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Based on review of the hospital's medical staff credentialing files, Governing Body (GB) minutes, and interview, the hospital failed to document and appoint a medical director over the hospital's dialysis service.

The findings are:

Review of the hospital's credentialing and personnel files on 1/26/2022 at 3:33 PM revealed there was no documentation for a medical director appointment over the hospital's dialysis service with approval by the GB and Board of Directors. On 1/27/2022 at 9:29 AM with the Chief Nursing Officer (CNO), he/she reported, "There is no approval by the board or the Governing Body. It is definitely not something we do annually" and confirmed the finding.

Based on record reviews, interviews, and review of the hospital's policy/procedure, the hospital failed to ensure its staff documented the delivery of the patient rights' documents on admission or to obtain two hospital signatures, or documented an attempt was made after admission to give the documents to the patient/family for 7 of 20 patient charts reviewed for patient rights data. (Patient #1, #4, # 5, #9, #16, #17, and #18)

The findings are:

Patient #4
On 1/26/2022 at 10:16 AM, review of Patient #4's chart revealed the health consent form stated, "patient unable to sign" with one Registered Nurse's signature and no second signature as required by the hospital's policy. The second page of the health consent form was absent. The patient was ordered respiratory isolation. The patient was admitted on 1/17/2022. There was no documentation of any attempts after the patient's admission to give the patient/family the admission documents regarding patient rights, health consent for treatment, and informed consent. The finding was verified by the Chief Nursing Officer (CNO) at 10:15 AM on 1/27/2022.

Patient #9
On 1/26/2022 at 10:54 AM, review of Patient #9's chart revealed the health consent form stated "Unable to Sign" with two signatures present. The patient was admitted on 1/10/2022 and discharged on 1/25/2022. There is no documentation in the patient's chart of any attempts after the patient's admission to give the patient/family the admission documents regarding patient rights, health consent for treatment, and informed consent. The finding was verified by the CNO at 10:15 AM on 1/27/2022.

On 1/27/2022 at 8:50 AM, review of the hospital's policy for "Obtaining Consent", revealed, "If the healthcare provider has attempted to obtain the patient's consent, however, has been restricted due to communication barriers, i.e.-unconscious- and there isn't a family member or guardian present, the consent form should be documented to show the patient is unable to sign. The consent must be witnessed by the Registration Clerk and the nurse with documentation as to why the patient is unable to sign. If the condition restricting the patient from signing is resolved or a family member or guardian presents, the Registration Clerk or Nurse should attempt to get the consent form signed."



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Review of the electronic medical records on 1/26/22 at 2:24 PM for Patient #5, admitted 1/24/22, and on 1/26/22 at 3:20 PM for Patient #16, admitted 12/29/21, revealed there were no initials on the health consent form, titled, "Consent Upon Admission For Medical Treatment", indicating the patient had acknowledged receiving information on the HIPAA Privacy statement, Lewis Blackman Patient Safety Information Sheet, and Patient's Bill of Rights. The finding was verified by the Chief Nursing Officer after a review of Patient #16's record on 1/26/22 at 3:25 PM and after review of Patient #5's chart on 1/27/22 at 9:05 AM.


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Patient #1
On 1/26/2022 at 1:20 PM, review of Patient #1's chart revealed a CONSENT UPON ADMISSION FOR MEDICAL TREATMENT, page 1, was unsigned by the patient, and marked "pt.(patient) unable to sign". The hospital had no documentation that containing the patient was informed of his/her patient rights. On 1/27/2022 at 11:56 AM, the Medical Records Director verified the finding.

Patient #17
On 1/26/2022 at 11:40 AM, the Medical Records Director revealed the hospital was unable to provide documentation for inpatient consent for treatment forms or documentation containing information concerning patient being informed of patient rights for Patient #17. On 1/27/2022 at 11:56 AM, Medical Records Director verified the finding.

Patient #18
On 1/26/2022 at 12:11 PM, the Medical Records Director revealed the hospital was unable to provide documentation that Patient #18 was informed of his/her patient rights. Page 2 of CONSENT UPON ADMISSION FOR MEDICAL TREATMENT had not been initialed by the patient. On 1/27/2022 at 11:56 AM, Medical Records Director verified the finding.

Based on medical record reviews and interview, the hospital staff failed to provide documentation concerning patient rights and accurate health consent documentation for 1 of 1 patient with special needs (Patient #1).

