fully developed or implemented and were unclear.

Findings included:

1. The policy titled "Labeling, dating [sic] & Storage" with "Effective Date: 5/28/2018" and last "Revised: [this was blank]" was reviewed and reflected:
* "Approved By: [name of] CDM CFPP"
* "Purpose To ensure the ... Nutrition Department is following all federal and local government guid lines [sic] on food safety."
* "Labeling and Dating ... All items must be marked with a received date to ensure proper food rotation ... All items that are removed from the original package must be marked with the received date and expiration date ... All food items that are made need a date of when it was made and a use by date ... Use by date must be 4 days after date it was made. The first day is the day it was made. (example Potato salad made on 6/26/2024 the use by day would be 6/29/2024.} [sic] ... All items that are open must have an open date and must be secured tightly."
* "When product must be received at appropriate times and at the recommended temperature [sic] ... Frozen products must be put away within 2 hours of of receiving it ... Dry goods must be put away with in [sic] 3 hours after delivery ... All items must be marked with a received date to ensure proper food rotation ... When putting away product you must follow FIFO9First in First out) [sic]".
* "All food items must be stored at least 6in about [sic] the ground ... Chemicals cannot be stored with food items ... All chemicals must be stored off the ground ... All products must be rotated by using FIFO."
* No references noted.

The policy was unclear and not fully developed. For example, the policy lacked references and therefore it was unclear whether the policy was based on nationally recognized standards. Although the policy stated that food items "must be marked with a received date ... must be marked with a receive date and expiration date ... need a date of when it was made and a use by date ... must have an open date ... ", the policy did not specify a date format. The hospital did not fully implement its labeling and dating policy as food items were observed undated and stored less that 6 inches above the ground. Refer to Tag C-1208, Findings 23, that reflects observations noted during the Dietary and Nutrition Services tour and confirmation that Dietary and Nutrition policies had not been fully developed or implemented.

2.a. The policy titled "Animal Assisted Interventions" with "Effective Date: 08/18/2021" and "Review Date: (No Revisions)" was reviewed and reflected:
* "Approved By: [unknown employee name & no corresponding title or credentials]"
* Objective: To provide guidelines to ensure that animals allowed in the Lower Umpqua Hospital ... meet infection prevention and animal safety guidelines."
* "Definitions: Animal-Assisted Therapy (AAT) Dog: A dog that has been trained and evaluated to safely interact with individuals for a goal directed benefit in the use of therapy. Therapy dogs are required to ... pass a yearly review of skills and veterinary exams."
* "Animal Assisted Intervention Requirements and Eligibility ... Pass yearly veterinary exams ... Pass a yearly review of skills ... "
* "References: Adopted and revised from Banner Health Therapy Dog Program and Pet Visitation (2012) ... "A Protocol for Animal Assisted Therapy in a Midwestern Hospital" (2015) ... Occupational Therapy Capstones ... "

The policy was unclear and not fully developed. For example, the policy lacked infection control references, did not reflect whether the hospital considered recommendations by other professional sources such as the CDC, APIC or SHEA and therefore it was unclear whether the policy was based on nationally recognized standards. Key stakeholders, such as the Infection Control Committee, were not listed to ensure that the procedures had been evaluated for any unique infection control risks specific to the hospital's environment, whether the policy was consistent with other similar policies, or whether the policy had been evaluated by an interdisciplinary team of personnel involved in the use of AAT or animal visitations. The policy failed to describe who would be responsible for documenting, monitoring and tracking for compliance the "Animal Assisted Intervention Requirements and Eligibility". Refer to Finding 2.c., competencies for the AAT dog did not reflect yearly skills review per policy. It was unclear who had approved the policy, including whether leadership had reviewed and approved all aspects of the process.

2.b. The policy titled "Pet Visitation" with "Effective Date: 05/02/2018" and last "Revised: 08/11/2022" was reviewed and reflected:
* "Approved By ... Director Infection Control [and] ... Chief Nursing Officer"
* Lower Umpqua Hospital .. acknowledges the virtue and importance of patient-pet contact in a healthcare setting and promotes an environment supportive of the patient's needs while complying with Center [sic] for Disease Control ... guidelines on animals in health care facilities, to provide direction and guidelines for staff including required assessment, identification and restrictions to ensure compliance with Americans with Disabilities Act ... for animal visitation."
* "Definitions ... Therapy dog - A therapy dog has been through a formal training program with its owner for the purpose of visiting healthcare facilities and providing structured interaction with patients."
* Sixteen references were listed including: ADA.gov; CDC; and APIC.

The policy failed to reflect key stakeholders, such as the Infection Control Committee, to ensure that the procedures had been evaluated for any unique infection control risks specific to the hospital's environment, that the policy was consistent with other similar policies, or that the policy had been evaluated by an interdisciplinary team of personnel involved in the use animal visitation or AAT. It was unclear whether leadership had reviewed and approved all aspects of the process.

