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Based on interview, and record review, the facility failed to ensure that its State license included all services offered by the hospital, as required by state regulations, when the license did not include Outpatient Surgical Services.

This failure had the potential to result in patients being unaware of all available services being provided at this hospital.


Findings:


During a review, of the hospital's current State license, it was noted that it did not include Outpatient Surgical Services, as an approved service.

During an interview, on 10/16/23 at 11 am, the Chief Nursing Officer (CNO) confirmed, that the hospital did indeed provide some outpatient surgical procedures. She was asked about their License, since it did not list outpatient surgical services, as an approved service. The CNO said they had renewed their License, in the same manner as they always do every year. The CNO said, that she had thought surgical services was included in their License, and was a requirement so it wouldn't need to be included separately.

On 10/17/23, the CNO provided past Licenses since 2017, that were identical to the current one that did not include Outpatient Surgical Services.

California Title 22, 70041 was reviewed, and it indicated that License means the basic document issued by the Department permitting the operation of a hospital. This document constitutes the authority to receive patients and to perform the services included within the scope of these regulations, and as specified on the hospital license.

Based on observation, interview, and record review, the facility failed to ensure that patient-care equipment in their clinics were inspected, and maintained in safe operating condition when:

1. The otoscopes (a medical instrument used to evaluate symptoms of the ear and ear drum), ophthalmoscopes (a medical instrument used to evaluate symptoms of the eye), ophthalmoscope chargers, and ophthalmoscope transducers (an electronic unit that provides power to the ophthalmoscopes) located in the walk-in medical clinic's exam rooms did not have the required annual inspections to test them for performance or safety.

2. A centrifuge (a device that separates blood cells to process specific laboratory tests), microscope, thermometer, X-ray box (a wall-mounted, lighted screen used to view X-rays or other medical images), and infant scale located in the family practice clinic did not have the required annual inspections to test them for performance or safety.

These failures had the potential to compromise the accuracy of patient assessments (the medical provider's evaluation of a patient's health) and patient safety, creating a risk of increased patient illness or injury which could lead to negative clinical outcomes.


Findings:

1. During a concurrent observation, and interview, on 10/18/23, at 8:30 am, with Licensed Vocational Nurse (LVN) 1. it was stated, that the Director of Plant Operations/Safety (DPOS) was responsible for managing the annual inspections of the clinic's medical equipment, and ensuring that inspections were conducted prior to the annual due dates. LVN 1 reported that the DPOS placed either an orange Inspection Sticker, or a blue Tested Sticker, on all medical equipment that passed the annual safety and performance inspections. The stickers were marked with the equipment's most recent date of inspection, indicating that the next annual inspection was due 12-months from the sticker date. LVN 1 verified that the four exam rooms in the facility's walk-in clinic had the following medical equipment overdue for annual safety and calibration (a test that ensures medical equipment is providing accurate results) inspections while still being available for patient use: four ophthalmoscopes overdue on 9/02/23, four otoscopes overdue on 9/02/23, four ophthalmoscope chargers overdue on 9/02/23, and one ophthalmoscope transformer overdue for electrical inspection on 8/22/23.

2. During a concurrent observation, and interview, on 10/18/23 at 9:30 am, LVN 2 reported she was appointed as the facility's clinic manager on 6/01/23, and was responsible for the oversight of all facility clinics. LVN 2 confirmed that the DPOS was responsible for the clinic's annual medical equipment safety and performance inspections. LVN 2 had not yet developed a communication process to inform the DPOS of medical equipment that had inspection stickers with upcoming due dates. LVN 2 stated, that she relied on the DPOS to track upcoming equipment due dates, or make rounds in the clinic buildings to check inspection stickers. LVN 2 verified that the facility's family clinic had the following medical equipment overdue for annual safety and calibration inspections while still being available for patient use: an x-ray view box over due on 8/22/23, an infant scale overdue on 8/22/23, a microscope overdue on 8/22/23, a centrifuge overdue on 8/22/23, and a thermometer overdue on 8/22/23.

During a concurrent observation, interview, and record review, on 10/18/23 at 11:15 am, the DPOS confirmed, that she was responsible for tracking the inspection due dates for the clinic's medical equipment and performing the annual safety inspections and calibration testing on all low-risk medical equipment (medical equipment not used for emergency services). DPOS used the facility's Clinic Inventory Spreadsheet as a tracking tool to ensure that all medical equipment was inspected by the listed due dates. DPOS confirmed, that the medical equipment verified with LVN 1 and LVN 2 were overdue for their annual safety and calibration inspections while still being available for patient use. The DPOS stated, that "she was spread real thin," and her increased workload made it difficult for her to access the clinic buildings to perform the low-risk medical equipment inspections by the due dates.

During an interview, on 10/18/23 at 2:39 pm, with the Chief Nursing Officer (CNO), she stated, that the DPOS was responsible for ensuring that all facility equipment was inspected and calibrated annually by the equipment due dates. The CNO reported she was not aware that medical equipment in the facility clinics were overdue for routine safety and performance inspections, and that she would work with the DPOS to resolve the issue immediately.

A review, of the facility's policy titled, "Equipment Management Program,", revised 1/15/07, indicated that all medical, diagnostic, therapeutic and other patient care equipment will be tested at least annually, and more frequently as necessary based upon rules or regulations and/or manufacturer's recommendations. An updated inventory of all equipment shall be maintained at all times.

A review, of the facility's document titled, "Clinic Inventory," dated 9/18/23, indicated that all equipment requiring annual routine safety and performance inspections were to be compiled on a spreadsheet that included the device description, the device manufacturer, and the last date the device was inspected.

Based on interview, and record review, the facility failed to ensure that its Emergency Department (ED) policies relating to triage, and reassessment were implemented, for two of eight ED patients (Patients 15 and 16).

This failure had the potential to result in ineffective patient care and a potential decline in their condition, which could lead to negative clinical outcomes.


Findings:


The facility's policy tilted, "Triage Upon Patient Presentation To The Emergency Room," revised 8/27/20, was reviewed, and indicated that upon patient presentation to the ED, the registration clerk: 1. Asks the patient the reason for the visit. 2. Notifies the licensed nurse of the chief complaint. 3. Keeps the patient informed of the anticipated time to be seen. The licensed nurse: 1. Obtains a brief history of the patient. 2. Documents triage time and chief complaint. 3. Determines the appropriate order that the patients are to be seen. 4. Admits the patients to the ED according to policy. 5. Patients that are awaiting treatment in the ED will be assessed every 60-minutes by a licensed nurse.

