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Based on record review and interview, the facility failed to ensure the governing body reviewed facility specific data including but not limited to quality indicators, adverse events, safety of patients, security, and maintenance of the facility resulting in the failure to effectively understand the facility's operations, identify areas for improvement, and take action to improve patient care which could affect all patients served by the facility. Findings include:

See Specific Tags:

A-0045 Failure to ensure periodic medical staff evaluations are conducted
A-0083 Failure to ensure all contracted and non-contracted services are part of the quality program
A-0085 Failure to maintain a list of contracted services

Based on record review and interview, the facility failed to ensure oversight for 22 of 22 medical staff regarding granting of privileges and periodic reviews resulting in the potential for unrecognized issues with medical staff personnel and the potential for unrecognized, unmet patient needs and poor patient outcomes. Findings include:

On 7/10/2024 at 1949, review of the "Quality Assurance & Performance Improvement Plan 2024" which was submitted June 2024 revealed the facility's "service areas include: (bulleted points) Psychiatry, Surgery, Internal Medicine, Gynecology, Family Medicine, Anesthesia, Pathology, Radiology."

Additionally, on 7/10/2024 at 2041, review of the "Board of Managers Q4 2023 Meeting Minutes" dated 4/10/2024 revealed there were 18 providers. "These include 4 Psychiatrist, 2 Physicians, 4 Surgeons, 2 OB/GYN (obstetrics/gynecology), 3 NPs (nurse practitioners), and 1 PA (physician assistant)."

On 7/11/2024 at 1124, CEO Staff A, who was part of the Board of Managers, was queried as to why they had 4 surgeons and 2 OB/GYN physicians on staff when the hospital was providing only endoscopy and psychiatric services. Staff A stated some of the medical staff were "legacy" and had been practicing within the last year, so were still credentialed. He was "unsure" why there would be OB/GYN physicians on staff, but surmised that it must be a requirement for the medical residency program.


47415

On 7/11/24 at approximately 1100, Staff PPPP provided medical staff credentialing files for review. This review revealed the following for the described medical staff:

Family Medicine Staff X:
Basic Life Support (BLS) certification on file expired 5/20/2019, Advanced Cardiac Life Support (ACLS) certification expired 6/2021. (required by facility policy).
Reappointment letter sent 1/16/23, however there was no reappointment application available for review.
No current ongoing provider performance evaluation (OPPE) or peer review for 1/16/23 reappointment.
Delineation of Privileges Form - dated 7/1/2020 was missing an approval signature by the department chair.

Gastroenterology (GI) Physician Staff JJJ:
Drug Enforcement Agency (DEA) Registration in file expired 9/30/23.
Board Certification documentation expired 12/31/18.
Reappointment letter sent 1/16/23, however there was no reappointment application available for review.
No current Ongoing Professional Practice Evaluation (OPPE) data in file, no peer review by same specialty for 1/16/23 reappointment available for review.
Last query to National Practitioner Data Bank (NPDB) dated 3/8/16.

Psychiatric Physician Staff LLL:
Delineation of privileges form for psychiatry dated 4/2/24 was missing an approval signature by the department chair.
Appointment letter dated 4/25/24 grants Staff LLL initial appointment to ACTIVE status (Bylaws require PROVISIONAL status for initial applicants for a minimum of 12 months).

Psychiatry Physician Staff MMM:
Last reappointment letter in file dated 2/19/19 and revealed appointment expired 1/19/21.

Psychiatry Physician Staff NNN:
DEA Registration on file expired 6/30/23.
Delineation of privileges form dated 3/22/23 was missing an approval signature by the department chair.
Initial appointment letter dated 3/24/23 appoints staff NNN to ACTIVE staff (Bylaws require PROVISIONAL status for initial applicants for a minimum of 12 months).
No Focused Provider Performance Evaluation (FPPE) per bylaw requirements.
No references for initial application found. (Bylaws require two references with initial application).

Obstetrics and Gynecology Physician Staff OOO:
Initial appointment application not dated.
Initial appointment letter (dated 3/4/23) granted Staff OOO ACTIVE staff privileges (Bylaws require PROVISIONAL status for initial appointment applicants for a minimum of 12 months).
No references for initial application found. (Bylaws require two references with initial application).
No Focused Provided Performance Evaluation (FPPE) per bylaw requirements.

Psychiatry Physician Staff QQQ:
Delineation of Privileges for psychiatry dated 3/15/23 was missing approval signature by department chair.
No performance review (OPPE) for reappointment found on file.

Psychiatry Physician Staff WWW:
No Reappointment application (reappointment letter dated 1/16/23)
No current OPPE or peer review found in the file.

Psychiatry Physician Staff XXX:
Initial appointment letter dated 6/27/24 grants Staff XXX ACTIVE status. (Bylaws require PROVISIONAL status for initial applicants for a minimum of 12 months).
No references for initial application found. (Bylaws require two references with initial application).

Anesthesia Physician Staff CCCC:
No reappointment application or board reappointment letter found for reappointment approval documents signed by department chair, Credentials Committee, Executive Committee and Board on 11/13/23.
BLS/ACLS certifications on file expired 3/20 (required per facility policy).
No current OPPE data or peer review found in credential file.

Pathology Physician Staff FFFF:
No reappointment application found, last Board appointment letter dated 8/1/21 (last appointment approval document signed 7/30/21.
No delineation of privileges form, a signed Laboratory Director Designee in file (no date) and Job Description for Clinical Consultant signed 7/22.
Background check dated 7/11/24 (during current survey).

OB/GYN Physician Saff EEEE:
Initial appointment letter (dated 3/14/23) granted Staff EEEE ACTIVE staff privileges. (Bylaws require PROVISIONAL status for initial applicants for a minimum of 12 months).
No Focused Provided Performance Evaluation (FPPE) per bylaw requirements.

Psychiatric Physician Staff DDDD:
Appointment approval documents signed and dated 6/7/22 by Credentials committee, 7/1/22 by Executive Committee, and 7/15/22 by the Board. The file did not contain documentation that a background check or NPDB query was completed prior to the initial appointment approval.
A single, undated application was noted in the file. A reappointment letter dated 1/16/23 was also present. (Bylaws require an application for each appointment and PROVISIONAL status for initial applicants for a minimum of 12 months).

Infection Control Chair- Physician Staff GGGG:
A credentialing file was requested and not provided for review for Infection Control Chair- Physician Staff GGGG.

Nurse Practitioner (NP) Staff RRR:
Initial appointment letter dated 5/27/24 appoints staff RRR to ACTIVE staff (Bylaws require PROVISIONAL status for initial applicants for a minimum of 12 months).
Medical Staff (MS) Approval form dated 5/30/24 not signed by Department Chair.
Background check and NPDB query on file both dated 6/3/24 (post appointment to ACTIVE staff).

NP Staff TTT:
NP license in file expired 4/9/24.
Initial appointment letter dated 6/30/23 appoints staff TTT to ACTIVE staff (Bylaws require PROVISIONAL status for initial applicants for a minimum of 12 months).
Background check in file dated 12/15/23 and NPDB query in file dated 12/18/23.
Supervising Physician Agreement not signed.
No Focused Provider Performance Evaluation (FPPE) per bylaw requirements.

NP Staff BBBB:
Appointment letter dated 3/14/23 grants Staff BBBB initial appointment to ACTIVE status (Bylaws require PROVISIONAL status for initial applicants for a minimum of 12 months).
Background check and NPDB query in file were dated 3/24/23 (post appointment to ACTIVE staff).
Standard Practitioner Application signed and dated 3/22/23.
No Focused Provider Performance Evaluation (FPPE) per bylaw requirements.

Certified Registered Nurse Anesthetist (CRNA) Staff KKK:
No reappointment application, reappointment letter from Board dated 1/16/23.
Last competency evaluation documentation in file dated 2/12/20.

NP Staff VVV:
Initial appointment letter dated 6/27/24 appoints staff VVV to ACTIVE staff (Bylaws require PROVISIONAL status for initial applicants for a minimum of 12 months).

Physician Assistant (PA) Staff PPP:
Initial appointment letter dated 4/1/24 appoints staff PPP to ACTIVE staff (Bylaws require PROVISIONAL status for initial applicants for a minimum of 12 months).

DNP Staff AAAA
NP license in file expired 11/29/23.
DEA registration expired 8/31/23.
Supervising Physician's Agreement dated 4/17/23.
BLS certification expired 7/20/23.
Initial appointment letter dated 4/18/23 appoints staff AAAA to ACTIVE staff (Bylaws require PROVISIONAL status for initial applicants for a minimum of 12 months).
Background check in file dated 12/15/23 and NPDB query in file dated 12/18/23.
No Focused Provider Performance Evaluation (FPPE) per bylaw requirements.

NP Staff ZZZ:
Initial appointment letter dated 6/27/24 appoints staff ZZZ to ACTIVE staff (Bylaws require PROVISIONAL status for initial applicants for a minimum of 12 months).

On 7/11/24 review of the Medical Executive Minutes for 2023 revealed: No Meeting Minutes for a Regular Annual Meeting of the Medical Staff. This annual meeting required per bylaws includes the election of medical staff officers. No documentation of an annual election of officers found for greater than 12 months. No Medical Staff Vice Chair, Secretary/Treasurer, or Members at large could be identified as active in positions at time of survey.

On 7/12/2023 at 1350, an interview with CEO Staff A was conducted, who stated an almost complete turnover of the medical staff occurred in October of 2022 due to service lines being suspended (urgent care, in-house radiology, and respiratory) and that the Chief of Staff is currently the only physician that attends the Executive Committee of Medical Staff and the structure of the medical staff is currently in revision with legal (since October of 2022). Officers of the Medical Executive Committee (Secretary and Treasurer) have not been appointed since October of 2022, no annual Meeting held in 2023, and that department chairs are not all current.

A record review of the Governance Plan of Oakland Physician Medical Center, LLC, d/b/a Pontiac General Hospital, dated 4/10/24 revealed: "The responsibilities and obligation of the Board shall include: ...3.7 Put in place an organized Medical Staff structure ...Board is responsible for all phases of the operation of the Company's hospital, selection of Medical Staff, and quality of care rendered in the hospital ...the Board is responsible for assuring that physicians admitted to practice in the hospital are granted hospital privileges consistent with their individual training, experience and other qualifications ...The Board shall delegate to the Medical Staff the responsibility and authority to investigate and evaluate all matters relating to Medical Staff and AHP membership status, clinical privileges and corrective action, and shall require that the Medical Staff adopt and forward to it specific written recommendations with appropriate supporting documentation that will allow the Board to take informed action".

Based on record review and interview, the Governing Body failed to ensure the endoscopy and anesthesia programs participated in the Quality Assurance Performance Improvement (QAPI) program resulting in the failure to effectively understand the facility operations and failure to identify areas for improvement which could affect all patients receiving endoscopy and/or anesthesia services. Findings include:

During the entrance conference on 7/9/2024 at 1020, a list of contracted services was requested. No list was provided prior to exit of survey on 7/16/2024 at 1400.

On 7/10/2024 at 1949, review of the quality meeting minutes dated 7/27/2023, 8/31/2023, and 3/2024 revealed no representation or information present regarding endoscopy services and/or anesthesia services.

On 7/10/2024 at 2041, review of the governing board meeting minutes dated 8/29/2023, 12/13/2023, and 4/10/2024 revealed no information regarding endoscopy and/or anesthesia services.

On 7/11/2024 at 1342, Director of Quality Staff F confirmed anesthesia was a contracted service and was queried as to why endoscopy and anesthesia were not part of the quality program. She stated she had taken over the position "less than 2 months ago" and was unsure why they were not included stating, "It's probably because they're outpatient."

Review of the "Quality Assurance & Performance Improvement Plan 2024" submitted by Staff F in June 2024 states, "The Quality Assurance and Performance Improvement (QAPI) Plan is a description of the Organizational, multi-disciplinary and systematic quality function. The intent of the QAPI Plan is to provide a coordinated, objective and systematic approach to improving and sustaining the performance through the prioritization, design implementation, monitoring and analysis of performance improvement initiatives. ...The goal of the QAPI program is to assure continuous and incremental performance improvement in the delivery of quality health care. The program promotes an organization-wide commitment to continually meet and/or exceed standards. The program emphasizes ongoing assessment of the dimensions of performance including surveillance of health care delivery involving qualifications and performance of those managing and delivering the services, the outcome of care and services delivered, the availability and utilization of support resources, facilities, staff, equipment and the environment to assure efficiency, cost effectiveness and accountability for all staff... The governing body has the ultimate responsibility and authority for oversight and implementation of the QAPI Plan... The Quality Council represents the collaborative efforts of the medical staff and hospital departments to monitor organization-wide patient care activities, identify opportunities for performance improvement, and make recommendations for performance improvement projects based upon defined measurements and outcomes... All departments, services and programs participate in the hospital's QAPI program... (Name of hospital)'s service areas include: (bulleted points) Psychiatry, Surgery, Internal Medicine, Gynecology, Family Medicine, Anesthesia, Pathology, Radiology."

Based on record review and interview, the facility failed to maintain a list of all contracted services resulting in the lack of tracking and verification of contractor responsibilities and the potential for negative and/or adverse outcomes for all patients receiving services in the facility. Findings include:

During the entrance conference on 7/9/2024 at 1020, a list of contracted services was requested. Contracts and agreements were sent for facility and plant operations, dietary, housekeeping, security, x-ray, ultrasound, and physicians.

On 7/10/2024 at 1343 during the medical record review of P-29, it was noted there was a laboratory downtime report from a pathology group inside of another nearby acute care hospital present with the findings of the biopsies that were taken during his procedure.