2.c. An undated document titled "Classes/exams taken with [AAT dog] and Handler [name]" was reviewed and reflected:
* "Puppy behavior and management ... September 11, 2017 - October 9 [sic] 2017 ... Coastal Canine Center in Coos Bay".
* "Agility training and commands ... September 14, 2019 - Oct 19, 2019 ... Coastal Canine Center in Coos Bay".
* "Advanced handling for agility ... January 18th, 2020 - February 22, 2020 ... Coastal Canine Center in Coos Bay".
* "Canine Good Citizen Test ... May 25th, 2019 ... The American Kennel Club".

The information provided lacked documentation of the hospital's AAT animal's yearly reviews of skills for 2021, 2022, 2023 or 2024. It was unclear whether the AAT animal present in the hospital met all required yearly competencies for a therapy dog as described in policy, "Therapy dogs are required to ... pass a yearly review of skills ... "

3.a. The policy titled "Employee Notification of Chemical Management and Application" with "Effective Date: 05-22-2019" and "Review Date (No Revisions)" was reviewed and reflected, in it's entirety:
* "Approved By: [unknown employee name & no corresponding title or credentials]"
* "Purpose: To ensure the safety and well-being of Lower Umpqua Hospital District's patients, employees, volunteers, and visitors when using new products, chemical, and pesticides."
* "Policy:
- When a new product, chemical, or pesticide is used in an area of work, all employees need to be aware of the application of said chemical.
- It will be the responsibility of the department manager to notify their staff of the usage of said materials.
- The SDS (Safety Data Sheet) on said material will be immediately available in the work area.
- The manager will go over the SDS sheets with staff to ensure staff know the physical and health hazards of the material being utilized in the work area.
- It is the responsibility of staff members to notify their manager if they feel they have health issue [sic] with any product, chemical, or pesticide.
All staff members can access our SDS in various ways including: Phone Number (see yellow SDS stickers in your department): [two phone numbers listed] Online SDS that can be accessed on all employee computer desktops Hard copies of the SDS sheets are located in admitting in the copy room."

The policy failed to describe labeling requirements for the transfer and filling of chemicals from its primary container to a secondary container and lacked written protocol on how those secondary bottles of chemicals were labeled, dated, tracked, refilled or replaced prior to expiration date or "Use By" date.

3.b. The policy titled "Hazard Communication Program" with "Effective Date: 05/22/2019" and last "Revised: 06/26/2024" [the second day of the survey] was reviewed and reflected:
* "Approved By: [signature of CEO]" No title accompanied the signature.
* "Objective: To ensure all affected employees understand the information concerning the dangers of all known hazardous chemicals used by LUHD and to protect LUHD employees and contractors who may come in contact with hazardous chemicals wile performing there job duties."
* "The written Hazard Communication Program ... will include ... Methods used to ensure that all containers ... are labeled, tagged or marked properly... Methods used to inform the employees of other employers of the labeling system used in the workplace."
* "The Hazard Communication Program will identify the following ... Workplace labeling system."
* "Responsibilities ... Ensure all containers are labeled, tagged or marked properly ... Material Manager is responsible for ... Contacting chemical manufacturers and/or distributors to obtain SDS and secondary labels for hazardous chemicals used or stored in the workplace ... Department Managers are responsible for ... Ensuring all chemicals in the departments are labeled properly, including secondary containers ... Employees are responsible for ... Becoming familiar with container labels ... Notifying the supervisor of torn, damaged or illegible labels or of unlabeled containers ... "
* "Labels and other forms of warning ... Chemicals transferred to secondary containers in the workplace must also be appropriately labeled ... When a chemical is transferred from the original container to a portable or secondary container, the container will be labeled, tagged or marked with a GHS label containing the following information: product identifier, signal word, hazard statement(s), pictograms(s), precautionary statement(s), and the name, address and telephone number of the chemical manufacturer, importer or other responsible party. *Include the lot number ad expiration date of chemical on the secondary container."
* "References: Approved by LUHD Board of Directors, June 26, 2024"

3.c. During an interview with the CNO on 06/26/2024, they stated that the phrase "*Include the lot number ad expiration date of chemical on the secondary container" was added to the policy just prior to the governing board meeting on 06/26/2024. The previously revised policy failed to include specific information about the need for an expiration date on secondary containers.

4. Refer to Tag C-1208, Findings 4.a., 4.b., and 4.c., that reflects TB screening policies were not consistent with nationally recognized standards. Employee screening policies were not fully implemented. A TB Risk Assessment upon which the hospital's TB screening policies, and a TB Exposure and Control Plan should have been based, was not fully developed or implemented; a final hospital-wide Risk Determination had not been determined per CDC recommendations and nationally recognized standards. The hospital stated that a TB Exposure and Control Plan, per CDC recommendations and nationally recognized standards, had not been developed or implemented.

5. Refer to Tag C-1208, Findings 6 through 12, that reflects Surgical Services policies that were not fully developed, were unclear, and not fully implemented in accordance with manufacturer's instructions and nationally recognized standards.

Based on interview, review of 1 of 1 medical record reviewed for discharge planning (Patient 18), and review of the DP P&P, it was determined the discharge planning evaluation and efforts were not complete, coordinated and effective, and did not incorporate consideration of this houseless patient's complex discharge planning needs for caregiver supports and resources in their temporary place of residence in the community.