The facility's policy titled, "Standards of Practice For Nursing: Emergency Department (ED)," revised 8/27/20, was reviewed, and indicated that the patient is evaluated according to Triage Categories Emergency Severity Index (ESI). This list is not all inclusive: a. Immediate (Level 1 or Emergent Red) immediate care, life-threatening conditions: acute chest pain, respiratory distress. Observation (Level 2 Yellow) - major injury or illness but stable; treatment and reassessment should occur within five to fifteen minutes: active labor, drug overdose, suicidal behavior. Urgent (Level 3 Green)- treatment and reassessment should occur in 15-45 minutes: abdominal pain. Dismiss (Level 4 Blue) - treatment and reassessment should occur in one to two hours: minor bites, minor burn.

1. A review, of Patient 15's record indicated, that she had presented to the ED on 7/3/23 at 1:19 pm, with a complaint of multiple insect bites to her arms and legs. The physician's note indicated no exam was done because the patient left without being seen. The time she left without being seen was documented as 4:30 pm. No triage note, or vital signs were found in the record.

During a concurrent interview, and record review, on 10/17/23 at 11:27 am, the Emergency Department Manager (EDM) confirmed, that Patient 15 arrived at 1:19 pm, and was noted to have left the ED, without being seen at 4:30 pm. The EDM stated, that there was no triage note or vital signs (blood pressure, temperature, pulse, respirations) because he did not get out to see her but the physician's note indicated the patient had multiple insect bites. He said they were very busy that day, and after a review of the ED log, said there were about seven to eight patients in the ED waiting room, and their two ED beds were full, at the same time this patient was there. EDM said with some of the patients he did a quick assessment in triage area then the patients went back to the ED waiting room, but he was unable to recall seeing this patient, and did not make any note or take vital signs. He said he was the only nurse assigned to work the ED on that day, and worked with one ED Tech (unlicensed staff similar, to a nursing assistant). He said around the 4th of July, was usually a busy time for the facility and the population of the town explodes with tourists. EDM was asked to check the schedule for the inpatient unit for that shift. He did so, and said there were two nurses working that day but he did not know how many patients were in the hospital at that time.

On 10/17/23 at 12:20 pm, the Chief Nursing Officer (CNO) was asked and provided a copy of the inpatient census on 7/3/23, which was zero.

2. A review, of Patient 16's record indicated, that he had presented to the ED on 9/14/23 at 1:23 pm, with depression and suicidal ideations. His triage acuity was a Level 3 - Urgent. There was a nurses note, which indicated that the county mental health had arranged for an appointment the following day, and did not feel the patient needed to be placed on an involuntary hold. Patient 16 was discharged home with his father at 5:02 pm, (approximately three and one half hours after arrival).

During a concurrent interview, and record review, on 10/17/23 at 10:50 am, EDM confirmed the above information. He said vital signs had been done upon arrival, and had not been repeated during the time Patient 16 remained in the ED. He agreed there should have been a repeat set vital signs prior to Patient 16's discharge.

Based on interview, and record review, the facility failed to ensure all policies were reviewed at least biennially (every two years).

This failure had the potential for facility staff to follow policies that did not reflect the most current standard of practice, thereby compromising patient care, health and safety which could lead to negative clinical outcomes.


Findings:


A review, of some of the facility's policies from the Emergency Medicine Department did not include the last date of review, and indicated that the date of origin, or last revision date was more than two years past.

On 10/18/23 at 11 am, the Health Information Management Director (HIMD) was requested to provide evidence of the last review date for all of the facility's patient care policies.

On 10/18/23 at 4 pm, HIMD provided the most recent review dates for all facility's policies in the various departments, as listed below. This included a full review by the department as well as the medical staff and governing board.

The Dietary Department policy's had last been reviewed on 5/14/19.

The Emergency Medicine Department policy's had last been reviewed on 9/22/16.

The Imaging Department policy's had last been reviewed on 12/18/19.

The Infection Control policy's had last been reviewed on 11/17/16.

The Nursing Department policy's had last been reviewed on 7/26/18.

The Pharmacy Department policy's had last been reviewed on 12/16/16.

The Surgical Services Department policy's had last been reviewed on 12/18/20.

The Critical Access Hospital policy's had last been reviewed on 1/26/17.

The Anesthesia and Post Anesthesia Care Unit policy's had last been reviewed on 2/12/14.

The Respiratory Care policy's had last been reviewed on 7/27/22.

The HIMD stated, that she was new to this position and now has a method to ensure that all policies are reviewed as required.

Based on observation, interview, and record review, the hospital exhibited deficiencies in maintaining a drug storage area that adheres to accepted professional standards of practice as evidence by:

1. Insufficient storage practices were identified concerning Rocuronium, and Succinylcholine (paralytic medications used during surgery), in the anesthesia cart, along with inadequacies in storing Lispro insulin (a medication to control blood sugar levels) without a specified beyond-use date. These lapses pose potential risks to patient safety, emphasizing the critical need for enhanced storage protocols to ensure the integrity and effectiveness of these medications.

2. The organization and stocking of the emergency crash cart exhibited discrepancies, deviating from approved hospital policies and procedures. This departure highlights the urgency of aligning with established protocols to ensure the cart's effective organization and stocking, thereby upholding the hospital's commitment to adherence to standardized practices.

3. Failure of nursing staff to consistently complete daily emergency crash cart checks, raising concerns about the hospital's commitment to emergency preparedness and response measures.

4. The hospital was found to be using an outdated 2011 version of the Broselow tape in their emergency crash cart, despite the most recent version being available from 2019. This older version of the Broselow tape may present accuracy issues, particularly when used for overweight and obese patients. Furthermore, the latest versions of the tape have introduced precalculated doses, a feature designed to minimize the risk of medication errors. Therefore, it is crucial for the hospital to update their equipment to ensure the most accurate and effective treatment possible.

5. The hospital did not have easy access readily available cold saline and insulin for a malignant hyperthermia emergency. Malignant hyperthermia (MH) is a potentially life-threatening reaction to certain medications used during general anesthesia. In an MH crisis, it's crucial to have immediate access to specific treatments such as cold saline and insulin.

6. The facility's medical clinics had 18 expired vaccine doses, and eight expired medications available for patient use.

7. The hospital had oral contrast (substance that patients swallow that causes the organ or tissue to be seen more clearly during x-rays), available for use, that had expired.

These failures pose potential risks to patient safety and emergency preparedness, which could lead to potential negative clinical outcomes.


