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Based on observation, interview and record review the facility's governing body failed insure the facility's written policy and procedures were implemented to ensure patient safety.

1.Failed to ensure the facility's policy and procedure was implemented in that expired medication and supplies were available for use.


This practice has the potential for putting all individual patient at risk of injury or death. The facility has a current census of 149 patients.

Policy Reviewed:

Review on 11/17/2022 of the facility's current policy #200.20, titled, "Medical Emergency", Patient Care Procedures, last reviewed 03/31/2020: 1. Policy: A. The hospital maintains the following emergency equipment: Emergency Carts and/bags contain the following supplies listed on the attached inventory sheet: 1 Gluctose 15, and 1 Suction Yankauer.

Review 0n 11/17/2022 of the facility's current policy #PHR-132, titled, "Medication Management" last reviewed 05/2020 reads: 1.0. Statement of Purpose: Emergency medication and antidotes, suitable for the facility and level of care, will be readily available in the Med-Dispense system to ensure prompt and appropriate care in an emergency situation. 2.0. The Medical Staff in coordination with the Pharmacy and Therapeutic Committee will select and annually review the list of medications. It is the policy of the facility that the Pharmacy checks and replenishes all emergency medications and antidotes immediately when the pharmacy is open. 4.0. Procedure: 4.1 Pharmacy staff check all medications and will replace all items used or soon to expire. 4.4 During monthly nursing medication room inspections, the Pharmacy will check par levels and electronic expiration dates.

Observation on 11/17/2022 at 1210 of the C unit nursing station along with registered nurse staff ID #E a bag identified as the Emergency Bag for the unit was inspected. Surveyor along with staff ID #E identified one tube of Glutose 15 oral glucose gel, 37.5 grams, LOT # 0372022, Expiration date: 302/22 and one Yankauer Suction tip, Lot: 1502283, Expiration date: 09/17/2021.

Interview on 11/16/2022 with staff ID #E, resource registered nurse for the facility confirmed the above finding and stated the expired items should have been removed from the emergency bag and replaced.

Based on observation, interview and record review the facility's governing body failed insure dietary contracted services were furnished in a safe and sanitary manner and the facility's written policy and procedures were implemented to ensure patient safety.

1. Failed to ensure that expired food items were not available for consumption.
2. Failed to ensure that refrigerators were cleaned and sanitary.
3. Failed to ensure the temperature of nourishment refrigerators located on the patient care units were properly monitored and documented.

This practice has the potential for putting all individual patient at risk of injury or death. The facility has a current census of 149 patients.

Review on 11/18/2022 of the Governing Board Bylaws last updated and approved on 02/23/2022 by the Governing Board.

Section 7.5 - Contracted Services: 7.51 The Board shall provide mechanisms to ensure the services provided under contract are in compliance with all applicable conditions of participation, regulations and JCAH standards for the contracted service. 7.52 The Board shall ensure that contracted services are performed safely and effectively through implementation of the performance improvement program and through mechanisms used to ensure that contracted services staff members are qualified and competent.

Policy Reviewed:

Review of the facility's current "safety Management Plan"; last reviewed January 2022. I. Introduction: The Safety Management Plan defines the Mechanisms for interaction and oversite for the primary functions involved with the Management of Safety. Objective: Provide a plan that complies with all local state and federal guidelines/regulations. Provide a safe environment for patients, staff and visitors. SM-19: Refrigerator Cleaning Policy: Purpose; To ensure hospital refrigerators in the medication and exam rooms, employee lounges and patient kitchens are cleaned and defrosted on a regular Basis. Policy: It is the policy that all refrigerators are maintained on a daily basis by pharmacy, food services or clinical staff. Procedure: 1. Food Service staff is primarily responsible for discarding outdated food from refrigerators. Unit staff on their respective units will monitor for outdates and timely placement of delivered food items into the refrigerators on the units. 2. The HBHH staff on the night shift will monitor refrigerator temperatures in the patient nourishment refrigerators. A schedule for emptying out, cleaning and defrosting refrigerators will be established for each unit and will be conducted by HBHH staff on the night shift. 4. The Dietary Department Director assigns staff to clean the refrigerator using the appropriate product weekly on a rotating basis as needed. 5. The condition of all refrigerators will undergo surveillance during Plant Operation rounds and Risk Management Rounds on a regular basis. Compliance, completion of refrigerator logs will be reported to the Safety/Risk Management/Infection control Prevention Committee.