The findings are:

Patient #1
On 1/26/2022 at 1:20 PM, review of Patient #1's chart revealed a Consent for Out
patient Hospital Procedures" &(and)/or "Treatment from the Emergency Department (ED)" signed by Patient #1 and signature of a witness. Review of the form, titled, "CONSENT UPON ADMISSION FOR MEDICAL TREATMENT", page 1, was unsigned by the patient, and marked "pt.(patient) unable to sign", but no reason was given and no co-signature by staff per hospital policy. On 1/27/2022 at 11:56 AM, the Medical Records Director verified the finding.

Based on record reviews, interviews, and review of the hospital's policy, the hospital staff failed to ensure the Advance Directive information was received by the patient/patient representative and/or did not contain the two signatures required by hospital policy for 7 of 20 patient charts reviewed. (Patient #1, #4, #5, #9, #16, #17, and #18)

The findings are:

On 1/24/2022 at 2:00 PM, review of the hospital's policy for Advance Directives stated, "During the admission process, admitting personnel will provide patients/or their designated representative with written material informing patients of their rights to make health care decisions."

Patient #4
On 1/26/2022 at 10:16 AM, review of Patient #4's chart revealed the health consent stated, "Patient unable to sign" with one Registered Nurse's signature instead of the required two per policy. The second page of the consent documentation was not in the chart. The patient was admitted on 1/17/2022. There was no documentation in the chart stating an attempt was made after admission to give the patient/family the admission documents regarding advanced directives and patient bill of rights. The finding was verified by the Chief Nursing Officer (CNO) at 10:15 AM on 1/27/2022.

Patient #9
On 1/26/2022 at 10:54 AM, review of Patient #9's chart revealed the health consent stated "Unable to Sign" with two signatures present. The patient was admitted on 1/10/2022 and discharged on 1/25/2022. There was no documentation in the chart stating an attempt was made after admission to give the patient/family the admission documents regarding advanced directives. This finding was verified by the CNO at 10:15 AM on 1/27/2022.

On 1/27/2022 at 8:50 AM, review of the hospital's policy for Obtaining Consent revealed, "If the healthcare provider has attempted to obtain the patient's consent, however, has been restricted due to communication barriers, i.e.-unconscious- and there isn't a family member or guardian present, the consent form should be documented to show the patient is unable to sign. The consent must be witnessed by the Registration Clerk and the nurse with documentation as to why the patient is unable to sign. If the condition restricting the patient from signing is resolved or a family member or guardian presents, the Registration Clerk or Nurse should attempt to get the consent form signed."

Patient #1
Patient record review on 1/26/2022 at 1:20 PM revealed Patient #1 had a CONSENT UPON ADMISSION FOR MEDICAL TREATMENT, but page 1 was unsigned, marked "pt.(patient) unable to sign" and the hospital was unable to provide documentation containing information concerning patient being informed of patient rights. On 1/27/2022 at 11:56 AM, Medical Records Director verified the finding.

Patient #17
On 1/26/2022 at 11:40 AM, the hospital was unable to provide documentation for inpatient consent for health treatment or documentation containing information concerning patient being informed of patient rights. On 1/27/2022 at 11:56 AM, Medical Records Director verified the finding.

Patient #18
On 1/26/2022 at 12:11 PM, the hospital revealed it had no documentation containing information concerning patient being informed of patient rights. Page 2 of CONSENT UPON ADMISSION FOR MEDICAL TREATMENT was not been initialed by the patient. On 1/27/2022 at 11:56 AM, Medical Records Director verified the finding.


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Review of the electronic medical records on 1/26/22 at 2:24 PM for Patient #5 who was admitted 1/24/22, and on 1/26/22 at 3:20 PM for Patient #16 who was admitted 12/29/21 revealed no initials on the hospital form, labeled, "Consent Upon Admission For Medical Treatment", indicating the patient had acknowledged receiving information on Advance Directives (Make Your Wishes Known). The finding was verified by the Chief Nursing Officer after a review of Patient #16's record on 1/26/22 at 3:25 PM and Patient #5's record during an interview on 1/27/22 at 9:05 AM.

Based on observations, interviews, and review of the hospital's policy, the hospital staff failed to maintain confidentiality of a patient's medical record information on a computer screen and a paper patient diagnostic report.

The findings are:

On 1/25/2022 at 8:30 AM, review of the hospital's policy on Confidentiality revealed, "Every employee, volunteer, student intern, contract workers, and medical staff members and their employees have the responsibility to maintain confidentiality.