Findings:


1. During an observation, on 10/16/23 at 4:44 pm, it was observed in the anesthesia cart contents revealed the presence of Rocuronium and Succinylcholine in the first drawer. These substances are integral in medical procedures, where Rocuronium is a muscle relaxant often used to facilitate intubation, and Succinylcholine is a medication employed to induce short-term paralysis, aiding in procedures such as surgery or certain diagnostic tests. Their presence in the anesthesia cart indicates their potential use in managing patients undergoing medical interventions.

A review, of the manufacturer's information indicated that both Rocuronium and Succinylcholine are recommended for storage under refrigeration. This underscores the importance of maintaining a controlled temperature environment to ensure the stability, and effectiveness of these medications as per the guidelines provided by the manufacturer.

During an interview, on 10/16/23 at 4:44 pm, Registered Nurse (RN) 1, functioning as the house supervisor, stated both Rocuronium and Succinylcholine have the flexibility to be stored without refrigeration for a period of up to 14 days. She candidly recognized the challenge in determining the exact length of time these medications were kept outside refrigeration, a problem exacerbated by the lack of a beyond-use date on the label. She further highlighted that a common practice in many hospitals is to label vials with dates, which offers a systematic method to identify when medications should be disposed of after being removed from refrigeration. This practice ensures the safety and effectiveness of the medications administered to patients.

A review, of the USP Chapter 797, which outlines guidelines for compounding sterile preparations in healthcare settings, commonly recommends a maximum 28-day beyond-use date (BUD) for multi-dose vials once they have been opened. This guidance, particularly applicable to low-risk level compounding, serves to maintain the sterility and stability of medications. The 28-day limit is a general standard, providing a reasonable timeframe for the use of the medication while minimizing the risk of microbial contamination.

During an observation, on 10/16/23 at 2:44 pm, in the medication room or front room refrigerator, a partially used multi dose vial of insulin Lispro was identified, lacking a beyond-use date. Insulin Lispro is a type of insulin, which is a hormone your body normally makes to control the level of sugar in your blood. People with diabetes either don't make enough insulin or can't use the insulin they do make effectively, so they sometimes need to take insulin as a medication.

During an interview, on 10/16/2023, at 2:44 pm, RN 1 found a half-used insulin vial in the fridge. She didn't know why it was used, or who used it. Also, the vial didn't have a date on it when it was first opened. The beyond-use date was unknown for the vial.

2. A review, of the hospital policy titled, "Crash Cart Checks," revision date 10/31/19, indicated that the purpose of this policy was to ensure that all equipment is available and usable when needed for emergencies.

During the observation, on 10/16/23 at 3:15 pm, of the medication room, discrepancies in the emergency crash cart were identified, raising concerns about adherence to hospital protocols and patient safety. Notably, the presence of Romazicon (a medication given to reverse sedation) 0.5 milligram/5 milliliter (mg/ml) vials in the emergency crash cart tray was noted, yet this medication was absent from the hospital's emergency medication crash cart policy.

Furthermore, the tray contained two Sodium Bicarbonate 50 mEq/10 ml syringes, whereas the policy specified only one. Conversely, the policy listed Dopamine 400 mg/10 ml, but none was found in the emergency crash cart.

During an interview, on 10/16/23 at 3:15 pm, RN 1 stated, that an assessment of all six emergency crash carts across the hospital revealed non-compliance with the established hospital policy. Recognizing the importance of aligning with protocols to ensure optimal patient care, RN 1 candidly acknowledged that improvements must be made. This acknowledgment underscores a commitment to addressing deficiencies in the stocking of emergency crash carts, reflecting a proactive approach to enhance the hospital's adherence to policy standards. It emphasizes the significance of ongoing monitoring, evaluation, and adjustments to uphold a consistent and high standard of emergency preparedness throughout the hospital.

3. A review, of the hospital policy titled, "Crash Cart Checks," with a revision date of 10/31/19, indicated that the responsibility assigned to day and night shift nurses to perform checks on the emergency crash carts. According to the policy, these checks involve ensuring the availability of all equipment and verifying the integrity of medications, with documentation on a provided checklist.

A review, of facility's Daily Crash Cart Checklist for the Emergency Room in October 2023, indicated discrepancies. On both October 5, and October 6, during the evening shift, there was no verification of the cart lock, and the defibrillator was overlooked.

A review, for September 2023, of the Daily Crash Cart Checks for the Emergency Room, indicated a lapse in the day shift's duties. On September 3, the day shift did not check the defibrillator, and on September 30, both the cart lock, and the defibrillator were neglected by the day shift.

A review, of the Emergency Department's Daily Crash Cart Checks in August 2023, indicated that the day shift failed to inspect the defibrillator, and the cart lock on August 28. These observations emphasize the need for a comprehensive review, and adherence to the hospital policy during daily crash cart checks, with a focus on reinforcing consistent practices for equipment verification and documentation to ensure patient safety.

During an interview, on 10/16/23 at 4 pm, the Emergency Department (ED) Manager stated, that the nurses had forgotten to check the defibrillator and cart lock periodically. He said this was an ongoing issue. The ED Manager conveyed that there has been a persistent challenge regarding the periodic checks of the defibrillator and cart lock by the nursing staff. This acknowledgment from the ED Manager sheds light on an ongoing issue within the hospital, emphasizing the need for corrective measures to address this recurrent lapse in adherence to established protocols.

4. During an observation, on 10/17/23 at 3:55 pm, in the Emergency Department, a 2011 version Broselow tape was found on the emergency crash cart. The Broselow tape is a color-coded length-based tape measure that is used throughout the world for pediatric emergencies. It relates a child's height as measured by the tape to their weight to provide medical instructions including medication dosages, the size of the equipment that should be used, and the level of energy when using a defibrillator. The Broselow tape is designed for children up to approximately 12 years of age who have a maximum weight of roughly 36 kilograms (kg) (79 pounds).

Compared to the 2019 version Broselow tape, the 2011 Broselow tape lacks certain critical features. One significant issue is its accuracy with overweight and obese patients. A study found that the tape underestimated the weights of these patients. Specifically, it misclassified overweight patients by one zone 83% of the time, while obese patients were misclassified by one zone 71% of the time and by two zones 23% of the time. This indicates a need for adjusting the length-based dosing zones for these patient groups. The new version also has had precalculated medication doses to reduce the risk of medication errors.

During an interview, on 10/17/23 at 3:55 pm, RN 1 expressed uncertainty as to why the hospital was still using the older version of the Broselow tape. She recognized that the newer version of the tape contains updated information. She also acknowledged the need for the hospital to update their Broselow tape to the latest version.