Findings include:

1. Review of the findings that follow from Patient 18's medical records reflected that discharge planning for this patient was a complex and challenging process. The patient primarily self-directed their discharge planning, had a strong desire to be in setting where they could self-direct their activities and life, and was opposed to facilities for reasons that included they would not allow smoking. The patient did not have a permanent residence, did not have family support in the area, and did not have a guardian or legally appointed representative. The hospital's DP worked extensively on the patient's discharge plans and had actively attempted to locate a facility residence for Patient 18 but none would accept the patient. However, it was not clear that efforts were exhaustive and coordinated effectively with the State/local APD CM, and it was not clear what the patient's actual financial, State insurance/benefits, VA benefits, and other related resources were to provide for their access to services for housing, living, and care. Although the patient had expressed to a physician on 10/24/2022 that they were "interested in caregivers," there was no indication in physician notes or discharge planning notes for these hospitalizations that staff had approached the patient or the State/local APD CM with the idea of discharge back to a hotel/motel, an apartment type residence, residential living, or low-cost housing, with the services of non-skilled in-home care services or other community and caregiver supports.

2.a. Review of Patient 18's medical record reflected that on 10/20/2022 Patient 18 was brought to the ED by ambulance from a hotel/motel where they were living, and was in observation status until 10/24/2022 on which day they were admitted as an inpatient. They had a primary diagnosis of Failure to Thrive and were discharged to a shelter on 10/28/2022.

2.b. Physician notes and documentation included:
*The ED physician note reflected "Patient brought in by ambulance from a hotel where [they were] living, found to be sitting in [their] own diarrhea for unknown amount of time ... patient recently signed [themselves] out of [SNF/NF] despite recommendations against this. [They have] been living in a hotel since that time ... 80-year-old ... with a history of CKD, coronary artery disease, peripheral vascular disease, alcohol abuse brought in by ambulance from [their] hotel room ... On exam, [the patient] is nontoxic-appearing but is in distress. [They have] severely excoriated skin of [their genitalia] and buttocks ... patient was previously living at [SNF/NF] but left against advice of providers choosing instead to stay in a hotel room ... Patient has admitted today that [they are] unable to care for [themselves] and does need to be placed. [They] requested [they] be admitted back to [SNF/NF] but [was] declined as the patient apparently was quite difficult and even smoked alcohol [sic] into the facility which puts [them] at risk of losing their license. Our discharge navigator is aware of the situation and states that arrangements are attempting to be made for placement of this patient ..."

* The observation H&P dated 10/20/2022 reflected the physician's "Assessment and Plan" to include "Failure to thrive in adult ... admit to observation, discharge planning. PT, OT eval."
* Physician notes dated 10/21/2022 reflected "Moderate agitation ... Nursing reports that [Patient 18] refuses care and medications from time to time. Physical therapy reports that [the patient] was able to transfer safely but refuses to use walker ... Reluctantly working with staff. Difficult social situation as patient left AGAINST MEDICAL ADVICE from rehab center and is living in a motel but unable to care for [themselves] including getting back and forth from the bathroom."
* Physician notes dated 10/22/2022 reflected "Behavior bit better today. Not refusing [their] many medications and treatments ... We will continue [patient] as observation with goal of returning back to motel under self-care."
* Physician notes dated 10/23/2022 reflected "Making slow and steady improvement as anticipated. Tolerating Bactrim for UTI ... Behavior is generally improved ... Doing well in supported system here in the hospital. We will have discharge planning and Adult Protective Services continue to work with [them] to see if [they] would ever consent and find a bed at an assisted living care facility or foster home type setting."
* Physician notes dated 10/24/2022 reflected "... pain from [patient's] back seems to be persistent and moderate to severe. [They give] history of all fall [sic] in [their] motel room. Concerned that [the patient] may have a fracture. Will obtain CT scan of lumbar spine and make further determinations pending results ... Patient continues to be bedbound. Has difficulties with transfers and ambulation. Physical therapy and Occupational Therapy should work with patient again today. We will see if [they have] any more rehab potential since [they have] been on antibiotics for urinary tract infection. Also improving mentation. Consider adjusting to inpatient."