On 7/10/2024 at 1417, review of the medical record for P-31 revealed there was a "Histology Cytology Report" present with a header of another nearby acute care hospital with findings of the biopsies that were taken during his procedure. Similarly, the medical records for P-32, P-33, and P-34 all had pathology findings from this nearby acute care hospital.

On 7/11/2024 at 1000, review of the contracts and agreements provided by the facility revealed a lack of contract/agreement for pathology and for anesthesia providers.

During an interview on 7/11/2024 at 1342, Quality Director Staff F confirmed anesthesia was a contracted service and there were some agency nursing staff as well.

During review of staff files on 7/12/2024 at 1116, it was noted Registered Nurse (RN) Staff M had a "Nurse Independent Contractor Agreement" present.

A compiled list of all contract services which included what services and responsibilities were supplied by the contractor was not provided prior to exit of survey.

Based on observation, interview and record review the facility failed to assure that patients are free from physical and verbal abuse, receive appropriate treatments in a safe, secure, hazard-free, clean and sanitary environment, patients and their representatives are notified of their rights and made informed decisions regarding their care, and all received grievances are addressed and resolved in appropriate manner and timely, resulting in negative outcomes to patients and the likelihood of adverse outcomes to all patients in the facility. Findings include:

See Specific Tags:

A-0117 Failure to assure that patients and/or patients' representatives were notified of the patient's rights in advance of furnishing or discontinuing patient care.

A-0122 Failure to review, investigate, and resolve patient's representative grievance within a reasonable time frame according to facility's process and procedures.

A-0123 Failure to provide a written notice of the investigation of the grievance, results of the investigation, and the date of completion of the investigation of the patient's grievance.

A-0129 Failure to ensure that patients' rights requirements are met.

A-0131 Failure to assure that informed consents are obtained and documented appropriately.

A-0144 Failure to ensure care in a safe setting.

A-0145 Failure to ensure that all patients are free from all forms of abuse and/or harassment.

Based on observation, interview and record review, the facility failed to ensure that patients and/or patients' representatives were notified of the patient's rights in advance of furnishing or discontinuing patient care for three patients (P-3, 4 and 15) of 10 patients reviewed, resulting in inaccurate/incomplete patient records, uninformed patients and/or representatives and the possibility for negative outcomes to the patients. Findings include:

Initial tour of the facility was conducted on 7/9/24 from 1055 to 1230 with Director of Nursing, Staff C. Several patients were observed and interviewed on unit 6 North (6N) at 1130. P-15's record was reviewed during the tour of 6N unit's nurses' station. Important Message for Medicare (IMM) form was identified. Form was signed as "guardian consented" and dated 5/15/24. No time when consent was obtained was noted on the form, no witness signatures or date and time when informed consent was witnessed by staff was noted on the form. Staff C was asked if the form was complete, she stated "no" and confirmed the findings.

P-4 medical records were requested and reviewed. P-4 was admitted to facility on 6/13/23 and discharged on 6/30/23 at 1115. Second Important Message for Medicare form was identified. Form was signed as "reviewed with guardian" and dated 6/30/23 1054. No staff signature was evident on the form.
During a phone interview with P-4's guardian on 7/9/24 at 1715, she stated that she picked up her son (P-4) on 6/30/23 after a more than 10-hour drive from upper part of the state. She shared that facility's staff did not contact her that day and she found her son waiting for her in the facility's lobby. She stated she did not sign or discuss any discharge documents with staff that day.

On 7/11/24 at 1220 Director of Social Work, Staff GG, was interviewed. During interview she was asked if second IMM form presented to patients or/and responsible parties before discharge needed to be signed by staff if it was presented over the phone. Staff GG said that staff should sign their name on the form if they conducted conversation with guardian over the phone.

Facility Informed Consent and Discharge Planning Policies were requested on 7/9/24 and reviewed on 7/15/24. Policy "Discharge planning evaluation and Referral", dated 11/01/2008 and revised 3/12/2024, and "Informed consent for Treatment" Policy, dated 11/01/2008 and revised 6/14/2023, did not have any outlined directives regarding instructions to fill and furnish 1st and 2nd Important Message for Medicare forms for patients and /or their representatives.

Policy "Admission and Intake Procedure: Involuntary and Voluntary Recipients", dated 11/01/2008 and revised 6/25/2024, indicated:
k. Admission to unit - Voluntary/Involuntary Recipient:
- Intake, Social Worker, Nurse, or Case manager screens for appropriateness of admission, insurance coverage and notifies designated staff.
-The staff processes the admission papers, provided Patients' Rights Booklet and escorts the Recipient to the unit.
-The following paperwork shall be completed:
d. HIPAA Acknowledgement
e. Section 489 of Mental Health Code
f. Formal Voluntary Form
g. Confidentiality Statement
h. Important Medicare Message Letter (IMM), if applicable


47415

On 7/10/2024 from 1400 to 1430, an interview and record review of P-3's medical record was conducted with the Director of Nursing (DON) Staff C. This record review revealed no documentation present in the medical record indicating the Important Message from Medicare (IMM) was reviewed with P-3 prior to discharge. This finding was confirmed by DON Staff C.

Centers for Medicaid Services (CMS) regulations state hospitals must issue the IMM within 2 calendar days of the day of admission and obtain the signature of the beneficiary or his or her representative to indicate that he or she received and understood the notice. The IMM, or a copy of the IMM, must also be provided to each beneficiary within 2 calendar days of the day of discharge.

Based on interview and record review, the facility failed to review, investigate, and resolve a patient's representative grievance within a reasonable time frame for one patient (P-4) of 3 patients reviewed, resulting in denying the patient rights for grievance process and unsatisfactory outcomes for the patient's responsible party. Findings include:

On 7/11/24 at 1010, during interview with Quality/Risk/Compliance officer, Staff HH, she stated that all grievances received by the facility are logged and investigated by her. She stated that she personally acknowledges receipt with patients or sends a letter of acknowledgement within a day. She explained the process of investigation and stated that the facility always follows up with complainants regarding the results of the investigations.

P-4 medical record was requested and reviewed on 7/9/24 at 1730. P-4 was a 36-year-old male admitted to facility on 6/13/23 with diagnosis of psychosis. Patient was petitioned for inpatient admission due to his recent self-injurious behaviors. P-4 had a history of seizures disorder, autism, mild intellectual development disorder, non-verbal. He had an appointed guardian, who was his mother. Patient was discharged on 6/30/23. All grievances, investigations, and documentation pertaining to P-4 care in a facility was requested on 7/9/24 and reviewed on 7/10/24.

Record review of grievance documentation provided by facility revealed the following.
Acknowledgement/Intervention letter dated 01/25/24, that was sent to the P-4's guardian, indicated that grievance/complaint was submitted to facility on 7/6/23.

This letter contained the following: "Due to administrative issues the office is reviewing your complaint today. Your complaint has been assigned for investigation. A Rights Advisor will be contacting you soon. Under most circumstances, the investigation will be completed within 90 days. While the investigation is being conducted, you will receive a status report on its progress every 30 days. When the investigation is completed, a Report of Investigative Findings (RIF) will be sent to the Hospital Director. The Director will send you a summary report 10 days after he/she receives the RIF. The Summary Report will include information on the Recipient Rights Appeals, which allows you to appeal the findings or action through the independent review process".

Review of this letter revealed that facility received the complaint on 7/6/23, and the Acknowledgement/Intervention letter was sent on 01/25/24. Report of Investigative Findings (RIF) was signed by administrator, Staff G, on 5/1/24 (11 months after complaint was submitted). Additional documents regarding status reports were requested yet none provided.

During interview with Staff HH, on 7/11/24 at 1010, she was not able to comment on the dates in the letter or results report. When asked about the grievance submitted on behalf of P-4, she responded it was before she assumed the responsibility of Compliance Officer (in November 2023) and she was not aware of the complaints regarding P-4's care in the facility.

Facility Patient Complaint and Grievance Policy was requested and reviewed on 7/12/24. Policy, dated 11/01/08 and revised 1/26/24, indicated:
"Procedure. 8. Immediate notification to the Director or Manager establishes the timeliness of action in which the matter is investigated and resolved. 9. Investigation and documented response to the complainant are expected within (7) seven days after the complaint is received, or a notification letter that investigation is ongoing and follow up communication will be sent when concluded within 30 days".

Based on interview and record review, the facility failed to provide 1 (P-3) of 3 patients reviewed for grievances with written notice of a grievance investigation, resulting in denying a patient of their right to a complete grievance process. Findings include:

On 7/10/2024 at 1000, review of the Grievance Log for the past six months revealed an entry for P-3 (Diagnosis Bipolar disorder, admission 5/31/24) recorded as received on 6/17/24.

On 7/11/2024 at 1400, review of the grievance form completed by P-3 dated 6/14/2024 revealed the grievance concern was regarding privacy being violated because of the video and photo surveillance in the facility. The grievance form was date stamped received 6/17/24.

On 7/11/2024 at 1410, an interview was conducted with Quality/Risk/Compliance staff HH who stated that she picks up grievances from unit boxes on Mondays, Wednesdays, and Fridays. Staff HH stated that she received P-3's grievance on 6/17/24 (Monday) and P-3 was discharged on 6/14/24 (the previous Friday). Staff HH stated P-3's concern was considered a grievance because it was submitted in writing. Staff HH confirmed that an acknowledgment letter was not sent, she spoke with the family regarding the receipt of the concern by phone on 6/17/24. Grievance log stated a closure letter was sent, when asked to see copy of final letter, Staff HH stated the log was in error, no closure letter was sent.

On 7/12/2024 review of facility policy titled, "Patient Complaint and Grievance Policy" dated revised 1/26/24 revealed, "A written complaint is always considered a grievance ...the resolution or corrective action is communicated to the patient by phone, letter or conference, when appropriate ...All final resolutions of a concern/issue are provided as verbal or written notice to the complainant." (CMS) regulations require written resolution response to complainants.

Based on interview and record review, the facility failed to ensure that patient rights were exercised for one (P-2) of 10 patients reviewed for patient rights, resulting in the unmet exercise of patient rights. Findings include:

A record review of P-2's medical record revealed that on 5/14/2024, P-2 was ordered the medication haloperidol 5 mg intramuscularly every 6 hours as needed for breakthrough agitation.

On 7/9/2024 at 1530, during medical record review with Director of Nursing Staff C, the q-15-minute safety checks performed on 5/21/2024 by the Mental Health Technician revealed that P-2 was sleeping prior to 0530, calm from 0530 to 0630 and from 0730 to 1000. From 0630 to 0730, P-2 was noted to be responding to internal stimuli while at the nursing station. On 5/21/2024 at 0830, P-2 refused the medication hydroxyzine 50 mg to be taken orally for anxiousness. On 5/21/2024 at 0903, P-2 received an intramuscular dose of haloperidol 5 mg for anxiety.

On 7/10/2024 at 1130, LPN Staff JJ was interviewed and was asked why she administered the haloperidol intramuscularly to P-2 since the patient was noted as "calm" at that time during safety checks. Staff JJ stated that P-2 was "frail, and nervous by nature." She did not recall the patient being hostile. Staff JJ stated that prior to administering the medication, she confirmed the situation with the Charge Nurse. When asked if she ever threatened P-2, Staff JJ said "no." When asked did you say to the patient "If you don't take the oral medications, I will give you a shot," Staff JJ replied "yes."

On 7/10/2024 at 1145, Director of Nursing Staff C was interviewed and confirmed the statement that Staff JJ communicated to P-2 about giving her a shot was a threat.

On 7/12/2024 at 0930, interviewed Physician Resident Staff NN. Staff NN when asked if a patient refused their medications would it be appropriate to administer an intramuscular shot of haloperidol, he said it would not be appropriate.

On 7/15/2024 at 1400, the facility's "Patient Admission Packet" was reviewed, and the information indicated that as a patient, "You have the right to refuse care" and "You have the right to be treated with courtesy and respect."

Based on interview and record review the facility failed to ensure that informed consents are given and documented appropriately for four patients (P-2, 3, 4 and 15) of 10 patients reviewed for informed consents, resulting in violation of patients' rights for informed decision and potential for negative physiological and psycho-social outcome for the patients. Findings include:

Facility's policy for consents for treatment was requested on 7/9/24 and reviewed on 7/10/24. Policy "Informed Consent for Treatment", dated 6/14/23, indicated:
"If a change in the plan of care involves the use of psychotropic medications, the physician or nurse shall explain the risk/benefits involved. The Recipient shall receive oral and written information regarding the medication. The RN shall obtain the Recipient...informed consent, utilizing the "Informed Consent for Medication" form. The medication education will be documented on the consent form".

P-15's medical records were reviewed on unit 6 North (6N) on 7/9/24 at 1120 with Director of Nursing, Staff C, present. Consent for medical treatment was identified to be signed as "guardian consented". No date and time when consent was obtained was noted on the form, no witness signatures or date and time when informed consent was witnessed by staff was noted on the form as well. Staff C was asked if the consent form was completed appropriately. She stated "no" and confirmed the findings.

P-4's medical record was requested and reviewed on 7/9/24 at 1730.
P-4 was a 36-year-old male admitted to facility on 6/13/23 with diagnosis of psychosis. Patient was petitioned for inpatient admission due to his recent self-injurious behaviors. P-4 had a history of seizures disorder, autism, mild intellectual development disorder, was non-verbal. He had an appointed guardian (his mother). Patient was discharged from the facility on 6/30/23.

On 7/10/24 at 0915 P-4's record was reviewed with Staff C to confirm that all medication consents were reviewed and signed with patient's guardian. Staff C could not find the signed Risperdal (Risperidone- antipsychotic medication) consent at the time of the chart review, neither was it a part of provided full medical record.