5. Malignant Hyperthermia (MH) is a potentially life-threatening reaction to certain medications used during general anesthesia. In the event of an MH crisis, it's crucial to have immediate access to specific treatments. The Malignant Hyperthermia Association of the United States (MHAUS) recommends certain immediate management strategies for MH. In the context of MH, insulin and cold saline serve specific purposes. Insulin, used in conjunction with dextrose, helps manage hyperkalemia, a condition characterized by an excessive amount of potassium in the blood. Insulin aids in driving potassium back into the cells, thereby reducing the level of potassium in the blood. Cold saline is used for cooling the patient's body. During an MH crisis, the body enters a hypermetabolic state, leading to a rapid and dangerous increase in body temperature. Cold saline can be administered intravenously to help reduce this temperature.

During an observation, on 10/17/23 at 11 am, in the Operating Room, an emergency cart for Malignant Hyperthermia (MH) was available. This cart was strategically placed for quick and easy access to emergency medications needed for MH. However, it was noted that the cart did not contain cold saline and insulin, two crucial components for managing an MH crisis. These essential items were located in a locked medication room at a medical-surgical area outside of the operating room. Further within this room, they were stored in a secured automated cabinet, also known as a medication dispensing machine. Access to this machine required the entry of a password, adding an additional layer of security before one could reach the emergency medication. This setup could potentially delay the response time in an emergency situation.

During an interview, on 10/17/23 at 11:15 am, RN 1 acknowledged the potential difficulties in accessing cold saline and insulin during an emergency. She recognized that the current setup could delay the response time in a Malignant Hyperthermia (MH) emergency situation. To address this, RN 1 mentioned that they plan to have an ice chest with cold saline, and insulin readily available during operating room procedures. This proactive measure could significantly improve the response time in case of an MH emergency.


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6. On 10/18/23 at 10:10 am, during a concurrent observation of the facility's clinic medication cabinets and medication refrigerator, and an interview, with the Clinic Manager/Licensed Vocational Nurse (LVN) 2, she stated that the facility's pharmacist was responsible for conducting monthly audits of all medications stored in the clinic's medication cabinets, and refrigerators. LVN 2 reported the clinic's Certified Nursing Assistants, and Medical Assistants also conducted monthly medication audits to ensure there were no missed expired medications that were available for patient use. LVN 2 reported the facility did not have a documentation process to ensure the CNAs, and MAs completed monthly medication audits.

LVN 2 verified the following medications, and vaccinations were expired, and available for use:

2 vials of 50 mg/1cc. Benadryl (a medication given to treat allergic reactions) injectables, Expired (EXP). 8/23.

3 Tetracaine HCL. sterile eye drop solutions. EXP 7/23.

1 Sterile water irrigation. EXP. 3/23.

1 box of 100 Povidine/iodine prep pads. EXP. 10/22.

1 box of Lubricating jelly, individual packages. EXP. 9/23.

5 DTap, (diptheria, tetanus, and pertussis vaccine)/Hepatitis B vaccine/IPV (Polio vaccine) combination doses. EXP. 10/05/23.

13 Prevnar (pneumococcal vaccine) doses. EXP. 9/23.



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7. During a concurrent observation, and interview, on 10/18/23 at 3:15 pm, the Radiology Tech (RadT) checked the cabinet where CT (imaging procedure that uses a combination of x-rays and computer technology to produce images inside the body) scan contrast (substance that causes the organ or tissue to be seen more clearly) was kept. There were two 450 milliliter bottles of contrast, "berry smoothie readi cat 2," available for use, with an expiration date of 6/2023. RadT confirmed this, and removed the bottles and said the bottles would be returned to the pharmacy.

Based in interview, and record review, the facility failed to implement policy and procedures to ensure the nutritional needs of inpatients were met in accordance with recognized dietary practices when:

1. There was not a system in place, including having a policy and procedure, to determine nutritional priority of admitted patients.

2. There was not a policy and procedure developed for nutrition assessments.

3. Menus did not meet the nutrient reference values (Dietary Reference Intakes) used by professionals working in the field of nutrition and health.

These failures to implement policies to ensure the nutritional needs of patients were met had the potential to result in worsening outcomes of patient prognosis.


Findings:


1. A review of the facility's policy titled, "Nursing Documentation," dated 7/30/20, indicated that upon admit the RN (Registered Nurse) must appropriately fill out the "Acute Care Nutrition Screening Form," to: 1. Determine nutritional priority of the patient. If the priority is a 1 or 2, the RN must email the dietitian; 2. Utilize email group "registered dietician," to notify the dietitian. For the 72 hour reassessment, on day 3 (72 hours) the RN must complete a reassessment of the patient. In addition, if the patient's priority has changed to a 1 or 2 from the initial priority, email a copy of the screening to the dietitian.

A review, of the medical record for Patient 23, indicated that she was 75 years old, admitted with uncontrolled diabetes with critically high blood sugars, and hyponatremia (lower than normal sodium in the bloodstream).

A review, of the "Acute Care Nutrition Screening Form" completed for Patient 23 on 4/15/23, indicated a diagnoses including hyperglycemia (high blood sugar), and hyponatremia. The form was marked to indicate that Patient 23 was a level 2 nutritional priority based on poor control of diabetes. The form showed a priority 2 was a moderate nutrition risk. The directions on the form indicated to notify the Registered Dietitian via email at email group, "Registered Dietitian," for a priority 2 patient.

In an interview, with Registered Nurse 1 (RN) 1 on 10/18/23 at 11:46 am, RN 1 confirmed that Patient 23 was admitted to the hospital on 4/5/23, and discharged on 4/17/23. RN 1 confirmed, that Patient 23 was screened as a priority 2 nutrition risk upon admit. RN 1 confirmed, that the Registered Dietitian (RD) was not emailed, and was not informed about Patient 23. RN 1 stated, that in cases when the RD was notified of an admitted patient, she responded with a summary of nutrition recommendations.

A review, of the medical record for Patient 24, indicated that they were a 78 years old, and admitted to the hospital on 5/9/23, with altered mental status by history and Leukopenia (low white blood cell count).

A review of the, "Acute Care Nutrition Screening Form," for Patient 24 initially completed on 5/9/23, indicated the "Day 3 Patient Re-Assessment," was blank. On the Day 3 Patient Re-Assessment, there was a check box to indicate if a patient was "Eating less than 50% of meals," as well as a check box to indicate nutrition priority 1, 2, 3, 4. There was a fill in box to indicate the date and time the RD was contacted and a fill in box to indicate the RN who completed the Re-Assessment Screening. The form showed an Albumin (protein in the bloodstream) lab result of 2.1-2.7 was a Priority 2 nutrition risk. The directions on the form indicated to notify the Registered Dietitian via email at email group, "Registered Dietitian," for a priority 2 patient.