* The inpatient admission H&P dated 10/24/2022 reflected the physician's "Assessment and Plan" to include "Failure to thrive in adult ... The patient was unable to care for [themselves] in the face of fall with worsening back pain and diarrhea. Per [SNF/NF] was fairly independent with a scooter, and would be most appropriate in assisted living facility. [Patient] is interested in caregivers. Currently [patient] resides in a hotel where ... cannot use toilet because [their] scooter will not fit into the bathroom. The plan is to improve [patient's] mobility to where [they are] again independent with [their] transfers. Will bring scooter from [hotel room]."
* Physician notes dated 10/25/2022 included "... Discharge planning pursuing assisted living placement ... Extensive imaging negative for any acute fractures ... Encourage mobilization, out of bed to scooter for all meals. Placement pending."
* Physician notes dated 10/26/2022 reflected "Patient is frustrated with [their] living situation. [SNF/NF] believes [patient] needs assisted living facility. The patient tried living independently but learned a [hard way] that [they need] assist.[sic] [They are] agreeable to go to assisted living facility. [They are] tired of being in the hospital. [They were] not allowed to go out and smoke which is somewhat frustrating to [them]. [Patient] does not want nicotine patch."
* Physician notes dated 10/27/2022 reflected "[Patient] was slow to improve with [their] pain and mobility ... was started on antidepressants/ antianxiety medications with risperidone and Effexor and subsequent labs showed significant hyponatremia 124. Sodium level quickly improved with gentle IV fluids and free water restriction. The new psych meds felt to contribute and were discontinued. [Patient] is now transferring independently out of bed to [their] scooter ... Patient however is not very happy ... is grumpy and frustrated about [their] situation ... awaiting placement to a assisted living facility. No other new complaints."

* The physician Discharge Summary dated 10/28/2022 reflected "Plan: The patient is awaiting for assisted living facility placement. [They] will have to follow-up with [their] [APD CM]. In the meantime ... is being discharged to gospel mission [shelter]. Hospital Course: This is 80-year-old [patient] with extensive past medical history, prior long-term resident of [SNF/NF] until about 3 weeks ago when [they] decided to try living independently and moved to a hotel. [They] left [SNF/NF] without adequate support/assist, and moved into a hotel room with no access to a toilet on [their] scooter ... was admitted with acute on chronic low back pain, after reported fall complaining of diarrhea and severe skin rash/burn in perineal area ... was given gentle IV fluids and extra painkillers ... was slow to improve with [their] pain and mobility ... was started on antidepressants/antianxiety medications with risperidone and Effexor and subsequent labs showed significant hyponatremia at 124. Sodium level quickly improved with gentle IV fluids and free water restriction. The new psych medications felt to contribute and were discontinued. The past couple of days the patient is doing well ... eating very well ... able to independently transfer to [their] scooter ... has been a bit upset-feels like a prisoner because ... is not allowed to go outside to smoke ... appears at [their] functional baseline. [SNF/NF] recommended assisted living facility. Referrals were sent but there is no immediate opening. Patient has no further indications to justify hospital stay ... was given couple of options with local hotels, but with limited budget ... chose to go to the [shelter]. This is suboptimal situation, and the patient is at high risk for readmission ... will need a close follow-up from [their APD CM] as an outpatient for ongoing assistance with placement. I asked our discharge planner to alert them about the discharge. [Patient] is mentating well, and appears to be able to make [their] own decisions. [They] will be discharged with all necessary medications. Follow-up appointment is arranged with [their] PCP in about 2 weeks."

2.c. The hospital's DP notes and documentation included the following:
* On 10/20/2022 at 1545 the DP documented that "Patient presented to ER. It is reported that [they] recently checked [themselves] out of [SNF/NF] a few weeks ago. Called [SNF/NF] and confirmed, the declined accepting [them] back. Call to Roseburg APD ... It was requested that I call back and speak with [APD CM]. [They report] that they are aware and that there is a plan in place, [APD CM] will give further details."

* On 10/20/2022 at 1553 the DP documented that "Call to [APD CM], left voicemail requesting return call and if unable to reach this RN to call ER and speak with nursing. Will provide nursing a report."

* On 10/21/2022 at 1008 the DP documented that "Call to [APD CM] with the Roseburg office who is interim until a permanent CM is hired and assigned for the local area. If the Roseburg office is called, you will be directed to the CM of the day, so [they recommended] calling [the] direct line ... [They reported] that patient left AMA from [SNF/NF] on 10/8/22 and paid for 1 month at motel. [Out of area family member] is [patient's] financial rep and manages [their] Income Cap Trust, it is reported [they make] a significant amount of income. [Family member] has an ill spouse and is unable/willing to assume any further responsibilities and if the case closes will remove [themselves] from providing further assistance. [APD CM] was having difficulty making contact, [they] reached out to the [family member] to encourage patient to talk .... regarding care. [Their] initial contact was on 10/10/22 and reports during this exchange [they] "sounded reasonable", refused care giving, refused placement and further services so a form was mailed for [them] to sign to close the case. Initial contact to APS documented on 10/14 and again on 10/19. [APD CM] called [family member] and requested [them] to encourage patient to allow for a visit on 10/20 to discuss care option. [APD CM] reports that [they] and a trainee arrived at the motel at approximately 12:07. [They were] yelled at for waking [the patient] up ... reports that [they] opened the door, [patient] was dressed and In [their] chair, opened the door and wheeled [themselves] by with a cigarette to the smoking section. [Patient] reported that [they] had not yet signed the form closing the case [and] reported being "angry" with [SNF/NF]. [They] reported intention to continue to stay at the motel but the worker reported to [them] that motel will not be allowing [them] to extend [their] stay. At this point [they were] agreeable to go back to [SNF/NF]. At the time of my call yesterday [they] had not had a chance to reach out to [SNF/NF] about the possibility, updated [them] that they decline to accept [them] back. [APD CM] reports patient refuses to move out of the area although [they don't] have any family or natural supports in the area with [their] only tie being [their] PCP. [APD CM] offers to call Timber Town in Sutherlin to inquire about availability; although reports last week they did not have any and is not certain [patient] meets all specifications for this facility. [APD CM] reports that [patient] is 'probably not completely cognitively intact'. [They] will discuss this case with APS and discuss consideration for public guardianship but is unsure if there is enough to support a case for this ... reports plan to request case aides to start making calls to facilities regarding availability and requests and to be notified of discharge."

