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Based on observation, staff interviews, and review of maintenance records between May 17 through May 19, 2022, the facility failed to construct, install and maintain the building systems to ensure life safety to patients.

Findings include:

The facility was found to contain the following deficiencies.
K132 Multiple Occupancies - Contiguous Non-Health
K161 Building Construction Type and Height
K211 Means of Egress - General
K222 Egress Doors
K223 Doors with Self-Closing Devices
K225 Stairways and Smokeproof Enclosures
K251 Dead End Corridors and Common Path of Travel
K271 Discharge from Exits
K281 Illumination of Means of Egress
K293 Exit Signage
K311 Vertical Openings - Enclosure
K321 Hazardous Areas - Enclosure
K323 Anesthetizing Locations
K343 Fire Alarm System - Notification
K345 Fire Alarm System - Testing and Maintenance
K351 Sprinkler System - Installation
K363 Corridor - Doors
K511 Utilities - Gas and Electric
K521 HVAC
K712 Fire Drills
K754 Soiled Linen and Trash Containers
K761 Maintenance Inspection & Testing Door
K902 Gas and Vacuum Piped Systems - Other
K911 Electrical Systems - Other
K919 Electrical Equipment - Other
K923 Gas Equipment - Cylinder and Container Storage

Based on observation, staff interviews, and review of maintenance records between May 17 through May 19, 2022, the facility failed to construct, install and maintain the building systems to ensure life safety to patients.

Findings include:

The facility was found to contain the following deficiencies.
K132 Multiple Occupancies - Contiguous Non-Health
K211 Means of Egress - General
K222 Egress Doors
K223 Doors with Self-Closing Devices
K225 Stairways and Smokeproof Enclosures
K251 Dead End Corridors and Common Path of Travel
K271 Discharge from Exits
K281 Illumination of Means of Egress
K293 Exit Signage
K311 Vertical Openings - Enclosure
K321 Hazardous Areas - Enclosure
K323 Anesthetizing Locations
K343 Fire Alarm System - Notification
K345 Fire Alarm System - Testing and Maintenance
K351 Sprinkler System - Installation
K363 Corridor - Doors
K511 Utilities - Gas and Electric
K521 HVAC
K712 Fire Drills
K754 Soiled Linen and Trash Containers
K761 Maintenance Inspection & Testing Door
K902 Gas and Vacuum Piped Systems - Other
K911 Electrical Systems - Other
K919 Electrical Equipment - Other
K923 Gas Equipment - Cylinder and Container Storage

Based on record review, interview and observation the facility staff failed to follow their policy for the collection and identification of blood specimens in 1 of 1 blood collection observed, and failed to contact their donor service according to their policies and procedures in 1 of 2 death records reviewed (Patient #20) in a total universe of 2 death records.

Findings include: in the ED (Emergency Department)

Record review of facility policy "Specimen Collection and Test Requesting Guidelines" #62U3QES2XUJM-3-3094 dated 4/21/2022 revealed, under "Procedure...A. Specimen Identification: All specimens must be labeled at the time of collection with at least 2 patient identifiers..."

Observation in the ED on 5/18/2022 at 6:52 AM revealed ED RN (Registered Nurse) V exit ED Room B holding 6 specimen tubes of blood, and lay them on the counter at the nurses station. The tubes did not have any patient identifier on them. In an interview on 5/18 /2022 at 7:00 AM when asked what the protocol was for labeling RN V stated, "It's best to label at the bedside. I didn't do that this time."


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Review of Facility Policy #KT2N6QC5SZE5-3-2633, titled, "Tissue or Eye Donation Policy-Acute Care-MMC Ladysmith, last reviewed 6/3/2021, revealed, "3.3 Mandatory Reporting of Deaths to STATLINE: Determining Suitability: a. Donor Eligibility: All deaths must be reported to STATLINE, within 1 hour of the cardiac time of death....The responsibility for notifying STATLINE is that of the nurse caring for the patient."

Review of Patient #20 medical record revealed no documentation of notification of STATLINE to report patient's death or suitability for organ donation.

In an interview on 05/18/2022 at 09:50 AM with Nurse Informatisist X during record review, when asked where the death charting and record of contact with the organ procurement organization, Staff X stated, "There is no death charting present."

In an interview on 05/18/2022 at 10:00 AM with Quality Manager M when asked if the organ procurement organization is notified of all deaths, Quality Manager M stated, "It should be there and it's not there. I can't speak to what I can't find. It is a paper process, they fill out a paper checklist and it is scanned in, it's not there."