Later, on 7/10/24 approximately at 1600, paper copy of the consent was provided by Staff C. Provided consent had Risperdal listed as "medication", under indication was written "psych", dose was noted as 1-16 mg (no clarification was added if it was a daily, one time or a weekly dose). In signature line there was a statement that "phone consent from guardian" was obtained on 6/21/23. No time was documented. Nurse signature line had nursing staff name listed, signed and dated 6/21/23 1800. No second witness signature for a phone consent was documented. No physician signature was noted on a consent form. Staff C was asked if phone consents are signed with 2 staff/witnesses. She said yes. When asked if all lines with date and times on the form need to be filled in, she said yes.

Further review of P-4's medication administration record revealed: Risperdal order 1 mg oral, every AM and PM. It was signed by psychiatrist, Staff NN, on 6/21/23 at 1537 (prior to informed consent provided that was dated 6/21/23 and timed by nurse at 1800). Risperdal was given on 6/21/23 1 mg, oral per order, at 2120. No education regarding Risperdal medication provided to guardian was documented on consent or in patient's record.

During the phone interview with the P-4's guardian on 7/9/24 at 1715 she stated that she was not asked or consented for any additional medications except the two on admission (Clozaril and Klonopin).

Additional review of P-4's medical record revealed a consent form obtained via phone from the guardian dated 6/15/23 1620, witnessed by two licensed staff (registered nurses) and signed by physician on 6/16/23 at 0600. Consent was obtained for the following medications: Clozaril, indication- for psychosis, mood stabilization, withdrawal, dosage range: 100-900 mg. Also, Klonopin, indication- anxiety, benzodiazepine, dosage range: 1-4 mg. Dosage range did not specify if the range is for one administration or the 24-hour period. No consents were obtained for PRN (as needed) antipsychotic medications: Haldol 5 mg PO/IM (oral or intramuscular) Q 6h (every 6 hours) as needed for break through psychosis and agitation; Hydroxyzine 50 mg three times a day as needed for break through anxiety; Trazodone 50 mg oral three times a day as needed for break through anxiety and agitation.


47415


On 7/10/24 at 1400 record review for P-3 conducted with the assistance of CNO Staff C revealed no medication consents for psychiatric medications for P-3 found in medical record. P-3 was administered new medication Risperdal daily on an AM and PM schedule, and Haldol (intramuscular and oral) for breakthrough agitation (given orally on 6/5/24 and 6/9/24, and one dose given intramuscularly on 6/8/24).

On 7/10/24 at 1430 interview with CNO Staff C revealed medication consents are required for all psychiatric medications (completed by RN) and Staff C confirmed no psychiatric medication consents were present on P-3's medical record.


50585

On 7/9/2024 at 1530, P-2's medication consent was reviewed in P-2's medical record. The consent listed two medications, Seroquel for psychosis and Remeron for depression, however the dosage fields for both medications were left blank. P-2 signed the Psychiatric Medication Consent on 5/14/2024 at 2144.

Additional review of P-2's medical record revealed the following medications were ordered for P-2 on 5/14/2024: haloperidol 5 mg intramuscular every 6 hours as needed for breakthrough agitation and psychosis, haloperidol 5 mg by mouth every 6 hours as needed for breakthrough agitation and psychosis, mirtazapine (Remeron) 15 mg by mouth every night at bedtime for depression, quetiapine fumarate (Seroquel) 25 mg by mouth every night at bedtime for psychosis, hydroxyzine pamoate 50 mg every six hours as needed for anxiety, and trazodone 50 mg by mouth every night at bedtime as needed for insomnia. Haloperidol was not documented on the consent form.

On 7/15/2024 at 1345, the facility's policy "Consent: Informed Consent for Treatment," dated 6/14/2023 was reviewed and the policy indicated "If a change in the plan of care involves the use of psychotropic medications, the physician or nurse shall explain the risk/benefits involved. The Recipient shall receive oral and written information regarding the medication. The RN shall obtain the Recipient's informed consent, utilizing the "Informed Consent for Medication" form. The medication education will be documented on the consent form."

On 7/15/2024 at 1350, the facility's policy "Documentation of Medication Administration," dated 8/25/2023 was reviewed and the policy indicated "Nurse administering medications will ensure patient consent for psychotropic medications prior to medication administration."

Based on observation, interview, and record review, the facility failed to ensure care in a safe setting by failing to secure unoccupied units and failing to identify and mitigate environmental risks which were unique to the psychiatric population which comprised safety for all patients in the facility resulting in elopements and the potential for physical harm for all patients served by the facility. Findings include:

On 7/9/2024 at 1155, the surgical lab was entered. Upon entering, immediately on the left was a refrigerator. The front of the refrigerator had multiple pieces of signage present; however, also had a dried opaque substance across the lower half. Upon opening the refrigerator, the gasket on the inside of the door was almost completely black with what appeared to be mold along the top and side of the door. In the bottom of the refrigerator were folded blue pads to absorb anything that might drip from the racks. The back corner and along the back wall of the refrigerator were yellowish brown stains present. The shelves were empty except for temperature monitoring devices.

Multiple ceiling tiles were found to have a black substance on them that appeared to be moving across the tile. Air vents appeared rust colored. The stainless steel sink and counter area appeared stained with opaque fluid that had since dried, brown substances, and possibly some rust. On the stainless steel counter was what appeared to be a once white cutting board that had hundreds of cuts/scratches across the surface. Some areas of the board were stained black while other portions of the board were green. There was a vinyl chair pushed in tight to the stainless steel counter. The stitching on the chair was dark brown/black all the way across the back. The vinyl and stitching appeared dirt stained. The chrome on the back support of the chair appeared to have a crusty white substance on it as well as dried clear fluid drops.

On 7/10/2024 at 1020, the crash cart log in the pre/post op area was reviewed and found not to have been checked since 6/5/2024. When queried as why the cart had not been checked, Quality Manager Staff F stated it was only checked on the days that procedures were done. A policy was requested and the facility provided the policy #CLI-M-2 titled "Medication Management and Administration" addresses emergency medications on "emergency resuscitation carts"; however, the policy does not address the need for logging the equipment being ready for use and the lock unbroken.

Additionally, the crash cart was found to be dusty across the bottom. Adhesive residue was present on 6 of 6 drawers, the monitor appeared dusty, the pulse oximetry finger clip was wrapped in paper tape which appeared yellow in color. When asked to turn on the defibrillator, Staff F stated she was not clinical and requested Director of Nursing Staff C to come to the unit. On 7/10/2024 at 1135, Staff C met Staff F and surveyors back in the pre/post op area. When asked to turn on the monitor, the screen would come up, state it needed service, and immediately shut back off. After trying to troubleshoot for several minutes, Staff C found that neither the defibrillator or the suction were plugged in. Staff C stated it was her expectation that the defibrillator and suction be plugged in at all times when not in use to prevent the batteries from being completely drained and the units unable to function.

On 7/11/2024 at 1500, the surveyors went throughout the hospital, unescorted, and had unrestricted access to most units/departments in the hospital including units that were not in current use (rooms 510-515, 709-721, Intensive Care Unit, Surgical Recovery Unit, and Surgical Unit), with the exception of the locked psychiatric units that were currently in use and the emergency department (ED) where surveyors were stopped by security.

Former nursing unit, 5 North (5N), was entered on 7/11/2024 at approximately 1515. Several of the patient rooms were being used as offices for staff including the infection preventionist and the nurse educator. On 7/11/2024 at 1555, the soiled utility room on 5N was entered and found to have a cart with unused personal protective equipment (PPE) present as well as a crash (emergency) cart present. The crash cart was opened and found to have some medications and intravenous (IV) bags present. Some of the medications were found to be expired. Syringes and needles were also found to be present on the cart. The cart was sitting approximately 3 feet away from the hopper (flushing rim clinical service sink for disposal of liquid clinical waste). On the counter directly across from the crash cart was a sharps container that was full.

On 7/11/2024 at 1603, Nurse Educator Staff QQQQ was taken to the soiled utility room and shown the PPE cart and the crash cart. She stated, "I didn't even know that stuff was in here. It shouldn't be in here."

On 7/11/2024 at 1608, the area labeled pain clinic, an area not in use, was entered. It consisted of several rooms with equipment still present. None of the doors were secured.

On 7/11/2024 at 1610, the intensive care unit (ICU), which was not currently used, was found unlocked. An unlocked, partially stocked crash cart was present with medications and IV solution bags, needles and syringes. Some of the medications and lab tubes were found to be expired.

On 7/11/2024 at 1615, the surgical area, an area not in use with the exception of the endoscopy suite, was entered. Each of the seven operating rooms (OR) were entered and each had various stages of machinery and instrumentation present. Built in glass supply cabinets still contained suture materials, bandages, and sterile water and/or saline. Several of the OR suites had once sterilized blue packages of instrumentation sitting on carts and tables.

On 7/11/2024 at 1640, a clean supply storage area across from OR #4 was entered. All types of surgical and endoscopic supplies were present including, but not limited to: 0.9% NaCl 1000 ml (milliliters) x7, 5% Dextrose Lactated Ringers 1000 ml x5, 0.9% NaCl injectable bags 250 ml x9, trochars, and 15 jars (total) of formaldehyde in 3 different sizes. The items contained in the supply room were a mix of current and expired supplies.

On 7/11/2024 at 1705, OR #6 had a "Storage Room" posting on the door. It was entered and the room had opened/used surgical supplies throughout the room. A stretcher was present in the low position that had a sterile drape over the pillow, a second sterile drape covering the mattress area with the corner partially flipped back, and a third sterile drape at the foot of the bed partially on the floor. Suction tubing was on the cart and also visualized on the floor. Next to the bed was a draped surgical stand with a sterile basin present, an opened instrument box, and what appeared to be a sterile cup. The instrument table was fully draped with other sterile drapes present, sterile surgical gowns and opened sterile gloves were present as well as sterile towels and blue pads. A double ring stand was also draped with two basins present which contained smaller white sterile drapes, coban and wound dressings. A 60 cc (cubic centimeter) syringe also appeared to be present. The trash can also contained blue draping material. No blood was visualized.

On 7/11/2024 at 1735, the radiology department was entered on the way to the ED. Several doors were checked and found to be opened with various equipment present.

On 7/11/2024 at 1738, in the ED lobby, Security Officer Staff RRRR was queried as to the entrance of the ED (an unused unit). He showed where the entrance was; however, would not allow surveyors to proceed without authorization from management and/or administration. While waiting for administration to arrive, the door to the ED was tested and found to be unlocked. Staff RRRR was queried as to why he manned this area to which he stated it was the ambulance entrance for the arriving psychiatric patients. When queried as to why the ED doors were unlocked, Staff RRRR stated, "Sometimes we go back there."

Upon entrance to the ED on 7/11/2024 at 1748, the area was found to be mostly empty with some rooms used as storage. Some construction materials were present. Heavy dust was present on horizontal surfaces and the floor. It was difficult to visualize it being a once functioning ED. After walking through the area, it was noted that a door leading to the hallway was propped open.

Chief Operating Officer (COO) Staff G was queried on 7/11/2024 at 1800 as to why the units not in use were not locked as a patient who eloped but remained in the hospital would have ample space to hide and move about without being found as well as having access to medications, items that would pose a ligature risk, and items that could be used as weapons. Staff G did not have an answer. Staff G was then queried about OR #6. He was taken to the area and shown the room. Staff G appeared shocked on seeing the room and stated he did not know why the room was set up as though a surgical procedure had been done.

On 7/11/2024 at 1815, Director of Quality Staff F stated OR#6 had been set up to teach the medical students about sterile technique in the OR. She stated there was a sign posted on the door that stated it was a training room. On 7/12/2024 at 0900, the door to OR #6 was checked and found to be locked. The sign on the door stated, "Storage Room." The door to OR #6 from the core was found and it was noted there was a sign present on bold yellow with black letters stating "STORAGE RM." A white handwritten paper sign underneath stated, "Training Room #6." It is unknown when the white sign was posted.

In a handwritten statement to surveyors which was provided on 7/15/2024 at 1405, Security Officer Staff HHHH stated, "...the Facility Manager position was vacant between October '22 and November 2023..." He also stated the facility "has always been in reactive mode, no plan of action, until the (sic) have to do something... The reason you see sudden changes and quick fixes is because there was no plan of action to begin with. They should be in implementation phases and get away from being reactive just to get what you want."


38269

On 07/09/2024 at 1300 while touring with CEO Staff A, on 4-N, a developmentally delayed unit (DDU), the entrance door to the nursing station was open with no staff present. At the time of observation, the charge nurse Staff U was queried regarding the nursing station not being secured. Staff U stated, "I just left the station to go into the nutrition room and came right back. I know the door should always be closed and locked."

On 07/09/2024 at 1302 an interview with the CEO was conducted while on tour, confirming the nursing station doors are to be shut and locked at all times.

On 07/11/2024 at 1040 on the DDU the nursing station door was found unlocked.
On 07/11/2024 at 1015 on 6S the nursing station door was wide open to anyone passing by (including patients), and was not shut until brought to the attention of the charge nurse.

On 07/11/2024 a review of the facility's incident log from January 2024 through July 2024 revealed the facility had nine elopements between February 20, 2024, and July 06, 2024, resulting in four of nine eloped patients never being located. One of nine eloped patients was located and returned to the facility by law enforcement officers. The remaining four eloped patients were located inside of the hospital and were returned to their subsequent units.

Additionally, there were three patients listed in the incident log as "Found in an unauthorized area." The three additional patients were not counted in the nine patients mentioned above, but were within the same timeframe.