On 1/25/2022 at 9:44 AM, observations on the medical nursing unit revealed a computer screen opened with a patient's cardiology consult showing on the computer with no one present at the computer or at the nursing desk. A patient's Electrocardiogram (EKG) report was lying face up on the counter beside the computer screen. The computer screen went black at 9:47 AM. The Chief Nursing Officer (CNO) was notified of the patient data exposed on the computer screen and the screen blackout before it could be verified. The CNO stated the computer has a time out on the screen. On 1/25/2022 at 10:05 AM, RN #3 came to the nursing unit and saw the EKG face up on the desk and immediately turned it over so it would not reveal any of the patient's data. The finding was verified by RN #3 at 10:05 AM on 10/25/2022.

Based on record reviews, interviews, and review of the hospital's policy/procedure, the hospital licensed providers to include the Nurse Practitioners (NP) failed to write patient restraint orders every twenty-four hours for a patient with restraints and exceeded the twenty-four hour limit. (Patient #19)

The findings are:

On 1/25/2022 at 8:30 AM, review of the hospital's restraint policy, stated,
"A physician or other licensed provider that is actively on the Medical Staff may write an order for a restraint. The order must be for no longer than 24 hours."

On 1/27/2022 at 10:55 AM, review of Patient #19's chart revealed restraint orders (Non-Violent and Non-Self-Destructive Behavior) written by NP #3 on 12/2/2021 at 3:56 AM. It is unclear from the chart documentation when the restraints were removed on 12/2/2021. There was no restraint monitoring documentation after 6:00 AM on 12/2/2021, and there was no order for the discontinuation of the restraints.

On 12/4/2021 at 5:10 AM, an order for restraints (Non-Violent and Non-Self-Destructive Behavior) was written by NP #4. On 12/4/2021 at 11:22 PM, an order for restraints (Non-Violent and Non-Self-Destructive Behavior) was written by NP #4.

On 12/5/2021 at 10:31 AM, an order for restraints (Seclusion) was written by NP#5. On 12/5/2021 at 6:07 PM, a new restraint order (Seclusion) was created by NP #5 (The Chief Nursing Officer (CNO) stated the order was written incorrectly. The patient was not on seclusion.) On 12/5/2021 at 9:43 PM, a new restraint order (Non-Violent and Non-Self-Destructive Behavior) was written by NP #4. On 12/5/2021 at 11:40 PM, another restraint order was written (Non-Violent and Non-Self-Destructive Behavior) by NP #4.

On 12/6/2021 at 6:40 AM, a new restraint order (Non-Violent and Non-Self-Destructive Behavior) was written by NP #4.

On 12/7/2021 at 6:40 AM, a new restraint order (Non-Violent and Non-Self-Destructive Behavior) was written by NP#5. On 12/8/2021 at 7:00 PM, new restraint orders (Non-Violent and Non-Self-Destructive Behavior) were written by NP #3.

On 12/9/2021 at 9:50 PM, new restraint orders (Non-Violent and Non-Self-Destructive Behavior) were written by NP #3. The 12/8/2021 order and the 12/9/2021 restraints were greater than twenty-four hours. The finding was verified by the CNO at 10:55 AM on 1/27/2022.

Based on review of medical staff credentialing files, the medical staff minutes, and interview, the hospital failed to appoint a medical director over the hospital's Dialysis Service Program.

The findings are:

Review of the hospital's credentialing and personnel files on 1/26/2022 at 3:33 PM revealed there was no documentation for medical director appointment over the hospital's Dialysis Service Program with approval by the Medical Executive Committee. On 1/27/2022 at 9:29 AM with Chief Nursing Officer (CNO), he/she reported "There is no approval by the Board or the Governing Body. It is definitely not something we do annually."

Based on record reviews and interview, the Chief Nursing Officer (CNO) had no documentation that a verified person for supervision of the hospital's dialysis unit was qualified in the delivery of dialysis services via education and/or experience to supervise the dialysis department.

The findings are:

On 1/24/2022 at 2:00 PM, review of the organizational chart for the Nursing Department revealed the Dialysis Department falls under the total supervision of the CNO. On 1/25/2022 at 12:47 PM, review of the job description of the acute dialysis Registered Nurse (RN) showed this position reports to the CNO. On 1/26/2022 at 8:30 AM, review of the hospital's organization chart showed the lines of authority for the Dialysis Department falls under the CNO. On 1/26/2022 at 9:43 AM, review of the job description for the CNO stated, "Essential Function: Effectively directs the overall operation of nursing services." The CNO stated the Nursing Department has one nurse who has qualifications to perform dialysis and one new employee. If no dialysis nurse is present when dialysis is needed, "Patients are transferred to another hospital by the physician." The DON stated on 1/26/2022 10:00 AM, "I do not have any training in dialysis."