* On 10/25/2022 at 1129 the DP documented that "Met with patient who is alert and oriented x's 3 ... is pleasant and cooperative ... reports leaving [SNF/NF] and moving to Fir Groove so [they can] do [their] own cooking ... was placed in a room at Fir Groove that had a microwave, hot plate and air fryer ... reports that [they were] 'doing fine' until [they] sustained a fall out of ... wheel chair which led to an ER visit and discharged back to the motel according to [their] report. [Patient] reports then having incontinence of loose stool which [they] could not independently manage and ... was unable to access the bathroom in [their] room. [Patient] reports prior to the incontinence, [they were] utilizing the restroom of the restaurant across the street daily for BM's and then urinals in [their] room. It is reported that the Motel is unwilling to allow [patient] to return, patient reports that [they are] aware. When asked [their] plan for discharge, [they state] 'I want to leave, gather [my] things and figure out my next steps'. Instructed on discharge placement options available with [their] LTC Medicaid benefit. [They are] willing to consider ALF's, plan to call regarding availability. [They report] being told that Budget Inn by Safeway has kitchenettes and is ADA accessible, but has not called to verify. Discussed options to retrieving [their] power chair, [patient] suggests dial a ride, will call today. [Patient] instructs ... will need [their] cell phone charger and ... TENS unit controller. [Motel manager] from Fir Groove Motel calls regarding what to do with [patient's] belongings. Asked [motel manager] what do they typically do with residents belongings, [who] reports they store them for up to 90 days. Instructed that [patient] is in need of [their] charger, TENS controller and power chair. [Motel manager] goes into room and is able to locate phone charger and TENS controller, this RN agrees to retrieve these items on behalf of the patient from the front desk. Upon arrival to the Fir Groove front desk, items are placed into a clear plastic bag. [Motel manager] includes a sealed envelope with patient refund which [they have] labeled with refund amount of $150.00 ... Upon return, notified [first name] RN. We brought contents of the bag to the patient room, cell phone charger, TENS controller and signed sealed envelope ... Items will be placed in the safe for keeping until discharge. Call placed to [APD CM] and left voicemail requesting a call back. Patient has had multiple staff visitors from [SNF/NF], it may be worth discussing barriers to readmission and to see if they are willing to reconsider."

* On 10/25/2022 at 1325 the DP documented that "Assisted patient in calling Mast Bros. to arrange for electric wheel chair to be brought to LUH. Patient self paid for this service. Call to [motel manager] and notified [them], [they] will have chair ready for pickup in addition to charging cord. Notified nursing, security and registration department."

* On 10/25/2022 at 1356 the DP documented that "Call from [APD CM]. [They report] having reached out to the following facilities and left voicemails and awaiting responses: Regency, Life Care, Avamere CB. Avamere New Port does not have beds available. Instructed that patient would be appropriate for an ALF. [They report] leaving a voice mail with Ocean Ridge. This RN left voice mail at the following ALF Bay Side Terrace. Inland Point does not have any Medicaid rooms available. Pacific View in Bandon does not have rooms today but will have later this week and is willing to review packet."

* On 10/25/2022 at 1452 the DP documented that "Faxed referral to Pacific View for review."

* On 10/26/2022 at 0946 the DP documented that "Call to Budget Inn x 3, no answer. Call to City Center Motel, no answer."

* On 10/26/2022 at 1232 the DP documented that "Nursing notifies this RN that there is a [person] who reports [they have] collected patient's items from the motel and is inquiring what [they] should do with them ... Inquired regarding the amount of items, [they report] fills up the back of [the] van. Instructed [them] that I spoke with the motel yesterday, and that they reported they were required to hold on to the belongings for 90 days ... we are unable to store all [the patient's] belongings and that other arrangements will need to be made ... met with [first name] Quality and Safety RN and provided report ... to patient room so they may work on a plan. Patient requests to speak with [MD] who allows patient to go out to van to retrieve personal items. This RN accompanies patient and ensures the amount and appropriateness of items selected."

* On 10/26/2022 at 1528 the DP documented that "Voice mail left for Pacific View ALF admissions."

* On 10/27/2022 at 1214 the DP documented that they
"Called the following facilities:
Shore wood senior living - this is independent living and do not accept Medicaid
Spruce Point- No Medicaid rooms available
Inland Point- No Medicaid rooms available
Bayside Terrace - Referral faxed ...
Ocean Ridge - Referral secured email marketing@oceanridgeseniorliving.com
Pacific View - declined
Budget Inn called and the bathrooms are not ADA accessible ..."