Further review of the facility's incident log revealed that five patients successfully eloped from Five South (5-S), the all-male unit, on the following dates: 02/20/2024, 02/22/2024, 02/24/2024, 06/30/2024, and 07/06/2024. A sixth patient from 5-S successfully eloped from the facility's courtyard while on 1:1 monitoring by an assigned mental health tech (MHT).

Further review of the incident report revealed one patient eloped from Six South (6-S), an all-female unit, on 04/19/2024. One patient eloped from Four South (4-S), on 04/23/2024, and another patient housed on 4-S was able to elope from a visitation room located on the facility's first floor on 05/18/2024, while being monitored by security and an MHT.

In an interview with the COO Staff G and the DON Staff C on 07/11/2024 at 10:45, the COO shared that the post-elopement procedures were followed for all documented elopements which included informing facility's Security, initiating an overhead call "Doctor Wanderer," informing, Administrators in house including Nurse Supervisor and management. Additionally, the local Police Department was contacted, while the patient's physician, guardians, and primary contacts were informed.

The DON Staff C shared that a process for an MHT to check all doors were properly latched was put in place following the elopements. One MHT on every unit checks the doors every fifteen minutes and documents that the check was completed.

Review of the staff every fifteen (15) minute door rounding checks from the end of April 2024 through early July 2024 revealed:
4-South had been compliant with door checks from the end of April to current.
4-North had some time frames that lacked checks on 7/2/24 at 0300 - 0400; on 7/6/24 at 1730 -1915; and on 7/7/24 at 0000 -0500, 0530 - 0730.
5-South had some time frames that lacked checks on 6/27/24 at 1530 - 1930 and 2300 on 7/4/24 at 0530 - 0730.
6-North had multiple days with time frames that lacked checks which included on 5/24/24 at, 1900 -1930; on 5/26/24 at 0730 -0830; on 5/28/24 at 1530 -1915; on 6/25/24 at 0730 -2330; on 7/10/24 at, 1815 - 1915.
6 South had missing checks on 7/4/24 at 1330 -1530.
On 7/12/24 at approximately 1120, interview with the Director of Nursing revealed that the mental health techs did the rounding checks and that the nurse managers are supposed to double check that it's done and documented.

Facility policy titled "Precautions and Level of Monitoring" last revised 05-09-2024... III. Scope of Application: This policy applies to all staff providing direct care on behavioral health units. Page two, Precautions and Level of Monitoring, D, EP- Elopement Precautions, 15-minute checks and documentation on the patient observation record with restrictions per policy.

V. OBSERVATION PROCESS (LEVEL OF MONITORING): When patients are evaluated to determine if there is a need for special precautions, two decision points will be made by the physician, i.e. the physician will order the 1) precaution and will order the 2) level of monitoring appropriate for the patient. A. 15-minute Rounds Checks
1. Monitor the patient, documenting observed location and observed
behavior within 15 minutes of the time stamp on the "Rounds Sheet".
2. Note: Every patient's observed location and behavior is documented
within 15 minutes of the time stamp on the "Rounds Sheet". Physicians
do not need to order 15-minute rounds checks, as this is routine for all
patients. If the patient requires more intensive monitoring than the
routine 15-minute checks, the physician will order either Line of Sight
or Arms Length level of monitoring (with an assigned 1:1 staff).
B. Line of Sight
1. The patient is monitored continuously, with a direct line of sight always,
by an assigned staff member, including when the patient is using the bathroom.


45246

During the tour of the facility on 7/09/24 at 1140 nursing staff and patients were observed on 6 South (6S) unit. Nursing staff was observed entering the unit. After staff walked through the unit door, she proceeded to walk towards nurses' station and did not check if the door was closed after her.

On 7/11/2024 at 1605, during the tour of the 5th floor, three housekeeping staff were noted to exit 5 South (5S) unit. One staff was holding the door open, while the second staff was pushing the housekeeping cart slowly through. For some time, first staff was observed holding the unit door open, when a third housekeeper appeared and exited the unit. Meanwhile, there were several male patients standing near the exit and watching the housekeepers. After staff exited the unit they left the door, which shut on its own. Staff did not check if the door was closed/secured afterwards.


50585

On 7/12/2024 at 1430, during a tour of patient occupied unit 6 South (6S), it was observed that the 6S medication room door was not completely closed and could be entered without unlocking the door while patients were actively walking in the area. The following hazards were observed in the medication room: a glass bottle of spring water in the freezer in the medication refrigerator, handles on cupboards, and a plastic bag in the trash can. The Director of Quality Staff F also observed the door did not completely close and upon inquiry confirmed that the medication room could be entered without unlocking the door.

On 7/15/2024 at 1435, the facility's policy "Medication Management and Administration," dated 3/20/2024 was reviewed and the policy revealed "To prevent unauthorized access, medications are secured in accordance with law regulation. Outside the Pharmacy, medications are under continuous surveillance or in locked locations."

Based on record review and interview, the facility failed to protect one patient (P-36) from excessive use of force by staff, resulting in the potential for physical and psychological abuse to all patients served by the facility. Findings Include:

On 07/10/2024 the medical record for P-36 was reviewed. P-36 was an 18-year-old female admitted to the facility on 06/06/2024 for recurrent major depressive disorder. On 06/10/2024 the patient was placed in seclusion and restraints.

Review of records revealed on 06/10/2024 a "Code Team Strong" (additional staff assistance for unruly patients) was called for an incident in the 6S quite room involving P-36. On 07/12/2024 at 1115 a security video from 06/10/2024 at 2049 was reviewed with the Director of Nursing (DON), Staff C. The video revealed P-36 was in the quiet room pacing, flipped the mattress off the bed, then jumped onto the windowsill and used an unknown object to scrape and cut herself causing scratches and abrasions to the right thigh. Shortly after the patient began to self-harm, multiple facility staff entered the quiet room. DON Staff C verified and identified the nine staff members who entered the quiet room. Staff approached the patient then five staff members were observed physically restraining the patient in a supine (laying flat on one's back and face up) position on the windowsill. A nurse manager, Staff OO, was at the head of the patient. Staff OO had her hands on P-36's neck, below the chin. Mental Health Tech (MHT) Staff UU was also observed placing his hand on the forehead and neck of P-36. During the interaction involving P-36, a male staff member administered an injection into the arm of P-36, while Staff OO continued to have her hand on the neck of P-36. Some staff were seen leaving the quiet room, returning moments later with restraints. The staff secured restraints to the bed and multiple staff members carried P-36 to the bed, and secured the restraints to P-36. Staff UU was observed holding P-36's head down with his hand on P-36's forehead. Staff OO remained at the head of the patient's bed and continued to hold a hand on P-36's neck and throat area. While the patient was restrained, another staff member pulled P-36's shirt up and over her face, exposing her undergarments and chest. DON Staff C confirmed the techniques utilized by Staff OO and Staff UU were not Crisis Prevention Intervention (CPI) approved techniques to manage patient behaviors.

An interview was conducted on 07/10/2024 at 0930 with the facility's Quality and Risk manager, Staff F. The risk manager revealed that an investigation of the incident was triggered after review of Staff OO's incident report regarding P-36's aggressive behaviors (spitting and kicking) towards staff on 06/10/2024. The incident review revealed concerns with restraint documentation. After the investigation, Registered Nurse (RN) Manager, Staff OO was terminated. MHT Staff UU was re-assigned to a position not involving direct patient care. Staff were re-educated regarding safe CPI techniques. However, the facility did not identify and address how staff involved in the incident did not identify, intervene, or report Staff OO and Staff UU's actions as abuse.

On 07/12/2024 at 1135 during an interview with DON Staff C and Chief Operating Officer (COO) Staff G, the above findings were confirmed.

Based on record review and interview, the facility failed to have a Quality Assessment Performance Improvement (QAPI) program that utilized data collected to identify areas for performance improvement, failed to have priorities set for performance improvement, and failed to implement initiatives for performance improvement resulting in the failure to identify areas of opportunity to improve patient safety and quality of care for all patients. Findings include:

See Specific Tags:

A-273 Failure to incorporate measurable data
A-283 Failure to set priority to performance improvement projects
A-308 Failure to include all departments and services
A-309 Failure of governing body to ensure an ongoing quality program

Based on interview and record review, the facility failed to ensure an ongoing quality improvement and safety program that utilized data collected to identify areas for performance improvement resulting in failure to identify opportunities to improve the comprehensive care for all patients served by the facility. Findings include:

Review of the Incident Report Log from 1/2024-present revealed there were 3 patient elopements from 5 South (5S) during Q2, specifically the month of February 2024 (2/20, 2/22, and 2/24). The first patient made it outside of the building and was later found by police. A root cause analysis (RCA) was done. The other two patients were located within the facility and taken back to the unit. No RCAs were done for the patients who did not make it out of the building. Incidentally, it was noted between 3/31/2024-7/9/2024 there were six more elopements (4/19, 4/23, 5/18, 6/27, 6/30, 7/6).

Further review of the Incident Report log revealed there were 8 alleged staff to patient assaults (verbal and physical) between 1/9/2024-3/31/2024. Additionally, there were 112 patient to patient assaults between 1/1/2024-3/31/2024. There were no RCAs for alleged or actual assaults during this timeframe.

Review of fire alarm documents on 7/9/2024 at 1400 revealed the facility was in fire watch since 2/19/2024. This finding was confirmed by Facility Manager Staff E, who was new to his position in the last 2 months, at the time of discovery. The facility had no date or written plan for restoration of the fire alarm system prior to exit of survey.

Review of quality meeting minutes and quality data from Q3 2023-Q1 2024 was reviewed on 7/11/2024 at 1215. The quality meeting for Q2 had not yet been held. The information revealed a lack of depth for current concerns/issues. Nursing services was tracking the use of medication consents and stated approximate 85% compliance with a specific accreditation organization (AO) standard. Consistency in staff was noted to be an issue. No information regarding elopements including a plan to mitigate further elopement in the nursing department. There was no mention of staff to patient or patient to patient assaults nor plans on how to decrease the number of assaults within the facility. Facilities reported on repairs for the parking lot, a steam pipe being replaced in the kitchen, and the housekeeping "scope of service" being updated. There was no discussion or documentation anywhere regarding the facility being on fire watch since 2/19/2024-present, a current plan for fire watch, nor a plan to end the fire watch.

Director of Quality Staff F, who was new to her position in the past 90 days, was interviewed on 7/11/2024 at 1342. Staff F stated she was still trying to understand how her predecessor processed the quality information and stated she had many ideas for how to make it better. When queried about elopements, Staff F stated she "need(s) to stay on top of it." She was able to articulate the facility had purchased new doors which had not yet been installed and stated facilities was supposed to check the door and come up with a solution. Security was increasing their rounding. Staff F agreed that this was not documented in the quality meeting minutes.

Review of the facility's, "Quality Assurance & Performance Improvement Plan 2024" revealed the following:
"The goal of the QAPI program is to assure continuous and incremental performance improvement in the delivery of quality health care. The program promotes an organization-wide commitment to continually meet and/or exceed standards. The program emphasizes ongoing assessment of the dimensions of performance including surveillance of health care delivery involving qualifications and performance of those managing and delivering the services, the outcome of care and services delivered, the availability and utilization of support resources, facilities, staff, equipment and the environment to assure efficiency, cost effectiveness and accountability for all staff. Specific goals and objectives are:
1. To provide an effective, planned, systematic mechanism to design, measure, assess and improve the performance of the facility.
2. To develop Key Points Indicators for each department encompassing Quality, Safety, Customer Service and Finance
3. Foster a culture of safety, quality and accountability using Just Culture principles.
4. To achieve an effective reduction of medical/health care errors and other factors that contribute to unintended adverse patient outcomes.
5. To foster an environment in which patients, their families, and organization staff and leaders can identify and manage actual and potential risks to patient safety and implement proactive risk reduction strategies.
6. Foster process improvement and outcomes measurement
7. To enhance, maintain and continually improve the quality of patient care through intra- and/or interdepartmental measurement and assessment of patient care, resolution of problems and ongoing pursuit of opportunities to improve
patient care using highly reliable processes.
8. To facilitate a proactive approach toward continuous quality improvement and evaluate actions taken to assure that desired results are achieved and sustained.
9. To promote communication and reporting of performance improvement activities by and between departments, administration, medical staff, Governing Board and others as deemed necessary.
10. To maximize competent clinical performance by the medical staff and others through privileging, credentialing, orientation, training, and continuing education
11. To provide continuing education for staff related to quality and performance improvement.

SCOPE
The performance improvement program provides a mechanism for measurement and assessment of important processes or outcomes related to patient care and organizational functions including but not limited to adverse patient events, and other aspects of performance that assess processes of care, hospital service, and operations. Data is systematically collected for both improvement priorities and continuing measurement of those processes having the greatest impact on patient care and clinical performance, whether problems are suspected. Assessment findings are used to study and improve the processes that affect patient care outcomes, identify educational needs and evaluate clinical competence of employees, medical staff and allied health staff.
Comparative data will be analyzed for opportunities for improvement using both internal and external monitoring. External monitors will include at a minimum indicator identified for the Inpatient Quality Reporting (IQR) program, Outpatient Quality Reporting (OQR) program, Inpatient Psychiatric Facilities Quality Reporting (HBIPS initiative), HCAHPS - Patient Satisfaction, Employee Safety/Engagement. Internal monitors are selected by the various hospital department leaders along with their Administrator. Assessment findings are communicated to the Quality Council, Medical Staff and the Governing Board at least quarterly."

