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Based on review of Medical Staff Bylaws, review of Quality Review Committee Meeting Minutes and interview, it was determined the Governing Body failed to ensure the bylaws of the facility were implemented in that the Quality Review Committee failed to meet five (October and December 2023 and February, March and May 2024) out of twelve (June 2023 through May 2024) months reviewed. By not meeting monthly, it delayed all the recommendations to the Governing Body pertaining to the quality assurance tasks of the Staff and review and evaluation of the quality of the medical and hospital care. The failed practice had the likelihood to affect all patients that receive treatment and care in the facility. Findings follow:

A. Record review of the Medical Staff Bylaws, dated 2023, showed the committee was to meet monthly or more often as necessary.
B. Record review of the Quality Review Committee Meeting Minutes for the previous twelve months (June 2023 through May 2024) showed the October and December 2023 and February, March and May 2024 meetings were missed.
C. During an interview on 06/25/2024 at 10:37 AM, the Associate Director of Nursing verified the findings at B and stated they switched to quarterly meetings after the August 2023 meeting. The Medical Staff Bylaws had not been updated and approved, prior to the Quality Review Committee deciding to decrease the frequency of their meetings.

Based on review of policy, review of Pyxis Medstation Controlled Drug Activities Verification Log, and interview, it was determined the facility failed to adhere to policy in that two (Medical/Surgical and Emergency Room) of three (Medical/Surgical, Emergency Room and Obstetrics) Pyxis Medstations had missing Charge Nurse signatures. By not signing the Pyxis Medstation Controlled Drug Activities Verification Log at the end of each shift, the facility could not assure nurses were not leaving the building while there were pending discrepancies that should have been resolved, to prevent theft, loss and diversion. The failed practice had the likelihood to affect all patients in the hospital. Findings follow:

A. Record review of the facility's policy "Automated Dispensing Cabinet" approved January 24, 2024, showed the Charge Nurse was to review the Controlled Substance Activity reports for all users at the end of the shift. The Charge nurse was to sign and indicate on the Verification Log that the reports had been reviewed and was to report any irregularities to the Shift Supervisor or Unit Supervisor for further investigation.
B. Review of the Pyxis Medstation Controlled Drug Activities Verification Logs for Medical/Surgical and Emergency Room for the month of June 2024 (June 1st through June 23) showed the following missing Charge Nurse shift signatures:
1. Emergency Room 7 AM to 7 PM: 6/3, 6/4, 6/7, 6/8, 6/9, 6/12, 6/13, 6/17, 6/18, 6/21 and 6/22;
2. Emergency Room 7 PM to 7 AM: 6/3, 6/15, 6/16 and 6/23;
3. Medical/Surgical 7 AM to 7 PM: 6/3; and
4. Medical/Surgical 7 PM to 7 AM: 6/9 and 6/13.
C. During an interview on 06/24/24 at 10:20 AM, the Director of Pharmacy verified the findings at B.

Based on review of Rules for Hospitals and Related institutions in Arkansas, review of Postpartum Hemorrhage Cart Checklist and interview, it was determined the facility failed to check the integrity of the seal at the beginning of each shift (per Rules) for one of one (Postpartum Hemorrhage Cart) kit observed on tour. The potential existed for the emergency medication kit not to have medications present for patient emergencies. The failed practice had the likelihood to affect all patients who needed medications in an emergency. Findings follow:

A. Record review of Rules for Hospitals and Related institutions in Arkansas, effective June 20, 2022, showed applicable personnel shall check the cart for the integrity of the seal each shift. Documentation shall reflect that the seal is intact.
B. Record review of the Postpartum Hemorrhage Cart Checklist showed the checklist was to be completed weekly on Tuesdays. The checklist started in December of 2023 and the last check was June 18, 2024. The signatures were weekly.
C. During an interview on 03/25/24 at 2:30 PM, the Director of Quality/ Stroke Co-Ordinator verified the integrity of the seal to the Stroke emergency medication kit was not being checked each shift.