Based on record reviews, interviews, and review of the hospital's policy/procedure, the Registered Nurse (RN) failed to document restraint monitoring every hour for 1 of 1 patient reviewed for restraints. (Patient #19)

The findings are:

On 1/25/2022 at 8:30 AM, review of the hospital's restraint policy, stated for (Non-Violent and Non-Self-Destructive Behavior) restraints that "the re-assessment and monitoring shall be done every hour."

On 1/27/2022 at 10:55 AM, review of Patient #19's chart revealed restraint monitoring by the nurse on 12/4/2021 at 6:11 AM, and the next restraint monitoring was documented at 7:42 AM.

The nurse documented restraint monitoring on 12/6/2021 at 4:55 AM, at 6:00 AM, at 8:00 AM, at 8:24 AM, at 10:00 AM, 11:00 AM, 11:25 AM, 12:26 PM, 2:00 PM, 2:35 PM, 4:00 PM, 5:00 PM, 5:19 PM, and 6:37 PM, and at 8:00 PM.

The nurse documents restraint monitoring on 12/7/2021 at 5:40 AM, at 7:00 AM, at 8:00 AM, 9:00 AM, 10:00 AM, 11:00 AM, 12:00 Noon, 12:43 PM, 2:00 PM, 2:50 PM, 4:00 PM, 4:24 PM, 5:50 PM, 5:56 PM, 6:22 PM, 6:23 PM, and 7:00 PM.

The nurse documented on 12/8/2021 at 5:57 PM and at 7:00 PM. The RN staff did not continuously document restraint monitoring every hour. The findings were verified by the Chief Nursing Officer (CNO) at 10:55 AM on 1/27/2022 who stated restraint monitoring documentation is to be done every hour. On 1/27/2022 at 11:43 AM, documentation was provided by the CNO that showed nursing staff received restraint training in June of 2021.

Based on record reviews, staff interviews, and hospital policy and procedure review, the hospital failed to provide assessment by a physician prior to the administration of anesthesia on the day of surgery for one of six closed patient charts reviewed for surgical services. (Patient #2)

The findings are:

On 01/26/2022 at 1:30 PM, record review for the Surgical Services revealed the facility utilizes a stamp to indicate History and Physical (H&P) was checked before administration of anesthesia. Patient #2's chart had no stamp with Physician initials and date to indicate H&P was reviewed prior to surgery on 01/25/2022. The findings were verified with the Director of the Operating Room (OR) on 01/26/2022 at 3:28 PM. The OR Director stated, "The doctors know they are suppose to sign and update H&P with the stamp." Hospital policy, "Admission of Patient to Operating Room," reads, "Appropriate History and Physical."

Based on observations, interviews, and review of the hospital's policy, entitled, "Out-Of-Date Medications", the pharmacy/respiratory therapy staff failed to ensure expired medications had been removed from staff access in the Radiology/Respiratory Therapy departments.

The findings are:

Observations on 1/25/22 at 2:55 PM of the locked emergency medication tackle box located in the CT (Computerized Tomography) room revealed expired medications. Lidocaine syringe, 2%(percent), 20 mg (milligrams)/ml (milliliter) expired in 6/2010. Three Epinephrine syringes, 1:100 expired in 3/2010. Two syringes of Atropine 1 mg. expired on 1 June 2011. One vial of Solumedrol 125 mgs. expired in 7/2010. One vial of Diphenhydramine, 50 mg/ml expired in 6/2011. Two 10 mls syringes of Sodium Chloride expired in 7/2010. The findings were verified with the Director of Radiology during an interview on 1/25/22 at 2:58 PM.

Observations on 1/26/22 at 9:30 AM of the Radiology Department's emergency supplies revealed a Respiratory Therapy locked tackle box on top of the crash cart. Inside the box were 2 packages of 0.9% Sodium Chloride Inhalation Solution 3 milliliters each that expired in January 2021. The findings were verified by the Director of Respiratory Therapy during an interview on 1/26/22 at 9:37 AM.

On 1/26/22 at 1:12 PM, review of the hospital's policy, provided by the facility, entitled, "Out-Of-Date Medications", revealed, "Medication expiration dates shall be monitored monthly...by the Pharmacy Department. Nursing stations and Pharmacy Department stock shall be monitored for out-of-date medications...".

Based on observations and staff interviews, the facility failed to ensure all doors with access to the facility were secured properly to protect employees and patient safety.