Based on record review and interview, the facility failed to identify and prioritize performance improvement (PI) projects that focused on prevalence and severity resulting in the failure to address improvements to the facility and less than optimal care for all patients. Findings include:

On 7/11/2024 at 1342 during an interview with Quality Director Staff F, who had been in her role for approximately 90 days, she was queried as to if the facility had any PI projects. Staff F stated each hospital department was tasked with a PI project. She supplied an untitled, undated list which she stated had been compiled by her predecessor. The list contained 29 lines in which a department was named, who the "owner" was, the key performance indicators, reason, and how the data would be obtained. Additional columns for frequency and notes were not used. It was noted that none of the PIs were prioritized, there was no indication when the improvement was started, how the improvement was implemented, how the improvement would be measured, nor when re-evaluation may occur. Additionally, the projects appeared to be the collection and review of routine data and/or audits instead of high risk, high-volume, problem area, or issues that might affect patient safety and/or quality of care. For example: Department-"Infection Control", Key Performance Indicator-"1) Hand Hygiene Compliance 2) Hospital Acquired Infections", Reason-"1) To minimize the risk for transferring of hospital acquired infections 2) To ensure the hospital is tracking,trending and measuring the risk of hospital acquired infections", How Data is Obtained-"1) 30 minimum observations per month of various health care workers from all disciplines to monitor hand washing compliance 2)Lab Results." Department: "Pharmacy", Key Performance Indicator-"1) Adverse drug reaction 2) Medication errors 3) Pharmacy Environment Temperature", Reason-"1) To ensure adequate monitoring, tracking and trending of ADRs (adverse drug reactions) 2) To ensure adequate monitoring, tracking and trending of med errors 3) To ensure medications are stored at appropriate temperatures.", How Data is Obtained-"Pharmacy Director to provide information."

On 7/11/2024 at 1348, Staff F was queried as to if any of the PI projects had been prioritized to which she stated the preparation for obtaining accreditation was taking priority over everything; however, stated that none of the PI were prioritized.

Based on record review and interview, the governing body failed to ensure all hospital departments and services were included in the facility's Quality Assurance and Performance Improvement program resulting in the inability to identify areas needing improvement and less than optimal care for all patients. Findings include:

On 7/11/2024 at 1200, review of the quality documentation from Q3 2023-Q1 2024 revealed no documentation present regarding the anesthesia department, the endoscopy department, or biomed.

On 7/11/2024 at 1342, Quality Director Staff F confirmed the above listed departments were not a part of the quality meeting minutes although anesthesia and "surgery" were listed on the performance improvement project list. The list was untitled and undated.

Based on interview and record review, the governing body failed to ensure an ongoing quality program that addressed patient safety concerns and had performance improvement projects that centered around quality of care and patient safety resulting in failure to understand and improve provision of services and safety for all patients served by the facility. Findings include:

On 7/11/2023 at 1200. review of provided quality data from Q3 2023-Q1 2024 revealed some meeting minutes, dated 7/27/2023, 8/3132023, and 3/28/2024, some performance improvement reports that had been compiled quarterly, and some random data with varying dates of collection. Additional the Quality Assurance & Performance Plan 2024 was provided. Some of the performance improvement reports were not signed or dated and the performance improvement was more of a collection of routine data to be monitored as opposed to a project being implemented with defined start and stop times, collection of data, analysis of results, re-evaluation, and implementation of improvements.

The "QAPI (quality assurance performance improvement) Meeting Minutes" had several numbered categories of departments which were to present for review. These departments included: nursing, recipient rights, quality/risk/compliance, infection control, physicians, dietary, facilities, environmental, medical records, laboratory, pharmacy, security, and human resources. Each category was able to list concerns and/or projects, action steps, note who was responsible, and provide a deadline. There were no categories for endoscopy, anesthesia, or most of the contracted services (housekeeping, x-ray/ultrasound, biomed, linens, pest control, pathology, agency staffing, etc.).

Review of the 7/27/2023 QAPI Meeting Minutes revealed social work, recipient rights, and utilization review were not present. Upon further review, physicians had no representation present. A note there stated they were only invited to the Quarterly Meetings. Security (contracted) also had no representation present.

Review of the 8/31/2023 QAPI Meeting Minutes revealed there was no discussion of recipient rights, infection control, physicians, environmental, medical records, or security.

Review of the 3/28/2024 QAPI Meeting Minutes revealed members were not in attendance for dietary, physicians, direct care staff, board member, and infection control. The environmental section indicated a ligature risk assessment had been completed on the units and identified concerns were being mitigated; however, they failed to consider all areas a psychiatric patient may be for consideration of ligature risk, specifically, the psychiatric visitation room.

During survey on 7/12/2024 at 0930, the psychiatric visitation room was found to be not psychiatric patient friendly with multiple ligature risks present, suffocation devices, alcohol-based hand sanitizer, and potential weapons readily available. An immediate jeopardy (IJ) was called on 7/15/2024 at approximately 1140. The immediacy for the IJ was removed on 7/16/2024 at 1030.

When interviewed on 7/11/2024 at 1342, Quality Director Staff F stated she was new to her position in the past month and a half and was still trying to understand the process her predecessor used in gathering, analyzing, and compiling data, but had many ideas on how to make improvements of her own. She also stated quality met monthly and that all departments were involved.

Review of the "Quality Assurance & Performance Improvement (QAPI) Plan 2024" revealed the following: "The governing body has the ultimate responsibility and authority for oversight and implementation of the QAPI Plan, as it maintains accountability for establishing and fostering a culture of safety and quality throughout the organization. The governing body sets the priorities for QAPI ensuring review of the indicators related to operations which are high risk, high volume and/or problem prone and indicators related to improved health outcomes and the prevention and reduction of medical errors. The governing body delegates to the Quality Council and the Director of Quality, the authority to implement and maintain the QAPI Plan. The governing body maintains oversight of the Plan and monitors performance improvement activities and accomplishments, through regular reports from the Medical Executive Committee and the Director of Quality. The governing body specifies the frequency and detail of data collection and defines broad objectives for performance and quality improvement through its strategic planning function."

Based on interview and record review, the hospital failed to ensure that it had an organized medical staff that operated under bylaws approved by their governing body which has the potential to affect the quality of medical care provided to all patients at the hospital. Findings include:

See specific tags:

A-0341 - The hospital failed to implement the credentialing process according to bylaws.

A-0347 - The hospital failed to maintain the medical staff organization and accountability according to medical staff bylaws.

Based on record review and interview the facility failed to ensure staff met criteria established in the Medical Staff Bylaws for appointment and/or reappointment for medical staff membership for 22 of 22 (Staff X, JJJ, LLL, MMM, NNN, OOO, QQQ, WWW, XXX, CCCC, FFFF, EEEE, DDDD, GGGG, RRR, TTT, BBBB, KKK, VVV, PPP, AAAA, ZZZ) credentialing files reviewed resulting the potential for less than optimal care for all patients.

On 7/11/24 at approximately 1100, Staff PPPP provided medical staff credentialing files for review. This review revealed the following for the described medical staff:

Family Medicine Staff X:
Basic Life Support (BLS) certification on file expired 5/20/2019, Advanced Cardiac Life Support (ACLS) certification expired 6/2021. (required by facility policy).
Reappointment letter sent 1/16/23, however there was no reappointment application available for review.
No current ongoing provider performance evaluation (OPPE) or peer review for 1/16/23 reappointment.
Delineation of Privileges Form - dated 7/1/2020 was missing an approval signature by the department chair.

Gastroenterology (GI) Physician Staff JJJ:
Drug Enforcement Agency (DEA) Registration in file expired 9/30/23.
Board Certification documentation expired 12/31/18.
Reappointment letter sent 1/16/23, however there was no reappointment application available for review.
No current Ongoing Professional Practice Evaluation (OPPE) data in file, no peer review by same specialty for 1/16/23 reappointment available for review.
Last query to National Practitioner Data Bank (NPDB) dated 3/8/16.

Psychiatric Physician Staff LLL:
Delineation of privileges form for psychiatry dated 4/2/24 was missing an approval signature by the department chair.
Appointment letter dated 4/25/24 grants Staff LLL initial appointment to ACTIVE status (Bylaws require PROVISIONAL status for initial applicants for a minimum of 12 months).

Psychiatry Physician Staff MMM:
Last reappointment letter in file dated 2/19/19 and revealed appointment expired 1/19/21.

Psychiatry Physician Staff NNN:
DEA Registration on file expired 6/30/23.
Delineation of privileges form dated 3/22/23 was missing an approval signature by the department chair.
Initial appointment letter dated 3/24/23 appoints staff NNN to ACTIVE staff (Bylaws require PROVISIONAL status for initial applicants for a minimum of 12 months).
No Focused Provider Performance Evaluation (FPPE) per bylaw requirements.
No references for initial application found. (Bylaws require two references with initial application).

Obstetrics and Gynecology Physician Staff OOO:
Initial appointment application not dated.
Initial appointment letter (dated 3/4/23) granted Staff OOO ACTIVE staff privileges (Bylaws require PROVISIONAL status for initial appointment applicants for a minimum of 12 months).
No references for initial application found. (Bylaws require two references with initial application).
No Focused Provided Performance Evaluation (FPPE) per bylaw requirements.

Psychiatry Physician Staff QQQ:
Delineation of Privileges for psychiatry dated 3/15/23 was missing approval signature by department chair.
No performance review (OPPE) for reappointment found on file.

Psychiatry Physician Staff WWW:
No Reappointment application (reappointment letter dated 1/16/23)
No current OPPE or peer review found in the file.

Psychiatry Physician Staff XXX:
Initial appointment letter dated 6/27/24 grants Staff XXX ACTIVE status. (Bylaws require PROVISIONAL status for initial applicants for a minimum of 12 months).
No references for initial application found. (Bylaws require two references with initial application).

Anesthesia Physician Staff CCCC:
No reappointment application or board reappointment letter found for reappointment approval documents signed by department chair, Credentials Committee, Executive Committee and Board on 11/13/23.
BLS/ACLS certifications on file expired 3/20 (required per facility policy).
No current OPPE data or peer review found in credential file.

Pathology Physician Staff FFFF:
No reappointment application found, last Board appointment letter dated 8/1/21 (last appointment approval document signed 7/30/21.
No delineation of privileges form, a signed Laboratory Director Designee in file (no date) and Job Description for Clinical Consultant signed 7/22.
Background check dated 7/11/24 (during current survey).

OB/GYN Physician Saff EEEE:
Initial appointment letter (dated 3/14/23) granted Staff EEEE ACTIVE staff privileges. (Bylaws require PROVISIONAL status for initial applicants for a minimum of 12 months).
No Focused Provided Performance Evaluation (FPPE) per bylaw requirements.

Psychiatric Physician Staff DDDD:
Appointment approval documents signed and dated 6/7/22 by Credentials committee, 7/1/22 by Executive Committee, and 7/15/22 by the Board. The file did not contain documentation that a background check or NPDB query was completed prior to the initial appointment approval.
A single, undated application was noted in the file. A reappointment letter dated 1/16/23 was also present. (Bylaws require an application for each appointment and PROVISIONAL status for initial applicants for a minimum of 12 months).

Infection Control Chair- Physician Staff GGGG:
A credentialing file was requested and not provided for review for Infection Control Chair- Physician Staff GGGG.

Nurse Practitioner (NP) Staff RRR:
Initial appointment letter dated 5/27/24 appoints staff RRR to ACTIVE staff (Bylaws require PROVISIONAL status for initial applicants for a minimum of 12 months).
Medical Staff (MS) Approval form dated 5/30/24 not signed by Department Chair.
Background check and NPDB query on file both dated 6/3/24 (post appointment to ACTIVE staff).

NP Staff TTT:
NP license in file expired 4/9/24.
Initial appointment letter dated 6/30/23 appoints staff TTT to ACTIVE staff (Bylaws require PROVISIONAL status for initial applicants for a minimum of 12 months).
Background check in file dated 12/15/23 and NPDB query in file dated 12/18/23.
Supervising Physician Agreement not signed.
No Focused Provider Performance Evaluation (FPPE) per bylaw requirements.

NP Staff BBBB:
Appointment letter dated 3/14/23 grants Staff BBBB initial appointment to ACTIVE status (Bylaws require PROVISIONAL status for initial applicants for a minimum of 12 months).
Background check and NPDB query in file were dated 3/24/23 (post appointment to ACTIVE staff).
Standard Practitioner Application signed and dated 3/22/23.
No Focused Provider Performance Evaluation (FPPE) per bylaw requirements.

Certified Registered Nurse Anesthetist (CRNA) Staff KKK:
No reappointment application, reappointment letter from Board dated 1/16/23.
Last competency evaluation documentation in file dated 2/12/20.

NP Staff VVV:
Initial appointment letter dated 6/27/24 appoints staff VVV to ACTIVE staff (Bylaws require PROVISIONAL status for initial applicants for a minimum of 12 months).

Physician Assistant (PA) Staff PPP:
Initial appointment letter dated 4/1/24 appoints staff PPP to ACTIVE staff (Bylaws require PROVISIONAL status for initial applicants for a minimum of 12 months).

DNP Staff AAAA
NP license in file expired 11/29/23.
DEA registration expired 8/31/23.
Supervising Physician's Agreement dated 4/17/23.
BLS certification expired 7/20/23.
Initial appointment letter dated 4/18/23 appoints staff AAAA to ACTIVE staff (Bylaws require PROVISIONAL status for initial applicants for a minimum of 12 months).
Background check in file dated 12/15/23 and NPDB query in file dated 12/18/23.
No Focused Provider Performance Evaluation (FPPE) per bylaw requirements.