A review, of "Lab Results: Last 24 Hours," indicated a lab collected for Patient 24 on 5/10/23, indicated her Albumin level was 2.2. This document showed a reference range for Albumin, and indicated and Albumin level of 2.3 (or lower) was low.

A review, of Patient 24's medical record indicated the following progress notes, and discharge summary notes.

"Patient Progress Notes" nursing order on 5/10/23, "Nursing to complete 72 hour dietary re-assess on day 3 of hospital stay."
"Progress Note" for 5/10/23, the Primary Care Physician (PCP) documented Patient 24 was extremely weak and eating about 20% of her meals.
"Progress Note" for 5/11/23, the PCP documented Patient 24 did not have much change in condition and Patient 24 was still extremely week and eating 30% of her meals.
"Progress Note" for 5/12/23, the PCP documented Patient 24 was still extremely week and eating 30% of meals.
"Discharge Summary" for Patient 24, the PCP documented by the time Patient 24 was discharged, she was eating 30% of her diet.

In an interview, on 10/18/23 at 12:05 pm, RN 1 confirmed, that Patient 24 was admitted on 5/9/23, and discharged on 5/14/23. RN 1 confirmed, that the Day 3 Patient Re-Assessment on the Nutrition Screening Form was not completed for Patient 24. RN 1 confirmed, that Patient 24 should have been identified as a priority 2 nutrition risk on the Day 3 Patient Re-Assessment. RN 1 also confirmed the RD was not contacted regarding Patient 24's nutrition priority risk, and there was no documentation from the RD regarding nutrition recommendations for Patient 24.

In an interview, on 10/19/23 at 10:10 am, RN 1 stated, there was a new electronic medical record (EMR) system which was launched/went live on June 5, 2023. RN 1 said because the new system did not have a nutrition screening for nurses to prioritize patient nutritional status upon admission, the RD had to review every patient that was admitted in order to prioritize the patient and to provide an initial nutrition recommendation. She explained the RD mostly worked remotely, and had access to the EMR.

As the interview, continued on 10/19/23 at 10:15 am, RN 1 stated in September, her review of patient medical records showed the RD was not informed about 6 patients who were admitted. RN 1 stated it was assumed the RD was looking into the EMR everyday to review patient admits but it was discovered toward the end of September she was not looking at the EMR every day. When this was discovered, a procedure was implemented for nursing to email the RD upon admission of all patients. RN 1 stated for the new EMR, there was no policy developed for the new nutrition prioritization system. RN 1 confirmed after the new procedure was implemented to notify the RD of any patient admissions, the RD was not notified of 3 out of 7 patients admitted from 9/28/23 - 10/14/23.

As the interview, continued on 10:20 am, RN 1 explained there was a QA (Quality Assurance) in place to improve nursing completing Acute Nutrition Screening on every patient, informing the RD of priority 1 and 2 nutrition risk patients, and completing the 3-day assessment (the project also included properly documenting patient weights and food preferences.) RN 1 stated this project was started in the first quarter (January - March) in 2022. Documentation of QA data for this project was reviewed with RN 1, which showed overall accuracy for Quarter (Q) 1, 2022 - Q2 2023 were as follows: Q1 2022 58%, Q2 2022 71%, Q3 2022 58%, Q4 2022 60%, Q1 2023 67%, Q2 2023 67%. RN 1 confirmed the goal rate of 80% accuracy was not met. RN 1 also stated QA for Q2 2023, and Q3 2023 would reflect the new EMR system. She stated she was involved with training nursing on the new system EMR system, but she was paying less attention to quarterly audits for QA because she was busy with the "build" of the system. Although, a QA project was implemented for nutrition prioritization, the data showed accuracy was not improving and was not being monitored for the last two quarters.

2. According to the 2023 Academy of Nutrition and Dietetics Nutrition Care Manual, the nutrition assessment is the first step of the Nutrition Care Process. It is a systematic method for obtaining, verifying, and interpreting data needed to identify nutrition-related problems, their causes, and their significance. It involves initial data collection and continual reassessment and analysis of the patient's status compared with specific criteria.

In an interview, on 10/19/23 at 10:50 am, RD 1 stated she did nutrition assessments for patients admitted to the hospital depending on the patient's nutritional status and/or number of days in the hospital. She stated the hospital did not have a policy and procedure for nutrition assessments, but she used her own references.

In an interview, on 10/18/23 at 2:30 pm., RN 1 confirmed while RD 1 used references from another hospital, the facility did not have a policy and procedure for nutrition assessments approved by the hospital's medical staff and governing body.

3. A review, of the document titled, "RD Approval of Menus," signed and dated by RD 1 on 8/11/23, showed, "The Registered Dietitian for the facility has reviewed the menus and spreadsheets and has agreed that the menus meet the therapeutic needs of ... resident population ... The Registered Dietitian also will have reviewed the nutritional analysis provided in the quarterly packet."

A review, of the facility's policy titled, "Menu Guidelines, Substitutions, Replacements, and Recipes," revised dated 12/31/20, indicated the policy purpose was to ensure the nutritional needs of the patients were met according to the Recommended Dietary Allowances (RDAs). In addition, the Dietary department is responsible for offering nutritionally adequate meals.

A. Per the National Institute of Health, Nutrient Recommendations: Dietary Reference Intake (DRI) are documents issued by the Food and Nutrition Board of the National Academies of Sciences Engineering, and Medicine. DRI is the general term for a set of reference values used to plan and assess nutrient intakes of healthy people. These values, which vary by age and sex, include Recommended Dietary Allowance (RDA): the average daily level of intake sufficient to meet the nutrient requirements of nearly all (97-98%) healthy individuals and often used to plan nutritionally adequate diets for individuals; and Adequate Intake (AI): Intake at this level is assumed to ensure nutritional adequacy and is established when evidence is insufficient to develop an RDA. The following lists the recommended level of DRIs that were no met based on the hospital's nutrient analysis. Ranges are based on age and gender.