The findings are:

On 01/26/2022 at 10:00 AM, a tour of the physical plant of the hospital revealed a door propped open in the kitchen area leading to the outside. The door propped open allowed easy access to the small kitchen area of the facility. On 01/26/2022, the findings were verified with Director of Plant Operations. The findings were verified with the Kitchen Manager (KM) on 1/26/2022 at 12:00 PM. The KM stated, "The staff empty the trash through that door. They have to re-enter through a different door down the hall. We have no badge swipe at this door. Staff are not to prop the door open."

Based on observations, interview, and review of the facility's policy, entitled, "CHECK OF INSTRUMENTS AND SUPPLIES USED BY STAFF", the hospital staff failed to remove expired supplies from the dialysis area, laboratory, and radiology area.

The findings are:

During observations of the dialysis area on 1/24/2022 at 2:00 PM, observations showed
1 Yankuer suction wand expired 1/6/2017 and 7 Optiflux 180 filters expired 8/31/2021.
On 1/24/2022 at 2:11 PM, Registered Nurse (RN) #1 confirmed the findings.

Facility policy, entitled, "CHECK OF INSTRUMENTS AND SUPPLIES USED BY STAFF", revealed, "All sterile supplies should be checked daily and before use for ...b. Expiration date ...NOTE: Any item that is expired or falls into any of categories A-E should be returned to the department that is responsible for supplying the item."



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Observations on 1/26/22 at 9:30 AM of the Radiology Department's emergency supplies revealed a Respiratory Therapy locked tackle box on top of the crash cart. Inside the box was an adult Carbon Dioxide detector that expired on 12/24/2020. The finding was verified by the Director of Respiratory Therapy during an interview on 1/26/22 at 9:37 AM.

Observations in the Lab on 1/26/22 at 11:50 AM revealed one opened container of Hemoccult developer that expired in 7/2021. The finding was verified with Phlebotomist #1 during an interview on 1/26/22 at 11:55 AM. Twenty-five plus Urinalysis preservative tubes expired on 10/31/21. The finding was verified with Phlebotomist #2 during an interview on 1/26/2022 at 12:00 Noon. Two boxes of sterile foam swabs #100 each expired in 7/2021. A full box of sterile 10 milliliter syringes contained syringes that expired in 6/2020 and 5/2021. The findings were verified with the Lab Director during an interview on 1/26/22 at 12:22 PM.


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On 01/25/2022 at 10:30 AM, observations in the second floor nursing units revealed the storage area connecting to the Intensive Care Unit (ICU) had several Oxygen tanks stored in the supply closet. No signage was posted indicating oxygen in use on the doorways to this storage area. The findings were verified with the Director of Cardiopulmonary Department on 01/26/2022 at 11:00 AM.

Hospital policy, "Cardiopulmonary Department Guidelines," reads, "All equipment and supplies will be stored appropriately so that it is in suitable condition for safe patient usage."

Based on observations, interviews, and review of hospital policy, entitled, "2019 NOVEL CORONAVIRUS (COVID-19), the hospital failed to adequately screen visitors.

The findings are:

Upon entering the hospital on 1/24/2022 at 12:30 PM, there was no staff member at the screening desk. On 1/25/2022 at 8:30 AM, the staff member at the screening desk took temperatures of all 4 surveyors, but only questioned one of the 4 surveyors. The screener stated, "You all are good, no symptoms". On 1/26/2022 at 8:30 AM, the hospital staff member at the screening desk took 3 of 4 surveyors temperatures, but asked no screening questions. During interview on 1/27/2022 at 11:51 AM with the Infection Control Director, he/she reported, "They should have been asking all the screening questions. I can't believe they didn't do that. They were stressed with you all coming in."

Hospital policy, entitled, "2019 NOVEL CORONAVIRUS (COVID-19), revealed, "Screening of COVID-19 can occur to or at time of facility entry ...All non-employees should be screened (until further notice) for the following:
Signs/Symptoms of COVID-19 per current CDC/DHEC guidelines, and
Recent close contact with a COVID-19 positive or suspected person.

Based on review of the Governing Body minutes and interview, the hospital failed to provide documentation for Governing Body (GB) approval of the hospital's organ procurement policies.

The findings are:

On 1/26/2022 at 3:06 PM, review of the hospital's governing body minutes revealed there was no documentation of GB approval for the hospital's Organ Procurement policies. On 1/27/2022 at 9:29 AM, the Chief Nursing Officer reported, "There is no approval by the board or the Governing Body. It is definitely not something we do annually", and confirmed the finding.