NP Staff ZZZ:
Initial appointment letter dated 6/27/24 appoints staff ZZZ to ACTIVE staff (Bylaws require PROVISIONAL status for initial applicants for a minimum of 12 months).

On 7/11/24 at approximately 1015, an interview was conducted with the Director of Medical Records/Registration and Credentialling Staff PPPP who stated that we have a credentialing checklist we follow. Physicians should complete an application, but they are not good at it. The NPDB is supposed to be queried with reappointment. Staff PPPP confirmed FPPE's, OPPE's, and peer evaluations were not present in applicable files. (as noted in individual file reviews listed above). Staff PPPP also confirmed there was no file for the Physician Chair of the Infection Control Committee.

On 7/12/24 at approximately 0845, an interview was conducted with the Chief of Staff, Staff X, who stated that physician reappointment is conducted every 2-3 years, and he reviews the data collected by the credentialing department and recommends approval or disapproval of physicians at the Executive Committee and to the Board of Trustees.

On 7/14/24 at 1000 review of the Medical Staff Bylaws and Rule and Regulations, dated 4/2024 revealed, "4.3.3.3 All applicants to the Medial Staff must be certified by a specialty board recognized by the medical staff department in which they will be members ...if a physician has been accepted to membership in the Medical Staff based on eligibility to take the certifying examination, and fails to achieve board certification, that physician will automatically and immediately ...be suspended ...All physicians who ...applied for membership ....prior to ...2000, will not be held to the Board Certification/Eligibility requirements ...4.5.2 All initial appointments shall be to the Provisional Staff Category for a period of 12 months ...4.7.1 Application for reappointment. Shall: ...be submitted to the Medical Services office on a form prescribed the by the ... Executive Committee and approved by the Board of Directors ...be signed by the applicants, the application shall state the continuing professional qualifications of the applicant ...4.8 Employment and Contract Appointments: When a physician services under any type of employment or contractual arrangement with the Hospital, the physician shall be required to obtain and maintain Staff membership in accordance with these Bylaws ...5.2.THE ACTIVE STAFF ...must have served on the medical staff .... For 1 year ...they are eligible to vote and to hold office ...5.2.2.4 All initial appointments shall be to Provisional Staff for a period of 12 months ...5.2.11 The Consulting Staff ... shall consist of ...physicians ...who meet the criteria for medical staff membership and whose knowledge and experience are of special value to one or mor departments of the Medical Staff ...Credentialing shall be accomplished in the same manner as other staff appointments ...13. MEETINGS ...13.1.2 ...The presence of 25% of Active staff shall constitute a quorum for the transaction of all business ...".

On 7/14/24 at approximately 1400 review of facility policy titled "Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE) Policy, dated and signed (reviewed/revised approved 11/2023) states: "FPPE process will be used to evaluate the competency and professional performance of an application ...FPPE is implemented for all initially requested privileges ...OPPE will be documented and will assist in the determination of whether the staff member's privileges will continue, need to be limited, or need to be revoked ...Data will be used as a measure of competency and will be reviewed at time of reappointment to determine eligibility ...All decision-making, evidence used in determination, and actions taken as a result of review will be documented and stored for reference."

On 7/14/24 at approximately 1430 review of facility policy titled "Provider Licensure and Certification" revised 3/06/2024 states: "...Ensure that all providers meet the minimum required certification and licensure requirements to deliver required services to patients. All licenses and certifications must be current, valid, and without any restrictions...Procedure: Position: M.D./D.O. (Non-Psychiatry)...Certifications...BLS...ACLS...Position: NP...Certifications...BLS..ACLS (Non-Psychiatry)..."

Based on interview and record review, the hospital failed to maintain a medical staff structure, resulting in the potential for inadequate oversight of the medical care provided and for potential negative patient outcomes to all patients cared for at the hospital. Findings include:

On 7/11/24 record review of Executive Committee (EC) meeting minutes dated 10/30/23 was conducted. Four initial physician appointments were listed in these minutes for the month of March 2023 (Staff QQQ, Staff NNN, Staff EEE, Staff OOO). All 4 initial applicants for privileges at the facility were granted ACTIVE staff Privileges.

No Meeting Minutes for a Regular Annual Meeting of the Medical Staff for 2023 were provided during survey. This annual meeting per bylaws was to include the election of medical staff officers. No documentation of an annual election of officers found for greater than 12 months. No Medical Staff Vice Chair, Secretary/Treasurer, or Members at large could be identified as active in positions at time of survey.

On 7/11/24 a record review of the "Oakland Physician Medical Center d/b/a Pontiac General Hospital Medical Staff Bylaws, Rule and Regulations" dated revised on 4/2024 revealed: "Active staff must have served on the medical staff ...for 1 (one) year...they are eligible to vote hold office, and are obligated to serve on committees...they shall actively participate in recognized functions for the medical staff appointment including quality/performance improvement, risk management.....including monitoring new appointees during provisional period...All initial appointments shall be to the Provisional staff for a period of 12 months...Officers shall be Chief of Staff...Secretary/Treasurer and two members at large...Officers of the Medical Staff shall be elected....and announced at the Annual Medial Staff Meeting...election shall be by written ballot...Chief of Staff will serve the two calendar years or until their successor is elected or appointed...the Secretary/Treasurer and members at large shall serve for one calendar year...vacancy other than chief shall be filled by special election...Staff Departments...There shall be 8 Departments including... Department of Infection Control, Department of Psychiatry, Department of Surgery, Department of Internal Medicine, Department of Anesthesia, Department of Pathology, Department of Gynecology...A vacancy in the office of Chair of a Department shall be filled by appointment of the Executive Committing in an expedited manner...Function of the Departmental Chair...to be accountable for monitoring all profession activities...maintain a continuing review of the professional performance all practitioners in the department who had delineated clinical privities..."

On 7/12/2023 at 1350, an interview with Chief Executive Officer (CEO) Staff A was conducted. CEO Staff A stated an almost complete turnover of the medical staff occurred in October of 2022 due to service lines being suspended (urgent care, in-house radiology, and respiratory) and that the Chief of Staff is currently the only physician that attends the Executive Committee of Medical Staff and the structure of the medical staff is currently in revision with legal (since October of 2022). Officers of the Medical Executive Committee (Secretary and Treasurer) have not been appointed since October of 2022, no annual Meeting held (required per bylaws), and that department chairs as identified are not all current.

Based on observation, interview, and record review, the facility failed to enure that registered nurses supervised and evaluated the nursing care for three patients (P-2, 4, and 24), and accurately docusment the administration times of a controlled substance to two patients (P-37 and 38) resulting in the lack of assessment and monitoring, incomplete documentation, inaccurate medical record and potential for negative outcomes for the patients. Findings include:

See Specific Tags:

A-0395 Failure to assure that registered nurses supervised and evaluated the nursing care.

A-405 Failure to accurately document the administration times of a controlled substance.

Based on observation, interview and record review, the facility failed to ensure that registered nurses supervised and evaluated the nursing care for three patients (P-2, 4, and 24) of 5 patients reviewed resulting in the lack of assessment and monitoring, incomplete documentation of 15-minute rounding for P-4, and failure to assess and monitor P-2's weights and the possibility of patients' deterioration in health status and preventable decline. Findings include:

During the initial tour of the facility on 7/09/24 from 1055 to 1230, with Director of Nursing, Staff C, nursing staff and patients were observed on different units. On unit 6S one patient was observed walking in a hallway barefoot. Staff C witnessed this observation.

On 7/15/24 at approximately 1450 tour of the 5 South unit was conducted with facility administrator, Staff G. Upon entrance to the unit a patient was observed exiting his room barefoot. Patient left ankle had an open bleeding spot. Patient proceeded to walk the hallway. Ten minutes later upon exiting the unit, the same patient was observed without footwear and had the same bleeding spot on his ankle.

Director of Nursing, Staff C, was interviewed on 7/9/24 at 1430. She was asked how often the facility require staff to monitor and assess patients. She stated that nurses do their full assessments every shift and mental health technicians perform safety rounding/checks every 15 minutes.

P-4's medical record was reviewed on 7/9/24 at 1730. P-4 was a 36-year-old male admitted to facility on 6/13/23 with diagnosis of psychosis. Patient was petitioned for inpatient admission due to his recent self-injurious behaviors. P-4 had a history of seizures disorder, autism, mild intellectual development disorder, and was non-verbal. Patient was discharged on 6/30/23.
Review of the documentation of the safety rounds every 15 minutes for P-4 revealed the following. Level of monitoring was marked as "Q15 minutes minimum" (every 15 minutes), precautions- suicide/safety.

There was no monitoring documented by staff on:
6/15/23 from 0645 till 0730 (last line indicated P-4 was "disruptive, loud, agitated" at 0630)
6/21/23 from 0415 till 0430
6/22/23 from 0245 till 0300
6/28/23 from 1745 till 1930

Facility's "Precautions and Level of Monitoring" Policy, dated 5/10/2021 and revised 5/9/2024, was reviewed on 7/14/24.
Policy indicated: "To provide a procedure to identify precautions for ongoing or continuous observation and level of monitoring based on patient's specific care needs, to initiate reasonable precautionary measures and to provide special care for patients who are at an increased risk for adverse event. Standards- Acute Inpatient Psychiatric Program: all patients admitted to acute inpatient psychiatric programs, regardless of whether they are on physician-ordered precaution or not, are monitored documented via observational rounds. Staff will document these observational rounds on a "Rounds Sheet". Documentation will include the patient's location and observation of the patient's behavior. This observation check will be documented within 15 minutes of the time stamp on the "Rounds Sheet".


38269

On 7/09/2024 a 1105 a tour of the 6 South female unit was conducted. Upon entrance to the unit P-24 was observed continuously walking laps around the nurses' station. A review of P-24's chart revealed a 1:1 monitoring order was written on 07/08/2024. At the time of chart review, Staff V (Registered Nurse in Charge) was queried as to the meaning of 1:1 monitoring.

On 07/09/2024 at 1110 Staff V stated, "one on one monitoring means that someone is assigned to have the patient in view at all times." Staff V was further queried if P-24 had an order for 1:1 monitoring and if so, who was monitoring the patient. Staff V responded, "P-24 does have an active order to be monitored 1:1 written on 07/08. Mental health technician (MHT Staff W) was assigned to 1:1 monitoring of P-24." Staff W was then observed standing at the nurses' station without leaving her stance between 1111 and 1135, while P-24 continued to walk around the perimeter of the nursing station. Staff V was asked if P-24 could be seen at all times while walking around the nurses' station, without following the patient. Staff V stated, "no there is no way you can see the patient without walking around the nurses station." Staff V was queried regarding the facility policy for 1:1 monitoring and she was able to articulate the facility policy and confirmed the policy was not being followed at the time of survey findings.

On 07/09/2024 at 1135 Mental Health Tech (MHT) Staff W confirmed solid walls obscure the view around the nurses' station they could not always see P-24.

Facility's "Precautions and Level of Monitoring" Policy, dated 5/10/2021 and revised 5/9/2024, was reviewed on 7/14/24.
Policy indicated: "To provide a procedure to identify precautions for ongoing or continuous observation and level of monitoring based on patient's specific care needs, to initiate reasonable precautionary measures and to provide special care for patients who are at an increased risk for adverse event. Standards- Acute Inpatient Psychiatric Program: all patients admitted to acute inpatient psychiatric programs, regardless of whether they are on physician-ordered precaution or not, are monitored ... V. Observation process (Level of Monitoring) B. Line of Sight 1. The patient is monitored continuously, with a direct line of sight always, by an assigned staff member ...2 ...There should not be any form of barrier between the staff and the patient, such as a desk or counter ...C. Close Proximity 1. The patient is monitored continuously by an assigned staff member who is continuously within a close proximity to maintain safety and intervene if necessary ...2. While monitoring the patient via arm's length observation document the observed location and observed behavior ...


50585

A medical record review of P-2's medical record revealed P-2 was admitted on 5/13/2024 with a weight of 83.1 pounds.

An initial Nutrition Consult note dated 5/16/2024 indicated the recommendation of weekly weights due to P-2's nutritional status.

On 5/24/2024, the Mental Health Technician Progress note indicated the patient was weighed and the recorded weight was 89 pounds (5.9-pound weight gained).

On 5/26/2204, the Nutrition Consult note indicated a current weight of 77.9 pounds (11.1-pounds weight loss in two days) and recommended weekly weights.

Nurse Practitioner Staff BBBB ordered on 5/27/2024 that P-2 be weighed every Monday and Thursday, the first order by a provider to weigh the patient since admission.

On 5/28/2024, Physician Staff NNN ordered that P-2 be "weighed daily and enter into progress note daily."

Additional record review of P-2's medical record revealed the following. On 5/30/2024, Staff NNN ordered P-2 to have "weights daily." On 5/30/2024, the Nursing Progress note indicated the patient was weighed and the weight was 83.8 pounds (5.9-pounds weight gain in four days).

On 6/8/2024, the Physician Psychiatric Progress note indicated "Patient weight currently up 10 pounds (Calculated actual body weight of 93.1 pounds) since admission."

On 6/10/2024, the Nursing Progress note indicated the "Patient ate 100% of meals, daily wt in progress." However, there was no documented weight recorded for that day.

On 6/12/2024, the Nursing Progress note indicated "Patient is a daily WT and calorie count for food intake." However, there was no documented weight recorded for that day.

On 6/13/2024, the Nursing Progress note indicated "Patient is on daily weights, and weight was obtained." However, there was no documented weight recorded for that day.

From 6/13/2024 to P-2's discharge on 6/25/2024, there was no further weights recorded for P-2.