The Dietary Reference Intakes (DRIs): Recommended Dietary allowances and Adequate Intakes, Elements:
- Calcium (milligram-a metric unit of measure): range 1000-1300 mg/day

The Dietary Reference Intakes (DRIs): Recommended Dietary allowances and Adequate Intakes, Vitamins:
- Vitamin D (microgram -a metric unit of measure): 15-20 mcg/day
- Vitamin E (mg): 14 years and over = 15 mg/day

The Dietary Reference Intakes (DRIs): Recommended Dietary allowances and Adequate Intakes, Macronutrients:
- Total fiber (gram): 21-38 gm/day

A review, of the document titled, "Nutritional Breakdown," was a one page spreadsheet dated Fall 2023, and showed a list of 5 diets: Regular, Small Portion, Large Portion, 2 Gram Sodium (a therapeutic diet low in salt), Consistent Carbohydrate (a therapeutic diet intended for patients with diabetes and/or issues with controlling blood sugar. The amount of carbohydrates are consistent for each meal), Lowfat/Cholesterol, Renal (a diet intended for patients with kidney disease), and Vegetarian. The spreadsheet also showed the nutrient values per diet for 32 macro (nutrients needed in larger portions in a diet) and micronutrients (nutrients needed in smaller amounts in a diet). In an interview on 10/17/23 at 3:05 pm, RD 1 indicated the spreadsheet was a summary of nutrients of the quarterly menu cycle, rather than daily breakdown. Examples of nutrients that did not meet the DRIs included fiber, Vitamin D, and Vitamin E.

The following nutrients/diets were not in accordance with the DRIs for the various ages and genders:

Dietary Fiber was not met for the Regular, Regular-small, Regular-Large, 2-gram sodium, Consistent Carbohydrate, Low/Fat, Low Cholesterol, Renal and Vegetarian Diets.

Vitamin D was not met for the Regular, Regular-small, 2-gram sodium, Consistent Carbohydrate, Low/Fat, Low Cholesterol and Vegetarian Diets.

Vitamin E was not met for the 2-gram Sodium, Consistent Carbohydrate, Low Fat/Low Cholesterol and Renal Diets.

In an interview, on 10/17/23 at 3:05 pm, Registered Dietitian 1 (RD 1) confirmed the menu was used for the hospital and the analysis was on a quarterly cycle rather than a daily analysis. RD 1 stated she approved the menus on a quarterly basis. She stated when she reviewed the menu she was "basically looking whether it [the menu] was going to meet needs of patients." She stated the menus were developed for the "elderly" population because the menus were also used for the skilled nursing facility as well. When she was asked how she verified the nutrients met the needs of other demographics (characteristics of the population such as age, gender) admitted to the hospital, she stated she knew the menus were typically low in potassium and vitamin D so sometimes she recommended a multivitamin. She stated she did not assess the menu to ensure it met DRIs. She stated she did not know the hospital patient demographics. RD1 confirmed the nutritional analysis for the quarterly fall menu was the one-page spreadsheet titled "Nutritional Breakdown" dated Fall 2023.

In an interview, on 10/18/23 at 10:15 am, the Health Information Director (HIMD) stated she did not know the patient demographics for the hospital.

An additional daily nutrient analysis for the Regular diet only was presented on 10/19/23. The analysis revealed in addition, the DRI for Calcium was not met for the Regular diets.

B. Review of the "Summary of Nutrition - 3 Day Emergency Menu" dated 2023, showed "the emergency and disaster menus have been written to provide adequate nourishment to all residents, regardless of diet order ... The Facility Registered Dietitian is to approve the menus and adapt them, as needed, for your particular resident population. The Calories and protein for the food items are listed below ..." The document read "Summary of Nutrition Breakdown - Three Day Emergency Menus: Regular Diets" and showed a breakdown of calories and protein for all food on for the Regular diet as well as the "Total Approximate Values/Day for Regular Diets" including calories, protein, fiber, fat, potassium, carbohydrates, and sodium. There was no nutrition breakdown or total approximate values for therapeutic diet emergency menus.

In an interview, on 10/17/23 at 3:05 pm, RD 1 confirmed, there was a nutritional analysis for the Regular diet emergency menu and no nutrient analysis for the therapeutic menus. However, it was noted that therapeutic diets such as the Renal and Consistent Carbohydrate diets had different menu items.

Review of the 3-day "Cooks spreadsheet Emergency Menus" dated 2023, showed food items and portion sizes of food items to be served for breakfast, lunch, and dinner for Regular diets, as well as 12 therapeutic diets. The therapeutic diet foods and portion sizes differed from the Regular diet. For example:

On Days 1-3 lunch and dinner, Consistent Carbohydrate (CCHO) diets received diet beverage or water, when the Regular diet received lemonade or punch, which would result in a different calorie level. In addition, for the nighttime (HS) snack, the CCHO received "no snack" when the Regular diet received graham crackers which would result in a difference in calories.

On Days 1-3 breakfast, the "Renal-60 gm (gram) protein Low Potassium, 2 gram sodium diet" (Renal diet) showed "no meat - serve 1/2c [cup] canned pears, peaches or applesauce" when the Regular diet showed 1 ounce of canned meat which would result in a difference in protein and calorie levels.

Based on observation, interview, and record review, the facility failed to ensure provision of an effective infection control program, and implement infection control practices in accordance with hospital policy, and nationally recognized standards when:

1. The Infection Prevention Nurse (IP) failed to survey the Operating Room (OR), OR anteroom (an area leading to the OR, where the operating room staff use surgical sinks to scrub their hands and arms before surgery), decontamination room (decontam., a room used to remove hazardous contaminants from medical equipment and instruments), central sterile processing/storage area (CS, a room where technicians clean, sterilize, process, and store medical instruments to prevent contamination and the spread of infection), and kitchen while conducting monthly environmental rounds.

2. Environmental Services (EVS), and OR staff, failed to conduct daily cleanings in the OR anteroom, decontam. room, and CS rooms.

3. The surgical area's decontam. room, which was utilized as an endoscope (a medical device used to look inside a body cavity or organ) reprocessing room (a room where endoscopes are manually pre-cleaned, tested, rinsed, inspected, and disinfected with a high-level disinfectant), was a storage area for sterile medical supplies, sterile laryngeal masks (an airway device used during the administration of anesthesia or as a life-saving measure for a patient with difficulty breathing), and clean surgical scrubs.

4. The area for OR staff to change into the required surgical attire (scrubs) was also a bathroom, and was not set up as a changing area.

5. The facility's family practice, specialty care, and walk-in clinics had 99 expired (EXP.) sterile medical supplies, 33 sterile medical supplies with brown discoloration, and two sterile instruments with damaged packaging available for patient use.

6. The ice machine used to make ice for patient beverages was not maintained free of residue on surfaces that came into contact with ice.

These failures had the potential to increase patient exposure to infectious contaminants (spread of germs, bacteria, and viruses), and have a negative impact on patient health, safety, and outcome which could lead to negative clinical outcomes.