Review of the facility's current policy titled "Refrigerator and Freezer Temperature Log", dated April 2020. All refrigerator temperatures must be 40 degrees Fahrenheit or below. All freezer temperatures must be 0 degrees Fahrenheit or below. If the refrigerator/freezer equipment is not maintaining the proper temperature, maintenance must be notified, and notation of the event must be noted on the temperature log. Please log all action plans.

Log records document time for AM and PM reading for both the refrigerator and freezer with initials of person completing the log.


Observation:

Observation of the facility patient care area on the morning of 11/16/2022 at 1145 along with the facility Chief Nursing Officer (CNO), staff ID #B and Director of Plant Operations, staff ID #D the nourishment rooms were toured with the following findings:

Patient Care Unit B:

1. Nourishment room refrigerator was observed have a cream-colored dried areas of spillage on the glass shelves, plastic pull out bends and door storage areas. Black areas approximately 2 x 3 inches was observed behind the storage bends.

2. Six single wrapped Land of Lake cheese sticks snacks were observed in the refrigerator with an expiration date of 11/11/22.
3. Review of the Refrigerator & Freezer Temperature Log for November 2022 failed to document temperature of the refrigerator and freezer temperature as required for the following dates:

" November 2, 2022, No PM refrigerator, or freezer temperature
" November 3, 2022, No PM refrigerator, or freezer temperature
" November 4, 2022, No PM refrigerator, or freezer temperature
" November 7, 2022, No PM refrigerator, or freezer temperature
" November 8, 2022, No PM refrigerator, or freezer temperature
" November 9, 2022, No PM refrigerator, or freezer temperature
" November 10, 2022, No PM refrigerator, or freezer temperature
" November 12, 2022, No PM refrigerator, or freezer temperature
" November 15, 2022, No PM refrigerator, or freezer temperature

Patient Care Unit C:

Nourishment room refrigerator was observer on 11/16/2022 to have a cream-colored dried areas of spillage on the bottom interior surface near the storage binds.

Interview on 11/16/2022 with CNO, staff ID #B confirmed the above findings and stated that the refrigerator cleaning and monitoring of the temperatures was responsibility of the dietary department.

Based on review of the facility policy, review of medical records from 2022, and confirmed in interview, the facility failed to support patient rights to make informed decisions to ECT (Electroconvulsive Therapy ) treatment for five of five patient reviewed.

Findings included:

Review of the ECT (Electroconvulsive Therapy ) policy (policy #1600.00) under Informed Consent revealed "prior to receiving ECT, every patient, voluntary or involuntary, adult or minor, shall be given full explanation of ECT, and written consent obtained."

Random review of the informed consents for ECT treatment in 2022 revealed five patients with incomplete consent forms (Patient #7, 11, 12, 13, 14). Consent forms used were an abbreviated version of the TAC RULE §405.117 Exhibit A Disclosure and Consent for Electroconvulsive Therapy.

The consents used were missing:

"I certify that this form and the written supplement have been fully explained to me, that I have read it or had it read to me, that the blank spaces have been filled in, and that I understand its contents. I have been given the opportunity to ask questions about my condition, alternative forms of anesthesia and treatment, risks of nontreatment, the procedures to be used, and the risks and hazards involved, and I believe that I have sufficient information to give this informed consent. If I am the guardian of the person of a patient who has been adjudicated incompetent to manage his or her own personal affairs, I certify that my decision to give or withhold informed consent is based on knowledge of what the patient would desire to the extent that I am aware.

I have the right to accept or refuse this treatment. If I consent, I have the right to revoke my consent for any reason at any time prior to or between treatments without affecting the qualify of care I receive.

I understand that my consent is for one individual treatment, and that additional treatments require additional written informed consent, which must also be evidenced by signature on this form."

An interview with the CEO (Personnel #C) on 11/17/2022 at 1435 hours in the conference room confirmed the above findings.