On 7/15/2024 at 1405, the facility's policy "Documentation: Nursing Daily Assessments, dated 8/25/2023 was reviewed and the policy indicated that "Daily weights should be obtained in early AM (prior to breakfast) and documented in the appropriate box."

Based on interview and record review, the facility failed to accurately document the administration times of a controlled substance to two patients (P-37, P-38) of two patients reviewed for controlled substance administration resulting in an inaccurate medical record and potential for negative outcomes for the patients. Findings include:

On 7/10/2024 from 0930 to 1030, during the tour of the Pharmacy, Director of Pharmacy Staff II explained the automated medication dispensing machine override report from 7/9/2024 0000 to 7/9/2024 2350 that printed on 7/10/2024 at 0745. The report revealed that five medications were removed via the override feature (nurse can remove a medication without a medication order) during that period. Based on the quality review by the Pharmacist, the report revealed that two lorazepam 2 mg injection vials were removed by Nurse Staff M without a documented medication order. The handwritten note on the override report stated Physician "Staff NN was putting the orders in."

This report also revealed that one lorazepam vial was removed for P-37 at 7/9/2024 at 1040 for aggression and the other vial was removed for P-38 at 7/9/2024 at 1033 for increased agitation.

On 7/10/2024 at 1620 LPN Staff M was interviewed about the two removals of lorazepam from the automated medication dispensing machine. She stated that during patient rounds, one patient was cussing at Physician Staff DDDD. Staff DDDD instructed her verbally to administer the lorazepam 2 mg and that Staff DDDD would put the medication order into the computer. Staff DDDD also instructed Staff M to administer lorazepam to another patient for increased agitation and again she revealed that Staff DDDD would put the medication order into the computer. Staff M acknowledged that both lorazepam doses were administered on 7/9/2024.

A medical record review of P-37 and P-38 medical records revealed the following. The medication order for P-37 was entered to start at 7/10/2024 at 0833 for lorazepam 2 mg intramuscular one time only and was documented by the nurse as "given" on 7/10/2024 at 1150. The medication order for P-38 was entered with a start at 7/10/2024 at 0828 for lorazepam 2 mg intramuscular one time only and documented by a nurse as "held" with no other comments noted in the medication log.

On 7/10/2024 at 1630, when asked where Staff M documented the lorazepam for P-38, she stated in the comments section "under Haldol entry." There were no comments observed in any of the haloperidol orders that were ordered for P-38 pertaining to lorazepam administration. The Nursing Progress Notes on 7/9/2024 at 1100 for P-38 indicated "Verbal order given for Haldol and Ativan 2mg IM stat. IM shot given in left buttocks patient tolerated well."

On 7/10/2024 at 1600, Director of Nursing Staff C was interviewed and confirmed for P-38 there was no documentation of the lorazepam administration in either the comments section of any order for haloperidol or under the lorazepam order itself. The Director of Nursing Staff C acknowledged these errors in documentation.

On 7/15/2024 at 1300, the facility's policy "Automated Medication Dispensing Machine Override Medication Policy", dated 1/24 was reviewed and the policy indicated that "When the automated medication dispensing machine profile interface is in place, the nurse will be allowed to remove from the automated medication dispensing machine only those medications for which there is an active order on the patient's pharmacy profile. Access to a small number of medications without an active order on the patient's profile will be made available through the OVERRIDE function. However, a physician's order must be written for every medication removed from the automated medication dispensing machine."

On 7/15/2024 at 1310, the facility's policy "Documentation of Medication Administration", dated 8/25/2023 was reviewed and the policy indicated "Medications administered to patients when ordered by the Licensed Independent Practitioner will be administered in a safe and timely manner and recorded on the Medication Administration Record (MAR)." The policy also states that "If a medication is omitted, document reason under "refused" or "held" and indicate reason under comments. Notify RN of patient medication being held or refused, as applicable. RN to document medication in EMR, and notify physician, as applicable."

Based on observation, interview and record review the facility failed to ensure safe dispensing of medications in accordance with standards of practice and failed to ensure all medications are stored in a secure manner resulting in the potential for negative outcomes to all patients. Findings include:

See tags:

A-500 Failure to ensure safe dispensing of medications in accordance with standards of practice

A-502 Failure to ensure medications are stored in a secure manner

Based on observation, interview, and record review the facility failed to ensure safe dispensing of medications in accordance with standards of practice resulting in the potential for negative outcomes to all patients. Findings include:

On 7/9/2024 at 1105, a bottle of carbamazepine suspension (seizure and bipolar disorder medication) was observed on top of the medication cart in the 6 North (6N) medication room. The labels on the bottle did not contain any information identifying the medicine as a hazardous medication.

On 7/10/2024 from 0930 to 1030 during a tour of the pharmacy department, Director of Pharmacy Staff II was interviewed and was asked for the policy on hazardous drugs covering the United States Pharmacopoeia (USP) Chapter 800 standards (provides standards for safe handling of hazardous drugs) that went into effect on November 1st, 2023. Staff II said he did not have a policy. Staff II stated they implemented the monthly surface sampling required by Chapter 797 in the USP that commenced November 1st, 2023.

On 7/10/2024 at 1600, Director of Nursing Staff C was interviewed. When queried whether she was familiar with USP 800 Standards and the impact on nursing, she replied that did not know anything about the program.

On 7/15/2024 at 1305, the facility's Medication Formulary was reviewed, and it was noted that the following hazardous drugs as defined on the 2016 National Institute for Occupational Safety and Health (NIOSH) List of Antineoplastic (medications used to treat cancer) and Other Hazardous Drugs in Healthcare Settings were on formulary at this facility: azathioprine (rheumatoid arthritis medication), carbamazepine (seizure and bipolar disorder medication), clonazepam (anxiety and seizure medication), colchicine (gout medication), divalproex (seizure and bipolar disorder medication), ergonovine (medication to stop excessive bleeding from the uterus), estradiol (hormone medication), fluconazole (anti-fungal medication), hydroxyurea (medication used to treat cancer), leuprolide (medication used to treat cancer), medroxyprogesterone (hormone medication), megestrol (medication used to treat cancer), methotrexate (medication used to treat cancer and rheumatoid arthritis), methylergonovine (medication to stop excessive bleeding from the uterus), misoprostol (hormone medication), oxcarbazepine (seizure medication), paroxetine (depression medication), phenytoin (seizure), progesterone (hormone medication), propylthiouracil (thyroid medication), spironolactone (blood pressure and fluid retention medication), tacrolimus (immunosuppressive medication, tamoxifen (medication used to treat cancer), temazepam (insomnia medication), valproic acid (seizure and bipolar disorder medication), voriconazole (antifungal medication), warfarin (blood clot medication), and zidovudine (HIV medication).

On 7/15/2024 at 1430, a review of the facility's policy "Medication Management and Administration", dated 3/20/2024, revealed " ...Medication dispensing adheres to law, regulation, licensure, professional standards of practice, including record keeping."

Based on observation, interview and record review, the facility failed to ensure all medications are stored in a secure manner resulting in the potential for unauthorized access and negative outcomes.

On 7/11/2024 at 1600, during a tour of the 5 North (5N) patient care area, the code cart was observed next to the Nurse Educator office and it was unlocked. Medications were present in a drawer covered in plastic. The dirty utility room was observed and found unlocked. Inside the room there was a supply cart. Inside the cart there were one-liter intravenous solutions bags (0.9% Sodium Chloride). Chief Operating Officer Staff B confirmed the findings and tried to lock the dirty utility room door afterwards. He was unable to lock the door.

On 7/15/2024 at 1425, the facility's policy "Medication Management and Administration", dated 3/20/2024 was reviewed and the policy indicated that "To prevent unauthorized access, medications are secured in accordance with law regulation. Outside the Pharmacy, medications are under continuous surveillance or in locked locations."


36887

On 7/9/2024 at 1155 an observational tour of the surgical floor was conducted. The surgical floor was not currently in use. In the hallway between the main desk and the endoscopy room was a satellite pharmacy. The door to the satellite pharmacy was found to be unlocked and upon entering, there were no staff present. The satellite pharmacy was stocked with medications. This was confirmed by Chief Executive Officer (CEO) Staff A at the time of discovery.

On 7/11/2024 at 1610, the intensive care unit (ICU), an unused unit, was entered and found to have a crash cart present that was unlocked. Upon opening the cart, it was found to be partially stocked with medications, intravenous (IV) bags of solution bags, needles and syringes. Some of the medications were found to be expired. The ICU unit was able to be accessed freely from the elevator that operated from the lobby of the building.

On 7/11/2024 at 1640, a storage area across from operating room (OR) #4 was entered and found to have IV bags of saline and lactated ringers present. The operating suite was not in use and able to be accessed freely upon entering the unit from the main corrider leading from the lobby of the building.

Based on observation, interview, and record review, the facility failed to provide and maintain adequate physical facilities for the safety and needs of all patients and was found not in compliance with the requirements for participation in Medicare and/or Medicaid 42 CFR Subpart 482.41(b), Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care, resulting in the potential for negative outcomes up to and including death in the event of a fire. Findings include:

A-0701 - Failure to mitigate ligature risks; Failure to maintain equipment
A-0710 - Failure to comply with applicable provisions of the 2012 edition of the Life Safety Code
A-0724 - Failure to maintain physical facilities
A-0726 - Failure to maintain ventilation systems

Based on observation, interview, and record review, the facility failed to develop and maintain an environment that was safe for patients resulting in the potential for patient injury and/or harm up to an including death for all patients currently served by the facility. Findings include:

On 7/12/2024 at 1135, the psychiatric visitation room, which was a former surgical holding area, was entered. The main part of the room was separated from the former nursing station and patient bay area by a filing cabinet that was pulled in front of the entryway (drawers facing away), leaving about a one foot gap between the entry way and the filing cabinet. There were chairs present with open backs and open arms, rolling office chairs, chairs with metal frames and plastic seats, and a round table. All of these items could be easily picked up and moved about the room. There was dirt and bits of debris on the floor. A partially empty bottle of water appeared to be present next to one of the chairs. There was a row of thin, metal lockers which were unsecured. Padlocks were present in the unlocked position and dangling from the locker latch system. Inside one of the lockers was a metal strip approximately 2" wide and 30" long that was unattached to anything. There was a sink present with a goose-neck faucet and paddle handles. There was a soap dispenser present on the wall. Next to the automated, plastic paper holder was an alcohol-based hand sanitizer unit that was partially full. Sets of cabinet doors were secured with zip ties. Drawers were unsecured. An electrical outlet was between the upper and lower cabinets and easily accessible. There were also two patient bathrooms with doors standing open and available for use. It was noted there were locks present on the doors. The bathrooms were similar in size and what was present. Inside the bathroom, each ceramic sink had a goose-necked faucet with paddle handles for the hot and cold water. The drain under the sink was exposed. There was an electrical outlet on the wall next to the mirror which was over the sink. The toilet area had a pull cord for emergencies. The cord was long enough to reach the floor-approximately 36-40 inches long. There was a grab bar with an opening between the bar and the wall. Toilet paper dispensers were present and made of plastic. Behind the toilet was another grab bar open between the wall and the bar, a deodorizing unit affixed to the wall that had a long thin tub going down the wall to the toilet. Additionally, the piping for the toilet was exposed with space between the pipe and the wall. There was also a plastic toilet seat cover bin with covers present above the toilet. Above the toilet was a metal hook that was screwed to the wall. Additionally, plastic bag liners were found to be present in the bathroom trash receptacles.

The room used for psychiatric visitation had multiple areas of ligature risk, suffocation risk, ingestion risk, and potential weapons present that had been unidentified and unmitigated by staff.

On 7/12/2024 at 1627, Director of Nursing (DON) Staff C was asked about the visitation room. She stated the bathrooms in the visitation room were not working. "They use the other one or they take them (patients) back to the unit." She further stated the bathrooms were locked and there was no access.

Staff C was queried as to the visitation hours for patients. She stated visiting hours were M-F from 6-7 p.m. The four psychiatric units divided the days between them for visitation. Additionally, there were hours on Saturday and Sunday from 1-2 p.m.

On 7/11/2024 at 1303, during observation of the endoscopy suite, a small side room was observed to have 2 white containers (each approximately 2 feet wide by 3 feet tall) placed on a black stand. One container had a black and a dark red liquid in it, and the other container had a white liquid in it. Under the stand, there was a dried tan and white substance noted on the floor. The dried substance on the floor was observed to have spread across approximately 3 feet across the room and to the floor drain.

On 7/11/2024 at 1308, Director of Quality, Staff F observed the containers and stain on the floor and was queried as to what was in the containers and on the floor. Staff F stated that she was not sure, but the room used to be a radiology processing area but they have not done X Rays in years. When asked if the room was still in use, Staff F stated "no". When asked why the unidentified liquids were still in the room, Staff F stated that they were waiting to figure out how to properly dispose of the liquids.


19647

On July 9, 2024, at approximately 1330, observed in the 2 South mechanical room that air compressor 2 was turned off with its belt guards off and lying on the floor. There was no one working on the equipment at the time and the air compressor was not locked or tagged out. This was confirmed by interview with Staff B at the time of observation. In addition, medical equipment and machines such as C-arm tables (type of X-Ray device) were observed ready for use throughout the surgery unit.

On July 9, 2024, at 1410 during record review with Facilities Manager Staff E, there were no records of medical gas outlets required annual inspections.

On July 10, 2024, during record review at approximately 1230, it was discovered that there was an equipment inventory and a schedule for equipment preventive maintenance (PM) but not all of the equipment had PM procedures. Staff E commented that the new automated PM system was not currently able to print scheduled work orders.