Based on observation of the Emergency Department, Inpatient Facilities, Obstetrics Unit, and Operating Rooms and interview, it was determined the facility failed to maintain the building physical structure, safety, environment, and equipment in a state of good repair. The failed practice promoted the spread of infection and/or placed the patients at risk of fire. The failed practice had the likelihood to affect all patients, staff and visitors. Findings follow:

A. Observation of the Emergency Department on 06/24/24 showed the following:
1) at 10:51 AM, peeling paint in Emergency Room (ER) room 3
2) at 10:51 AM, dirty exhaust vents in ER room 3
3) at 10:54 AM, peeling paint in ER room 4
5) at 10:57 AM, door frame damage in ER room 2
6) at 10:58 AM, missing air conditioning vent and exhaust vent in Biohazard Room
7) at 11:00 AM, exposed wood under supply room sink
8) at 11:05 AM, peeling material around nurses station.

B. The findings in A were verified by the Head of Maintenance on 06/24/24 at the time of observation.

C. Observation of the Inpatient Department on 06/24/24 showed the following:
1) at 9:52 AM, door frame damage in room 217
2) at 9:52 AM, uncovered linen in the linen closet located in front of the nurses station
3) at 9:53 AM, food tray located in the soiled utility room
4) at 9:54 AM, exposed cooling pipes in linen closet
5) at 10:00 AM, broken electrical socket in bathroom of room 213
6) at 10:01 AM, calcium buildup around sink in room 212
7) at 10:02 AM, wall damage next to air conditioner in room 212
8) at 10:13 AM, electrical socket damaged in hallway leading into East Hall
9) at 10:15 AM, damaged fire doors in the East Hall
10) at 10:16 AM, mold located on the inside wall of the EV room in the east hall
11) at 10:16 AM, large hole in the inside wall of the EV room in the east hall
12) at 10:16 AM, wallpaper peeling and wall damage on the outside wall of the EV room in the east hall
13) at 10:18 AM, broken base board at the the bottom of fire doors leading into labor and delivery

D. The findings in C were verified by the Head of Maintenance on 06/24/24 at the time of observations.

E. Observation of the Obstetrics Unit on 06/24/24 showed the following:
1) at 10:39 AM, Peeling material around the nurses station

F. The finding in E was verified by the Head of maintenance on 06/24/24 at the time of observation.

G. Observations of the Operating Rooms (OR) on 06/24/24 showed the following:
1) at 2:12 PM, paint damage in OR 2
2) at 2:30 PM, emergency doors leading to operating rooms did not latch
3) at 2:32 PM, peeling baseboard outside of OR 3

H. The findings in G were verified by the Head of maintenance on 06/24/24 at the time of observation.

Based on observation, review of National Fire Protection Association (NFPA) 101 standards and interview, it was determined the facility failed to ensure that the generator was maintained in that an emergency stop switch was not installed on the generator and there was no battery powered emergency light installed on the generator. The failed practice did not ensure the facility had the means of stopping the generator in the event of an emergency, the generator would be able to run in the event of an emergency and did not ensure the facility staff had the ability to view the generator in the event of an emergency. The failed practice had the likelihood to affect all patients, visitors and staff in the facility. Findings follow:

A. Review of NFPA 101 standards showed the facility was to provide battery-powered emergency lighting as required by NFPA 101, 2012 edition.

B. On 06/25/2024 at 10:15 PM observation of the emergency generator showed there was no covered emergency stop switch installed 10 to 15 feet away from the generator.

C. On 06/25/2024 at 10:12 PM, observation of the emergency generator showed there was no battery powered emergency light installed on the generator.