* On 10/27/2022 at 1818 the DP documented that "Bayside Terrace called and declined due to level of care."

* On 10/28/2022 at 0946 the DP documented that "Updated clinicals faxed to Bayside Terrace. Call to Timber Ridge Independent Living Apartments and left a voicemail with inquiry on availability. Call to Ocean Ridge and left message requesting a return call."

* On 10/28/2022 at 1241 the DP documented that "Met with patient who is alert and oriented. Discussed discharge today. Provided options of Gospel Mission or Motel. Instructed that a bed at the Mission is not guaranteed, [they have] to arrive by 4 and complete an assessment. Provided information that regarding [their] transportation benefit through [their] OHP, will give [them] a brochure. [Patient] requests contact information for [their] state case manager, will provide [their] name and phone #. Call to the Mission, they request [they] call them directly, will provide [them] the phone # for [them] to call."

* On 10/28/2022 at 1305 the DP documented that "Handed off the following patient information to [their] discharging primary RN: brochure Ridesource brochure, copy of [their] trillium card, list of Reedsport/Coos Bay/[North Bend] hotels, Resource guide and [their] APD CM contact information. Went to follow up with patient if [they] called the Mission, currently [they are] on the phone with Roseburg DHS office."

* On 10/28/2022 at 1420 the DP documented that "Call from ... Roseburg APD. Provided report and anticipated discharge today with disposition pending patient's decision. [They report] a new [APD CM] has been assigned ... Will provide this contact to patient."

2.d. The patient signed their post hospital discharge instructions on 10/28/2022 at 1300.

3.a. On 11/04/2022 Patient 18 was brought to the ED by ambulance from a hotel/motel where they were living. On 11/05/2022 they were admitted as an inpatient. They had a primary diagnosis of "prostatic abcess" and were discharged to a hotel/motel on 11/10/2022.

3.b. Physician notes included:
* The ED note dated 11/04/2024 reflected the patient presented with a primary complaints of constipation and anal "burning." The physician wrote that the patient "resides at hotel and has been kicked out not welcome to come back, [they have] a motorized scooter apparently it is [only hotel] that will accomodate ... [they] will have to go someplace else such as Coos Bay or Eugene to find a hotel that will accept a scooter ... patient is awake alert conversant moves all extremities [they are] wheelchair-bound no acute gross focal deficits ... somewhat 'grumpy' which is the reason [they were] expelled from a hotel. But is independent and does attend to ][their] daily needs independently ... no acute psychiatric process identified."

* The inpatient H&P dated 11/05/2022 reflected "... homeless [person] who is wheelchair dependent and chronically incontinent of urine and stool for many years (unknown reasons per pt report). [They have] most recently been living at the Best Western Hotel but ... reports that [they were] 'kicked out' but cannot say why [they were] asked to leave ... reports that [they have] 'plenty of money' and has been paying [their] bill ... states that [they are] not welcome at the [shelter] due to being incontinent ... presented to the ED with c/o rectal and lower abdominal pain ... was found to be constipated and was manually disimpacted and given enemas which resulted in stool evacuation but ... continued to have pain and discomfort in the rectal area ... also c/o chills and subjective fever prior to admission ... underwent a CT abdomen/ pelvis and was found to have a prostatic abscess of 3 x 2.3cm ... has been admitted for antibiotic coverage. Pt reports [they haven't] been hungry for about one day ... denies n/v ... refused to eat here today ... has had a subjective fever and pain when trying to have a BM ... denies dysuria or hematuria ... denies flank pain. Denies soa or cough over baseline ... does have chronic DOE and cough productive of gray sputum ... is a smoker x many years and currently smokes about 10 cigarettes daily ... has a hx of heavy alcohol abuse and reports [they] still [drink] 'when I can get it' ... is not forthright when [their] last drink was. Denies any problems with alcohol withdrawal syndrome, shakiness or seizures. Denies any use of illicit drugs. Denies headaches, sore throat, change in vision. Denies chest pain or pleurisy. Pt is somewhat irritable and has a hostile attitude ... reports 'I've answered all of these questions before, I'm hurting and need some pain medicine' ... Will ask discharge planning to see [patient] to help with disposition when [they recover]."

* Physician notes dated 11/07/2022 reflected that "Patient reports that [they] 'hurts all over' ... is asking for [their] norco to be increased to 10mg q 4hrs ... reports that [they have] had significant back pain plus incontinence for many years following a lumbar fusion surgery ... wants to go live at [SNF/NF] again but they refuse to take [patient] due to ... alcoholism and combative behavior ... has been staying at the local Best Western but now ... reports if [they return] there [hotel] will have [them] arrested for trespassing [because they were] yelling at the housekeeping staff for not helping [them] clean up after [they] had some incontinence. No n/v. No f/c. Reports soa and cough are at baseline. Denies chest pain or pleurisy. Denies dysuria or hematuria. PT has been consulted but they have not yet seen [them] today ... Pt appears to be doing well ... does not appear septic and is afebrile here ... leukocytosis has improved ... is tolerating po and is taking oral cipro. I am concerned about [their] compliance if [they discharge] ... apparently is homeless and there is no good option at this point for long term care or an assisted living situation ... apparently is abusive and none of the local facilities will take [them]. I placed a call to [MD] in Medford--[their]facilities are short staffed and cannot take [patient]. Also placed a call to [another MD] who is medical director of several long term care facilities--await a call back. Will reach out to [their] APS social worker to see if there are any further options

* Physician notes dated 11/08/2022 reflected that "Patient is scooter dependent at baseline ... is at [their] baseline level of functioning per PT report ... is being considered for placement at two facilities in Medford ... reports [they are] willing to move there for long term care in assisted living."