Based on interview and record review the facility staff failed to follow the orientation policy to ensure patient care staff receive department specific orientation in 6 personnel files Registered Nurse (RNs) FF, V and W, Surgical Supervisor L, Emergency Dept. Supervisor D and pharmacy technician JJ) reviewed out of a total universe of 21 personnel files reviewed.

Findings Include:

Review of facility policy #4FAR5N4RSFP7-1560551054-21, last reviewed, 10/10/2021, titled, "Orientation Policy," revealed, "3.5 Center/Department Orientation: c...It is the sole responsibility of the department/center to determine and complete the new hire's departmental/center orientation schedule."

Review of Personnel Files for, RNs FF, V and W, Surgical Supervisor L, Emergency Dept. Supervisor D, and pharmacy technician JJ revealed no evidence of completion of department specific orientation.

In an interview on 05/18/2022 at 11:10 AM with Quality Manager M, when asked if there should be department specific evidence of orientation, Quality Manager M stated, "Yes, 6 files have no orientation unit specific checklists that we can find. The policy says we will do department specific orientation, so we will be out of compliance."

Based on observation and interview the facility failed to prevent unauthorized access to protected health information in 1 of 1 medical records departments in a total universe of 1 medical record department.

Findings:

During a tour on 5/17/2022 at 3:10 PM in the Medical Records Department with HIM (Health Information Management) Specialist KK a metal shelf was observed with paper patient records. In an interview with HIM KK on 5/17/2022 at 3:15 PM when asked about the documents HIM KK stated that they were papers waiting to be scanned into the electronic medical record. When asked about the cleaning of the department HIM KK stated that the hospital housekeepers come in and clean after hours, when HIM staff is not present." When asked if the papers that contain personal health information are secured when staff leave the department, HIM KK stated "No, should they be?"

Based on interview, observation and record review, the facility staff failed to follow its infection control program which adheres to the CDC (Centers for Disease Control) and AORN (Association of Operating Room Nurses) guidelines in 1 of 1 infection control plans reviewed. See Tag 1208.

The facility failed to maintain a clean and sanitary environment, failed to remove expired supplies, and failed to ensure proper refrigeration monitoring and safe storage of patient nutritional items. These systematic failures have the potential to affect all patients receiving care at this facility.

Based on observation, record review, and interview, staff at this facility failed to maintain a sanitary environment free of potential contamination to patients and staff by not adhering to infection prevention of the facility and nationally recognized standards of practice in 4 of 9 departments observed (Emergency Department, Operating Suite, Lab, Medical/Surgical). This has the potential to affect all 8 inpatients in the facility.

A review of the facility policy, titled "Infection Prevention and Control Services Policy" last revised and reviewed on 2/19/2021, revealed: "Purpose Statement: The purpose IP (Infection Prevention) is to provide a safe environment for patients, employees and visitors through continuous surveillance for infections, institution of appropriate infection prevention and control precautions, quality improvement activities, education, and research to continually update best practices to prevent and control infectious disease transmission throughout the health care system. 3.1 Regulatory Agencies: a. IP takes a comprehensive approach in providing services that aid in the detection, prevention and control of infections among patients, employees, and others. The services align with best practice standards developed by regulatory agencies such as: Association for Professionals in Infection Control and Epidemiology (APIC), Association of peri-Operative Nurses and Associates (AORN), Society of Gastroenterology Nurses and Associates (SGNA), Facility Guidelines Institute (FGI) and Centers for Disease Control and Prevention (CDC), Occupational Safety and Health Administration (OSHA), Food & Drug Administration (FDA), .... and American Society for Healthcare Engineering (ASHE). 3.2 Scope of Services: a. Surveillance of infection with implementation of control measures and prevention of infections. Identifies and corrects problems relating to IP practices. In conjunction with building services develops ICRA (infection control risk assessment) for construction and remodeling projects."

Examples in the ED (Emergency Department):

During a tour of the ED on 5/17/2022 at 10:20 AM with ED RN (Registered Nurse) BB 3 areas of chipped paint were observed on the far wall of the nursing station.

A tube with liquid medium was observed in Room C with an expiration date of 2/22/2022. Also observed in Room C was a stool culture specimen cup with medium and an expiration date of 4/22/2022.

In an interview with RN BB on 5/17/2022 at 10:25 AM RN BB stated, "I don't even know what the tube would be used for. It is the responsibility of the night nurses to check for expirations and remove from stock. We currently have 2 agency nurses that work nights and they must have overlooked these. The missing paint on the wall is from the chair hitting that area."

On 5/17/2022 at 10:25 AM during a tour of the Emergency Department with RN (Registered Nurse) BB a full-flush hopper toilet was observed in ED Room A. ED Room A has 2 beds, divided by a cloth curtain. The hopper toilet was observed to be approximately 5 feet from the bottom of the first bed and was covered with a removable clear plastic cover.