D. The findings in A through C were verified by the Head of Maintenance on 06/25/2024 at the time of the observations.

Based on observation and interview, it was determined that the facility failed to maintain a sanitary environment in that 15 doors to patient rooms on the Medical Surgical Unit were worn to bare wood, had holes, and/or had unfinished wooden plugs. The failed practice did not ensure the doors could be disinfected due to the porous nature of the wood. The failed practice had the likelihood of affecting all patients cared for in these rooms. Findings follow:

A. Observation of the Medical Surgical Unit on 6/24/2024 showed all patient room doors were worn to bear wood and had either holes left open in the door or the holes had been plugged with unfinished wooden plugs.
B. The findings in A were confirmed during an interview with Assistant Director of Nursing at 9:50 AM on 6/24/2024.


Based on observation and interview, it was determined that the facility failed to ensure tape residue was not present on the walls and doors of Room 216, 217 and 222. The failed practice did not ensure the walls and doors could be disinfected due to the sticky nature of the tape residue. The failed practice had the likelihood to affect all patients admitted to these rooms. Findings follow:

A. Observation of Room 216 and 217 on 6/24/2024 at 10:10 AM showed peeling tape holding up signs on the wall inside the patient rooms.
B. Observation of Room 222 showed there was a sign on the bathroom door held by peeling tape.
C. The findings in A and B were confirmed in an interview with the Assistant Director of Nursing at 10:10 AM on 6/24/2024.


Based on observation and interview, it was determined the facility failed to ensure the linen in the linen closet on the Medical Surgical Unit was covered. Failure to keep the linens covered did not prevent transmission of dust debris and infectious material. The failed practice had the likelihood to affect all patients who were receiving linen from the linen closet. Findings follow:

A. Observation of the linen closet on the Medical Surgical Unit at 9:53 AM on 6/24/2024 showed the linen were stored on shelves with no covering over the sides.
B. The findings in A were confirmed during an interview with the Assistant Director of Nursing at 9:53 AM on 6/24/2024.


Based on observation and interview, it was determined the facility failed to ensure a sanitary environment in that behind the Newborn Nursery door there was red colored discoloration and a large spider web with a live spider. The failed practice promoted the spread of infection and had the likelihood to affect all patients receiving care in the newborn nursery. Findings follow:

A. Observation of the Newborn Nursery at 11:30 AM on 6/24/2024 showed the floor behind the door was discolored and stained with dirt and a red discoloration and a large spider web with a live spider.
B. The findings in A were confirmed during an interview with the Assistant Director of Nursing at 11:30 AM on 6/24/2024.


Based on observation and interview, it was determined the facility failed to maintain a sanitary environment in that there were three environmental services carts stored in an unmarked room with a leak and a large puddle of water with a dustmop. The pipe in the room contained a black substance. The failed practice promoted the spread of infection and had the likelihood to affect all patients' rooms in which the carts were used. Findings follow:

A. Observation of an unmarked room at 11:45 AM on 6/24/2024 showed three environmental services carts were stored in the room. The room had a leak and a large puddle of water in the corner of the room with a dustmop standing in the puddle. The pipe from which the leak was coming had a buildup of a black substance covering the pipe and insulation.
B. The findings in A were confirmed during an interview with the Assistant Director of Nursing at 11:45 AM on 6/24/2024.


Based on observation and interview, it was determined that the facility failed to maintain a sanitary environment in that in the laundry area there was a gap between the door jamb and the nearby washer, and the concrete floor was not sealed. Failure to maintain this area promoted the transmission of infectious material to the freshly laundered linens. The failed practice had the likelihood to affect all patients admitted to the facility. Findings follow:

A. Observation of the laundry area at 11:40 AM on 6/24/2024 showed there was a gap between a door jamb and the washing machine that allowed dust and debris to flow in from the unfinished area behind the door.
B. Observation of the laundry area at 11:40 AM on 6/24/2024 showed the concrete floor was not sealed with did not allow for disinfection due to the porous nature of the concrete.
C. The findings in A and B were confirmed during an interview with the Assistant Director of Nursing at 11:40 AM on 6/24/2024.