Findings:


1. A review, of the facility's policy titled, "Infection Prevention Program," revised 12/18/14, indicated the policy's goals included for the Infection Preventionist (IP) to "identify and correct problems relating to infection prevention practices and ensure compliance with sate and federal regulations. The policy activities included for the IP to ensure ensure that policies, procedures, and aseptic practices are followed by personnel. The policy indicated that the IP, and appropriate department managers, were responsible for observing infection prevention practices and initiating appropriate corrective actions when needed.

A review, of the facility's document titled, "Environmental Rounds Worksheet for Infection Prevention," dated 10/11/23, indicated that the IP, and IP Assistant's (IPA) routine infection prevention activities included the observation and surveillance of the following facility departments: acute care, long term care, emergency care, and medical clinics. The IP and IPA's monthly rounds worksheet did not include observation or surveillance of the OR, OR anteroom, decontam. room, CS room, or kitchen.

During an interview, on 10/16/23 at 4:30 pm, the IP stated she did not go into the kitchen to assess infection control. IP stated, that she did not have a checklist developed for a kitchen inspection. IP stated, to receive information about the kitchen, she relied on the Dietary Services Supervisor (DSS) to bring kitchen logs to the quarterly Quality Assurance (QA) meeting.

During an interview, on 10/17/23 at 10 am, the Operating Room Supervisor (ORS) stated, that she had worked as the facility's ORS for approximately one year, and was still learning operating room nursing skills, and supervisory functions. ORS reported, that the facility's IP never entered the surgical services area to observe, or collaborate on infection prevention surveillance activities within the surgical services department.

During an interview, with the Chief Nursing Officer (CNO), and IP, on 10/17/23 at 10:19 am, the IP stated, that she had worked as the facility's IP for approximately one year, and was still learning her role and developing the facility's Infection Prevention Program. On 10/11/23, IP initiated a facility-wide environmental rounds procedure to survey the infection prevention practices of facility staff. IP confirmed that the surgical services and kitchen areas were not included in this surveillance procedure because she was unsure if her job role included oversight of those departments. The CNO, and IP acknowledged, that it was crucial for surgical services, and dietary services to be included in infection prevention activities and reported that they would immediately integrate the departments in the facility's Infection Prevention Program.

2. A review, of the facility's policy titled, "Cleaning Procedure for Central Supply," revised 8/27/06, indicated that the policy's purpose was to maintain a clean and sanitary environment in the Central Supply Area, for the cleaning, packaging, sterilization, and storage of supplies and instruments. The policy indicated, that that the Environmental Services Department (EVS) must clean the central supply areas on a a daily basis. The cleaning procedures included the daily cleaning of the central supply dirty (the facility's decontam. room), central supply clean (the facility's central sterile processing room), and central supply sterile (the facility's central sterile storage area).

A review, of the facility's document titled, "2023 Cleaning Log Surgical Services," dated 4/01/23 through 10/12/23, indicated that the facility's decontam. room, OR anteroom, and CS rooms were cleaned once every seven days from 4/01/23 to 8/30/23, and from 8/31/23 - 10/05/23.

During an interview, on 10/17/23 at 9:29 am, the Housekeeping Supervisor (HS) stated, that OR staff were responsible for the daily cleaning of the decontam. room, OR anteroom, and CS rooms. Housekeeping staff did not access these restricted areas because knowledge of aseptic technique and safe traffic flow (cleaning and movement practices that help prevent the spread of germs and viruses) were required.

During a concurrent interview, and record review, on 10/17/23 at 10 am, ORS confirmed that surgical staff were responsible for cleaning the surgical area. ORS reported that the decontam. room, OR anteroom, and CS room were being cleaned Tuesday through Thursday, which were the only days the facility's surgical staff were scheduled to work. ORS confirmed that daily cleaning did not occur, and verified that the Surgical Services Cleaning Log documentation indicated that cleaning occurred once every seven days.

During a concurrent interview, and record review, on 10/17/23, at 1:30 pm, IP and CNO verified that the facility's decontam. room, OR anteroom, and CS room were not cleaned on a daily basis. IP and CNO, acknowledged this potentially exposed patients to harmful infectious contaminants and reported they would immediately develop a daily surgical services cleaning schedule and auditing process.

3. A review, of the facility's policy titled, "Central Services Traffic Control," revised 9/24/19, indicated the policy's purpose was to control the movement of sterile and non-sterile items to the AORN standards. The policy indicated that all clean and sterile supplies and equipment are to be routed in the most direct path and only through clean areas. The central sterile storage area should be remote from the decontamination room so that sterile supplies can be protected from extraneous contamination.

On 10/16/23 at 11:53 am, during a concurrent observation of the decontam. room, and interview, with ORS, she verified that multiple sterile medical supplies were being stored on open shelving in the decontam. room, multiple sterile laryngeal masks were being stored on shelving near the base of the decontamination sinks, and multiple surgical scrubs were stored in a wall hung cabinet in the decontam room. ORS confirmed that the decontam. room was considered a "dirty area" where the contaminated colonoscopes (an endoscope that visualizes the rectum and large intestine) and esophogastroduodenscopes (an endoscope that visualizes the upper gastrointestinal tract) were cleaned. ORS reported due to the facility's limited storage space, the decontam "dirty room," was being used to store sterile supplies.

On 10/19/23 at 10:05 am, during a concurrent observation of a colonoscope cleaning in the decontam. room, and interview, with the Certified Gastrointestinal Technician (CGIT, a technician that has specialty training to clean, disinfect, and store endoscopes), CGIT stated that the decontam room was a "very dirty room," and that all supplies stored in the decontam room had potential to become contaminated by splatter from the endoscope cleaning sinks or aerosolized contaminants (airborne particles). During observation, CGIT cleaned a colonoscope by injecting a high-level disinfectant through the colonoscope tubing. During the injection, the syringe dislodged and splattered contaminated fluid across the decontam. room. The contaminated splatter soiled the room's shelving, floor, and CGIT's gown. CGIT stated, that contaminated splatter was typical during endoscope cleaning, which was the reason why sterile or clean supplies stored in the decontam. room were at risk for exposure to contaminants.

On 10/16/23 at 2:55 pm, during a concurrent observation of the decontam room and interview, with the CNO and IP, the CNO and IP verified that sterile medical supplies, sterile airway supplies, and clean surgical scrubs were being stored in the facility's decontam. room. CNO stated that the facility's decontam. room was a "clean/dirty room that was mostly dirty." CNO and IP acknowledged, that the sterile supplies and surgical attire had the potential to become contaminated during the endoscope cleaning process or from aerosolized contaminants when the surgical attire were removed from the cabinets.