On 5/17/2022 at 10:30 AM in an interview with RN BB, when asked if the hopper was used RN BB stated, "We use it all the time because we don't have a bathroom in the department and where else are we to dump bedpans and such." When asked if patients are in the room when the hopper is used RN BB stated that sometimes yes. When asked about transport of other bedpans from other ED rooms RN BB stated that they cover them and take them to the hopper in Room A to dispose of them. "We always cover the hopper when we are done."

On 5/18/2022 at 9:20 AM in an interview with ED Supervisor D, ED Supervisor D confirmed that the hopper is located in Room A because there is no soiled utility room in the department. When asked about used linen disposal ED Supervisor D stated we have a linen bag in the hall and when it is full we take it to the inpatient unit and place it down the shoot." Supervisor D stated that they are aware that it is an infection control issue but stated, "What else are we supposed to do?"

Record review of the facility's policy titled, "Outdated Sterile Supplies" #NSG O-11 dated 9/1/2018 reveals, under "Procedure: A. Shelf life will be as follows: 1. All wrapped items will have original sterilization date. 2. Wrapped items (not in plastic) will have a shelf life of six months...."

During a tour of the ED on 5/18/2022 at 3:30 PM with Quality A an emergency obstetric delivery packet was observed to be under a white sheet and lying in a warming isolette in the hall. The packet was wrapped in blue wrap, without a plastic outer covering and dated "5/3/2021". In an interview on 5/18/2022 at 3:30 PM with Quality A, he/she confirmed that the date was over the 6 month shelf life defined in facility policy.


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Examples in the Operating Room Suite:

AORN eGuidelines+ copyright 2012-2022 Inc., Guidelines for Perioperative Practice: Design and Maintenance of the Surgical Suite: 2.2.1: The requirements for each zone include the following: All zones: have surfaces on floors, walls, ceilings, and cabinets that are durable, smooth, cleanable, and able to withstand cleaning practices. Restricted zones: have ceilings that are monolithic (solid/smooth) or are drop in gasketed (fitted) ceiling tiles.

During a tour of the Operating Room Suite on 05/17/2022 at 1:30 PM with OR (Operating Room) Supervisor L, observed the procedure room where endoscopies are performed, has drop-in ceiling tiles with perforations, which prevents thorough cleaning if there is a splash.

During an interview on 5/17/2022 at 1:30 PM, OR Supervisor L confirmed that the tiles appeared to have perforations. Supervisor L stated, "This is very disappointing, this room was remodeled just a couple of years ago."

Examples in the Lab:

During a tour of the lab on 5/18/2022 at 9:30 AM with Lab Operations Manager Y and Vice President (VP) of Medical Affairs C, observed 3 chipped paint areas, silver dollar size, near the sink in the lab, multiple pieces of paper notes taped on walls, machines and computers, cardboard boxes stacked on top a lab machine, six blood bank boxes stacked on the floor, one ceiling tile with a brown colored stain and generalized clutter present on much of the working surfaces in the lab.

During an interview on 5/18/2022 at 9:30 AM, Lab Operations Manager Y confirmed that the lab space was crowded and appeared cluttered. Manager Y stated, "We are doing the best we can with the space we have."


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Examples on the Medical/Surgical unit:

During a tour of the on Medical/Surgical (Med/Surg) unit on 5/17/2022 at 9:45 AM with Med/Surg Team Lead I, multiple areas of chipped paint were noted on the walls in 6 patient rooms (#125, #126, #128, #129, #131 and #133) out of 14 patient rooms observed, multiple areas of chipped paint down both sides of the main patient care hallway between patient rooms, and a stained ceiling tile by the window in room #121.

During an interview on 5/17/2022 at 10:00 AM with Med/Surg Team Lead I, when asked about the paint chips on walls in the patient rooms, paint chips in main patient care hallway and the stained ceiling tile on the Med/Surg floor, Team Lead I stated "We are moving to a our new building soon and maintenance doesn't want to deal with these things."

Cleaning/Maintenance of the Food Storage Refrigerator:

A review of the facility policy, titled "Food and Nutrition-Nursing Stock Unit Policy-Acute Care" last revised and reviewed on 05/12/2022, revealed: "...3.5 Procedure for cleaning and care of pantry area have been developed by Nursing/Food & Nutrition/Housekeeping and are on file with the Infection Control Committee and include" a. Cleaning of refrigerator/pantry...3.6 Food and Nutrition Services personnel are responsible for daily temperature monitoring of unit refrigerator(s) on a posted temperature sheet..."