* Physician notes dated 11/09/2022 reflected that "Patient reports that [they are] feeling well today ... abdominal pain resolved after [they] had a large BM ... ate well today. Reports [they plan] to go live in a hotel again tomorrow [because] none of the assisted livings in the area will take [them]."

* The physician Discharge Summary dated 11/10/2022 reflected
80 year old homeless [patient] who is scooter dependent and chronically incontinent of urine and stool for many years due to a previous lumbar injury and surgery. [Patient] has chronic back pain and has a spinal stimulator in place. [They] also [have] a history of heavy alcohol abuse and has been belligerent and abusive to others which has caused [them] to be unable to be admitted to any of the local care facilities ([they] did live at [SNF/NF] previuosly [sic] but is unable to be readmitted there due to [their] verbal abuse of staff members) ... presented back to the ED c/o of rectal pain. [Patient] was found to be constipated and was disimpacted but continued to have ongoing pain and CT scan revealed a prostatic abscess. The pt was admitted for ongoing management. The pt was initially started on iv antibiotics. [Patient] did well without signs of sepsis or severe infection ... was able to be transitioned to po antibiotics ... was eating and transferring to [their] scooter at [their] baseline. [DP] did attempt to help [them] secure a new living situation but due to [their] previous abusive behavior, this was unable to be accomplished. [Patient] was discharged in good condition and the [DP] helped [them] secure transport to a hotel in Coos Bay. [Patient] is asked to f/u with [their] PCP within 1-2 weeks and [their] antibiotics were electronically sent to the pharmacy downstairs at LUH to enable [them] to easily pick them up.

3.c. Discharge Planner notes included:

* On 11/08/2022 at 0948 the DP documented "Call to Roseburg VA, spoke with [staff] in eligibility who reports patient is not located in the system which looks nationally. Voicemail left for [APD CM] requesting a return call."

* On 11/08/2022 at 1249 the DP documented:
"Referrals sent:
Bayside Terrace [Phone and Fax numbers]
New Friends ALF [Phone and Fax numbers]
Ridge View/Medford [Phone and Fax numbers]
Laurel Pines [Phone and Fax numbers]
Patient is agreeable to any ALF."

* On 11/09/2022 at 0950 the DP documented "Call from New Friends Florence, unable to accept."

* On 11/09/2022 at 1230 the DP documented "Voice mail left for [APD CM] x's 2. Call to Laurel Pines ALF, no answer or ability to leave a VM x's 4. Call to Ridgeview ALF and spoke with [staff]. [They report] plan to reach out to [staff] in admission for decision and someone will call this RN back. Bayside Terrace called and they currently do not have any Medicaid availability. Met with patient to discuss ... plan and update on status of referrals to ALF. [Patient] is interested in going to [North Bend/Coos Bay] to seek a hotel, provided [them] a list of hotels for the area. [Patient] inquires regarding transportation; instructed that ... Ridesource provided information that if patient is being transported from Reedsport to another city they could arrange wheel chair [sic] transportation. [Patient] inquires if that benefit will work for [their] upcoming MD appointment, call to Ridesource and confirmed that service from out of the area to Reedsport will be covered. Call to Ridgeview ALF, left message. Another call to Laurel Pines left message requesting a return call."

* On 11/09/2022 at 1641 the DP documented "Contacted Lone Oak ALF, they currently do not have Medicaid availability."

* On 11/10/2022 at 1535 the DP documented "Met with patient who is alert and oriented. [Patient] has secured a room at the City Center Motel. Transportation arranged through Ridesource for pickup at 1pm. Transportation for [their] DFHC f/u appt on Monday arranged with Ridesource for 8:30-9am pickup at the motel. They will provide return transportation. In large print typed out Monday's ride information to include p/u time and the phone # [they] can call Sunday to confirm. Notified patient, provided typed ride info and scanned copy into chart. Printed off VA eligibility application and form to request discharge paperwork. Called the phone # on the application that indicates they provide support if the veteran requires assistance for inquiry. There is not a physical location to go for assistance. They can assist over the phone. [They] recommended the patient reach out to any veteran service organization with inquiry if they provide support. Partially filled out the application. Assessed if patient would like to complete the application with my assistance, [patient] declined ... reports plan to come and see me on Monday. Provided a handout for VA Homeless support. Spoke with [APD CM] and provided update on plan. [They report] that [they have] reached out to 25 facilities and no acceptance. [APD CM] reports that the case has been escalated to the complex care coordinator. APD will continue to seek placement opportunities."