4. A review, of the facility's policy titled, "Central Services Attire," revised 9/24/19, indicated that the policy's purpose was to lessen the risk of workers serving as a potential source of infection to patients.

On 10/16/23 at 2:55 pm, during a concurrent observation of the surgical staff's changing area, and interview, with the IP and CNO, the IP and CNO confirmed, that the area for staff to change into surgical attire (scrubs) was also a bathroom (for all facility staff), which was not set up to serve as a changing area. The bathroom entrance was short, narrow, and lined with wall lockers and wall hooks that hung staff's personal clothing. The only widened area that allowed for bending and stooping to apply surgical attire was near the bathroom toilet and sink. The bathroom did not have a lidded toilet, or a separate enclosed stall for the toilet, and there was no barrier or designation that indicated an area of the bathroom was intended for changing into scrubs. The IC, and CNO confirmed, that this had the potential for cross-contamination from the bathroom onto scrub attire, and subsequently to patients provided with surgical services.

5. On 10/18/23 at 2:39 pm, a request was placed to the CNO for a copy of the facility's policy that addressed procedures for auditing the shelf-life, or EXP. date, of medical supplies. CNO reported the facility did not have a policy that outlined these procedures.

On 10/18/23 at 10:10 am, during a concurrent observation of the clinic's medical supply cabinets, and an interview, with the Clinic Manager/Licensed Vocational Nurse (LVN) 2, she stated that the facility's medical assistants (MAs) and certified nursing assistants (CNAs) were responsible for conducting monthly audits of all medical supplies and sterile instruments. Monthly audits included checking that medical supplies were not beyond EXP dates, or showing signs of discoloration and degradation (when a material loses quality) and that sterile instrument packages were not wet, damaged, or punctured. LVN 2 reported the facility did not have a documentation process to ensure monthly audits of supplies and instruments were completed. LVN 2 verified the following supplies were expired or degraded, and sterile instruments were compromised due to damaged packaging:

21 sterile surgical gloves. EXP 6/23.
2 sterile surgical gloves. EXP 1/23.
14 sterile biogel surgical gloves. EXP 5/22.
4 pediatric oxygen masks. EXP 1/22/23.
1 box of sterile eye pads. EXP 9/01/23.
4 pediatric oxygen masks. EXP 1/22/23.
14 sterile fenestrated drapes (surgical towels with holes that are used in surgery). EXP 6/23.
1 intravenous extension tubing (IV, a tube inserted in the vein to deliver medication or fluid). EXP 6/19.
1 sterile surgical towel. EXP 4/18.
2 sterile disposable operating room towels. EXP 4/20.
35 pediatric oxygen masks with nebulizers (a drug delivery device that administers mdication to the lungs). EXP 1/23.
5 Silicone Gastronomy tubes (G-tube, a tube inserted directly in the stomach to deliver nutrition) with areas of brown discoloration on the tubing and sterile packaging.
5 winged infusion sets (needles used for IV delivery of fluids, medication, or blood transfusion) with areas of brown discoloration on the tubing and sterile packaging.
15 seroma-cath wound drainage system (a tubing inserted under the skin that drains fluid into a collection bulb that is used after certain surgeries) with areas of brown discoloration on the tubing and sterile packaging.
Sterile iris scissor (scissors used to remove tissue of the eye) with punctured sterile packaging.
Nubia instrument (an instrument used in surgery) with punctured sterile packaging and two brown liquid marks.











34975

6. According to the 2022 Federal Food Code, characteristics of materials used in construction of food-contact surfaces of equipment are to be finished to have a smooth, easily cleanable surface; multiuse food-contact surfaces are to be smooth; and equipment food-contact surfaces are to be clean to sight and touch.

On 10/16/23 at 4 pm, the ice machine located in the staff breakroom was observed with the Director of Plant Operations/Safety (DPOS). DPOS stated the ice from the ice machine was used for patient drinking water. She confirmed she was responsible for cleaning the ice machine. DPOS opened the ice machine to view the inside components. There was rough, white residue on a significant portion of the inside surface of the ice chute from which ice is transferred into the ice bin. In addition, there was rough, white residue on the inside surface of the ice bin where ice was stored. In addition, there was black residue imbedded in the white, rough residue inside the ice bin. DPOS confirmed there was white and black residue on the ice chute and ice bin and stated, "there is lots of scale" and she said she did not know what the black residue was.

In an interview, with the Infection Prevention Nurse (IP) on 10/16/23, at 4:30 pm, IP stated she was aware of white mineral build-up inside the ice machine and thought it was due to "hard water." She stated she did not think the white build-up was a concern because the ice machine was clean and sanitized. She stated she was unaware of the black residue inside the ice machine bin.

Based on observation, interview, and document review, the hospital failed to prominently post signage in all areas of its Emergency Department (ED) informing the public, of their rights to seek and receive emergency services, with respect to examination and treatment of emergency medical conditions, including women in labor.

This failure to provide signage had the potential for the public and patients to be unaware of their rights when obtaining healthcare for medical conditions.


Findings:


A tour of the ED on 10/16/23 at 10:30 am, included the hospital lobby which also served as the ED lobby and waiting area, and the inside of the ED which included two rooms, with one bed in each of those rooms. The EMTALA (Emergency Medical Treatment and Active Labor Act) signs relating to the right to receive emergency services were seen in the ED lobby/waiting area. Ambulance patients entered from the back of the ED through a short hall that led to the two ED rooms.

During a concurrent interview, and observation, of inside the ED on 10/16/23, at 12 pm, the ED Manager (EDM) confirmed there were no signs posted inside either of the two patient rooms. In the ED, on one wall in the hall, there was an EMTALA sign that was framed in a 5 inch by 7 inch frame. He said if a patient arrived by ambulance they would be wheeled on a gurney through the back door into one of the ED rooms, and would have a problem seeing the one small sign on the opposite wall.

The facility's "EMTALA" policy, last reviewed on 9/26/16, indicated, "Signage - SHD (the hospital) shall post signs conspicuously in lobbies, waiting areas and treatment rooms where examination and treatment occurs in the form required by HCFA (Health Care Financing Administration) that specifies the rights of individuals to examination and treatment for emergency medical conditions and indicating that SHD participates in the MediCal program. Signs shall also state the name, address and telephone for the State Department of Health Services. Signs shall be posted in the emergency department, ambulatory clinics and other locations where patients may present for emergency services."