During a tour of the on Medical/Surgical (Med/Surg) unit on 5/17/2022 at 10:05 AM with Med/Surg Team Lead I, there was a sticky orange/yellow substance observed inside of the refrigerator door where food is stored for patients. The orange/yellow sticky substance covered the top of the inside of the refrigerator door, covered the top of the the turkey slice container on the first shelf of the door, and also covered over the individual syrups, creamers and ketchup packets on the second shelf of the door. When asked Med/Surg Team Lead I if there are any records of cleaning the refrigerator, Med/Surg Team Lead said "I don't think so, we just clean it when needed."

During an interview on 5/17/2022 at 10:08 AM with Med/Surg Team Lead I, when asked what the orange/yellow sticky substance was in the refrigerator, Team Lead I stated "I think maybe it was the chicken salad that spilled." When asked who does maintenance and cleaning of the refrigerator, Team Lead I stated "The night shift CNA's (Certified Nursing Assistants) check this and clean it if needed." Med/Surg Team Lead I confirmed there was no documentation for cleaning of the the patient food refrigerator.

During an interview on 5/17/2022 at 10:15 AM with Certified Nursing Assistant (CNA) GG stated, CNA GG stated, "I saw the spill in the refrigerator this morning and just haven't cleaned it up yet."

Review of the "REFRIGERATOR CHECKS" AND "FREEZER CHECKS" temperature logs for the patient food refrigerator revealed, there were no freezer temperature ranges documented on the log sheets-only refrigerator temperature ranges noted. Review of the last 4 months (02/01/2022-05/17/2022) of temperature log sheets available revealed, there were no refrigerator temperatures documented on 16 days out of 59 days, and no freezer temperatures documented on 16 days out of 59 days on the temperature logs.

During an interview on 5/17/2022 at 10:10 AM with Med/Surg Team Lead I, when asked what the freezer temperature range is-as it is not noted on the temperature log sheet, Team Lead I stated "I really don't know, I thought it was listed on there."

Storage of PPE (personal protective equipment):

A review of the facility policy, titled "COVID-19 PPE Guidelines" last updated on 01/21/2022, revealed: "...Discard your N95 respirator after every AGP (aerosol generating procedure) or when you need to remove your N95 mask..."

During a tour of the on Medical/Surgical (Med/Surg) unit on 5/17/2022 at 10:45 AM with Med/Surg Team Lead I, there were 4 N95 masks in brown paper bags on a utility cart in room #127. When asked Team Lead I who's N95 masks they were, Team Lead I stated, "These N95 masks should have been tossed after use, 3 of the N95 masks belong to nurses who no longer work here, and the other N95 mask belongs to a casual nurse who worked here last about 2 or 3 days ago." When asked what the expectation is for staff after wearing a N95 mask, Team Lead I stated "They should be tossing them after their shift." When asked why PPE (N95 masks and face shields) being stored on a utility cart in a patient room, Team Lead I stated, "We have limited space right now and this room isn't being used."

Based on interview and record review the facility failed to provide medically related social services and activities for 2 of 2 swingbed Pt's. (Patient) #17 and #19 out of a total of 21 records reviewed.

Findings Include:

Review of (Facility) Swing Bed Program binder revealed, "Swing Bed Activities: Activities during your Swing Bed stay are required. These activities are tailored to your interests......To start Swing Bed activities an activities assessment will be performed by the occupational therapist (OT) or the occupational therapy assistant."

Medical Record review of Patient (Pt.) # 17 admitted 05/06/2022 to current, with endocarditis (infection of the heart) and Pt. #19 admitted 3/21/2022 for an ORIF (Open reduction internal fixation) of the left ankle and discharged 04/01/2022, revealed no social services assessment or services were provided or being provided during their swingbed stay.

Medical Record review of Pt. #17 and Pt. #19 revealed no OT activities assessment was completed and no activities were provided or being provided during their swingbed stay.

In an interview with RN Case Manager PP on 05/18/2022 at 07:45 AM when asked if a social services assessment is part of the admission process to determine discharge needs, RN PP stated, "Yes, I typically do this."

In an interview on 05/18/2022 at 10:20 AM with RN Informatisist X when asked if there was evidence of a social services assessment or social services provided to Pt. #17 and Pt. #19, RN X stated, "No, I'm not seeing anything."

In an interview on 05/18/2022 at 10:20 AM with RN Informatisit X when asked if there was evidence of activities provided based on an assessment by occupational therapy to Pt. #17 and Pt. #19, RN X stated, "No, I'm not seeing anything."

In an interview with RN Case Manager PP on 05/18/2022 at 3:05 PM when asked what is the role of social services, RN PP stated, "We don't have a social worker on site, if needed we would consult a social worker in the system by phone."