* After the patient's discharge, on 12/02/2022 at 1607 the DP wrote that "Spoke with [Person's name] with Senior Service who reports making contact with the patient yesterday. [They were] able to provide the patient with [their] APD CM's contact information and was present while [patient] called [them]. [They] reviewed the APD notes and they indicate that [patient] was still residing at the City Center Hotel until at least 11/16/22. [They report] that [patient] states [they] left because [they] 'hated that place.' [Person with Senior Service] reports plan on making an APS report. [Person with Senior Service] went to follow up with the patient today at approximately 2pm in front of Safeway where [patient] was sleeping. [They] inquired if [they were] ready to 'look at somewhere to go to get out of the weather'? [Patient's] response was telling [them] to 'leave [me] alone and to go away!'"

4. Review of the one and one-half page "Discharge Planning" P&P in effect in 2022 revealed that it was generic and broad in nature. It primarily referenced "planning for the home care environment." It lacked reference to evaluation of what the patients' post-hospitalization location might be, including what "home care environment" might mean for a houseless individual or someone with no permanent residence. It lacked lacked reference to evaluation of patient's financial resources and governmental/insurance benefits and supports. It lacked reference to coordination of efforts with governmental/insurance agencies/companies. It lacked reference to evaluation of patients' needs for services of both skilled and non-skilled post-hospitalization providers and community organiziations and agencies. The only post-hospital service it referenced was for medical equipement. It lacked reference to management of complex and complicated discharge plannning situations.

5. During interview with staff that included the DQRM, NM and DP on 07/01/2024 beginning at 1400 at the time of the review of Patient 18's medical record, they stated that the DP at the time of Patient 18's hospitalizations was no longer employed with LUH, and that DP assessments were not complete.

Based on interview and review of medical record documentation for 2 of 2 SB patients reviewed for SB patient's rights (Patients 12 and 15) it was determined that the hospital failed to inform SB patients of their additional SB rights delineated above in this CFR 485.645(d)(1).

Findings include:

1. Review of the medical record for Patient 12 reflected they were admitted for SB services on 02/16/2024 and discharged to home on 03/13/2024. There was no documentation to reflect they had been informed by any method or in any form of their additional rights as a SB patient. During interview with SB staff at the time of the record review on 06/26/2024 beginning at 1238 they confirmed there was no documentation to reflect that Patient 12 had received information about their SB rights.

2. Review of the medical record for Patient 15 reflected they were admitted for SB services on 03/11/2024 and transferred to inpatient status on 03/19/2024. There was no documentation to reflect they had been informed by any method or in any form of their additional rights as a SB patient. During interview with SB staff at the time of the record review on 06/26/2024 beginning at 1422 they confirmed there was no documentation to reflect that Patient 15 had received information about their SB rights.

Based on interview and review of medical record documentation for 2 of 2 SB patients reviewed for SB patient's rights (Patients 12 and 15) it was determined that the hospital failed to inform SB patients of their additional SB rights related to admission, transfer and discharge delineated above in this CFR 485.645(d)(2).

Findings include:

1. Review of the medical record for Patient 12 reflected they were admitted for SB services on 02/16/2024 and discharged to home on 03/13/2024. There was no documentation to reflect they had been informed by any method or in any form of their additional rights as a SB patient. During interview with SB staff at the time of the record review on 06/26/2024 beginning at 1238 they confirmed there was no documentation to reflect that Patient 12 had received information about their SB rights.

2. Review of the medical record for Patient 15 reflected they were admitted for SB services on 03/11/2024 and transferred to inpatient status on 03/19/2024. There was no documentation to reflect they had been informed by any method or in any form of their additional rights as a SB patient. During interview with SB staff at the time of the record review on 06/26/2024 beginning at 1422 they confirmed there was no documentation to reflect that Patient 15 had received information about their SB rights.


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Based on interview and review of medical record documentation for 2 of 2 SB patients reviewed for SB patient's rights (Patients 12 and 15) it was determined that the hospital failed to inform SB patients of their additional SB rights related to freedom from abuse, neglect and exploitation delineated above in this CFR 485.645(d)(3).

Findings include:

1. Review of the medical record for Patient 12 reflected they were admitted for SB services on 02/16/2024 and discharged to home on 03/13/2024. There was no documentation to reflect they had been informed by any method or in any form of their additional rights as a SB patient. During interview with SB staff at the time of the record review on 06/26/2024 beginning at 1238 they confirmed there was no documentation to reflect that Patient 12 had received information about their SB rights.

2. Review of the medical record for Patient 15 reflected they were admitted for SB services on 03/11/2024 and transferred to inpatient status on 03/19/2024. There was no documentation to reflect they had been informed by any method or in any form of their additional rights as a SB patient. During interview with SB staff at the time of the record review on 06/26/2024 beginning at 1422 they confirmed there was no documentation to reflect that Patient 15 had received information about their SB rights.


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