Based on observation, interview, and record review, the facility failed to provide and maintain adequate physical facilities for the safety and needs of all patients and was found not in compliance with the requirements for participation in Medicare and/or Medicaid at 42 CFR Subpart 482.41(b), Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care, resulting in the potential for negative outcomes up to and including death in the event of a fire. Findings include

See the individually and below cited K-tags dated July 10, 2024.
K-161
K-211
K-222
K-281
K-291
K-321
K-324
K-341
K-345
K-346
K-351
K-353
K-355
K-372
K-374
K-521
K-531
K-711
K-712
K-781
K-918
K-920

Based on observation, interview, and record review, the facility failed to maintain the physical facilities, plumbing, eyewash stations and equipment, resulting in the potential backflow of contaminated water into the potable water supply causing potential harm to any staff or patients exposed to the water and potential harm to occupants exposed to injurious corrosive chemicals.
Findings Include:

On July 9, 2024, at approximately 1120, observed in the kitchen housekeeping closet, that the water supply to the automated chemical dispenser was left turned on but the wasting tee on the mop sink faucet was not working properly, leaving the atmospheric vacuum breaker under constant pressure for an extended time.

On July 9, 2024, at 1136, observed that the eyewash station in the main kitchen was blocked by a large trash container.

These findings were confirmed during interview with Staff B at the time of observation.

On July 9, 2024, at 1303, observed that the eyewash in the lab did not have sufficient water flow when tested, and was missing a dust cap. A review of the eyewash inspection log indicated that it had been tested weekly. There was no procedure available to review for how staff must conduct the weekly eyewash test.

On July 9, 2024 at approximately 1400, observed that the green self-contained eyewash station in the Powerhouse had no record of the water being refreshed with new water or added disinfectant in the past two years.

These findings were confirmed during interview with Staff UUU at the time of observation.


39083

On 7/9/24 at 11:33 AM, the trough water cycling plumbing lines, located at the dish machine soiled drain board in the kitchen, were observed to have two leaks, allowing for accumulation of soiled water onto the floor.

On 7/9/24 at 11:35 AM, a faucet, located at the wash station across from the dish machine in the kitchen, was observed to be provided with an atmospheric vacuum break (AVB) and was connected to a wall mounted chemical dispensing system. The faucet was observed to not be provided with a water wasting "T" to protect the AVB from being under constant pressure when the water is left on.

On 7/9/24 at 11:38 AM, the soiled tray carousel, provided for the dish machine in the kitchen, was observed to not be operating at this time. Director of Food and Nutrition (DFN) "TTTT" stated that the tray carousel is not in use, or will never be in use, and would like to get rid of it to close off that area of the kitchen. At this time, food debris and soil was observed underneath the tray carousel.

On 7/9/24 at 12:45 PM, 11 boxes of clam shell to-go containers were observed to be stored on the floor in the loading dock storage area. At this time, DFN "TTTT" instructed staff to store the boxes off of the floor.

On 7/9/24 at 12:40 PM, the reach-in cooler, located at the tray line in the kitchen, was observed to not be provided with an ambient air thermometer for proper temperature monitoring. At this time, DFN "TTTT" could not locate a thermometer in the cooler and confirmed the finding.

Based on observation, interview, and record review, the facility failed to properly maintain the ventilation system, resulting in potential harm to all occupants when not provided with clean, properly tempered air.

Findings include:

On July 9, 2024, at 1340, observed that the prefilters for Air Handling Unit (AHU) -1 were extremely dirty and partially caved in, allowing unfiltered air to bypass the pre-filters. The mechanical room was observed under a very heavy negative pressure (a pressure relationship of air being drawn into the room from adjacent spaces) which made it difficult to open the room door and caused the nearby cross corridor smoke barrier door to be drawn open by the air pressure. This occurred only when the air handling unit was running. A review of the preventive maintenance work order records indicated over 3 months had passed since AHU-1 had last been inspected.
This finding was confirmed during interview with maintenance staff WWW at the time of observation.

Based on observation, interview, and record review, the facility failed to maintain an ongoing infection control program designed to prevent, control, and investigate infections and communicable diseases for 12 months of 12 months reviewed, resulting in the potential for transmission of infectious agents to all patients served by the hospital. See specific tags:

A - 0748 - Failure to ensure that that the Infection Disease (ID) Physician who chairs the Infection Control Committee was credentialed and approved by the hospital's Governing Body.

A - 0749 - Failure to identify, monitor, and mitigate sources of infection.

A - 0750 - Failure to maintain a sanitary environment and equipment.

Based on interview and record review, the facility failed to ensure their Infection Control Program was chaired by a credentialed physician, resulting in the potential for less than adequate oversight of the facility's Infection Control Program and an increased risk for infection for all patients served by the facility. Findings include:

On 7/11/24 at approximately 1100 credential files reviewed with the assistance of Director of Medical Records/Registration and Credentialing Staff PPPP revealed that there was no credential file for the Physician Infection Control (IC) Chair (Staff GGGG).

On 7/14/24 at 1000 a review of the hospital's Medical Staff Bylaws revealed: "The Consulting Staff ... shall consist of ...physicians ...who meet the criteria for medical staff membership and whose knowledge and experience are of special value to one or more departments of the Medical Staff ...Credentialing shall be accomplished in the same manner as other staff appointments."

On 7/14/24 at approximately 1200 a review of the contract for the Infection Control (IC) Chair (Staff GGGG), Exhibit A lists the following services to be provided:
a. Act as head of the IC Program
b. Maintain all administrative medical supervision for the program.
c. Have authority and responsibility for the direction of the program (with facility leaders)
d. Participation in meetings related to the program.

On 7/14/24 at approximately 1300 an interview was conducted with the Chief Operating Officer Staff G who stated that Physician Staff GGGG is contracted to oversee the IC program and chair the IC Committee, he is not credentialed, he does not see patients.

Based on observation, interview, and record review, the facility failed to maintain an effective water management program to prevent waterborne pathogens and other chemical and physical hazards, resulting in the potential for harm or disease to all patients and occupants utilizing the facility's water supply.

Findings include:

On July 10, 2024 at 1113, observed that the bowl of the flushing rim clinical sink in the ground floor Decontamination Room was completely dry. The water from the tap of the hopper when flushed was very rusty for 2 seconds before becoming clear. At the time of observation, Staff B confirmed that this fixture had not been flushed recently.

Document review of the facility's water management program with Staff E at approximately 1145 revealed that there was no specific plan or procedures for routine flushing of low use fixtures. Documentation of water flushing by staff was not provided. Documentation of the required meetings for the water management team were not provided.

Based on observation, interview and record review, the hospital failed to maintain a clean and sanitary environment as part of their Infection Prevention and Control program, resulting in the potential for the spread of infection and food borne illness to all patients. Findings include:

On 7/09/24 between1100 and 1300, a tour of patient units 6 South (6S) and 6 North (6N) was conducted, and the following observations were made:

In clean supply storage room adjacent to the back of the nursing station on 6N the following expired sterile supplies were found: one (1) --18-gauge intravenous catheter with an expiration date of 9/20/21, twenty-three (23) - 24-gauge intravenous catheters with an expiration date of 12/31/21.

On 7/9/24 at 1120, RN Staff L, when queried, confirmed the 24- and 18-gauge intravenous catheters were expired.

In pantry refrigerator on 6N, five cups of fruit, plated for patient use were found not dated.

On 7/9/24 at 1130, Director of Nursing (DON) Staff C during an interview confirmed expired supplies and stated they should have been removed. Also stated that Nursing is assigned to check for expired supplies on a periodic basis, and that cups of fruit should have been dated with expiration date.

On 7/10/24 beginning at approximately 1000, a tour of the basement of the hospital the following observations were made in a storage room: Paper debris and dirt on floor, dirty water buckets on housekeeping carts, caps off cleaning products, both with hazard warning for severe eye and skin damage. Cleaning products had warnings to use with eye protection and protective clothing and to use near an eye wash station. No eye wash station evident in room, an eye wash bottle holder was noted in room with no eye wash bottle in it.

On 7/10/24 at 1030 an interview was conducted with housekeeping manager Staff SSS who accompanied surveyor during basement floor tour. Staff SSS stated that she works under the facilities manager, and she trains the housekeeping staff and observes their work for competency. Staff SSS was unable to provide an approved chemical list.

On 7/11/24 between 1430 and 1600, unit tours of 5 North (5N) and the Surgical Suite (level 1) were conducted, and the following observations were made:

5th floor janitor room adjacent to room sign 516 contained standing water, thick and brown in color, in corner floor bowl which was not draining.

Soiled utility room on 5th floor contained an overfilled sharps container, not secured shut, and not dated. Linen was also stored on the floor in this room.

Infection Control RN Staff T was asked about the areas on the 5th floor listed above and said he had not seen them.

Observations made on a tour of the endoscopy surgical suite during this time included: One (1) box of sterile gloves size 6 ½ with expiration date of 7/2019. Three (3) Injection needles 25 gauge with expiration date of 2/18/24. Twenty-five (25) polyp retrieval snare net(s) with expiration date of 5/22/24. Numerous pieces of surgical equipment in peel pack dated greater than 10 years ago, (example trocar in peel pack date 9/28/09).

In the supply room across from the OR room #4, the following observations were made: Seven (7) expired bags of 0.9% Sodium Chloride injection 1000 milliliters (ml). Five (5) bags of 5% Dextrose Lactated Ringers 1000 ml with an expiration date of 8/2021. Nine (9) bags of 0.9 Sodium Chloride 250 ml with an expiration date of 10/2021. Tissue collection containers which contain formaldehyde including the following: Ten (10)-3 oz containers which expired 9/2022, and two (2) -6 oz containers which expired 6/2021.

Director of Quality, Staff F who attended the surgical suite tour was asked about expired supplies and she stated she is waiting to be told she can dispose of the items.



36887

On 7/9/2024 at 1055, during the initial tour of the facility, the restraint room on 6 South (6S) was entered and a quarter sized brown colored spot was noted to be on the bed. The walls had been patched with joint compound; however, the joint compound had not been sealed in any way. Additionally, bugs were visualized in the light covers.

On 7/9/2024 at 1059, cracking paint that was slightly lifted away from the wall was observed at the top of the doorway of patient room 655. Room 655 was then entered and found to have dark colored spots on the wall near the head of the bed and on the side wall near the bed. Bugs were visualized in the light cover, and the heat/air unit on the wall was rusty.

On 7/9/2024 at 1108, the clean utility was entered on 6S. A sink was present right next to a cart containing clean towels and other linens. No splash guard was present. Additionally, the top of the hand towel dispenser was found to have heavy dust present.

On 7/9/2024 at 1110, the medication room was entered on 6S. An office chair was in the corner that had the foam of the armrest exposed. Tape residue/residual was found to be present on the medication cart as well as on cupboard doors. Twenty dixie cups with clear fluid in them were found on top of the medication cart. On 7/9/2024 at 1114, Registered Nurse (RN) Staff M was queried as to when the next medication pass was to which she replied, "In about an hour." She was then asked why the cups had fluid in them and the cups themselves did not have patient names, no date/time, and did not identify what was present in them. Staff M stated the ice machine had not been working for about a week and a patient had grabbed their water pitcher and broke it earlier that day. She had filled the cups with water to prepare for the upcoming medication pass.

On 7/9/2024 at 1141, 4 North (4N) was entered and RN Staff U was observed in the soiled utility room with bedding on the floor covering her feet and lower legs while she put a linen bag on the linen cart. She then proceeded to pick up the linen with ungloved hands, hold it close to her body which touched her from shoulders to her knees, and put the dirty linen in the linen bag. When queried as to why she wasn't wearing gloves, Staff U smiled, and stated, "I guess I forgot about them." She then proceeded into the nursing station and failed to perform hand hygiene or hand washing.

On 7/9/2024 at 1144 on 4N, Staff FFF was observed in the hallway with a clipboard carrying a used towel. He was not wearing gloves. He walked into the soiled utility room, opened the dirty linen hamper and dumped the towel into it. When queried as to where his gloves were, he stated, "I didn't touch the towel. Someone asked me to put it in the soiled utility for them. That is why it was on the clipboard." Staff FFF was then queried as to if the clipboard would then be considered dirty to which he stated, "I guess I didn't think of that." Staff FFF failed to perform hand hygiene or hand washing after disposing of the towel.

On 7/9/2024 at 1149, the dining room on 4N was entered and both heat/air wall units were found to be rusty.

On 7/10/2024 at 1004, Staff F accompanited the surveyors to the surgical/endoscopy area as she had past experience in the area. The surgery waiting room was identified by Quality Director Staff F as an area for patients waiting for endoscopy and visitors waiting visitation for the psychiatric patients. The room was entered and found to have a cardboard box sitting on the floor next to the trash can. In the sink/cupboard area, a "Wettask system" bucket was present with 2 masks. Signs of water damage were present with yellow and brown colored stains on the floor of the cabinet. A box of gloves, which was yellowed and water stained was present in the bottom cabinet next to the sink area. The countertop of the sink area was separated from the wall. Air vents x6 appeared rusty. Heavy dust was noted on the comment box. Multiple ceiling tiles had dried brown stains present. In the corner near the television, a ceiling tile had a large hole present.

On 7/10/2024 at 1020, the pre-op/recovery area for endoscopy was entered and was found to have 6 beds/carts present in Bays #3, 4, 6, 7, 8, and 9. Staff F stated the last patient care performed in this area was 6/5/2024. The blanket warmer next to Bay #9 was observed to have a thick, dark, sticky substance from the top to the bottom in a side groove near the door handles. Upon opening the top door, tape was discovered holding the gasket on the door.

In Bay #9, the base of the intravenous (IV) pole appeared to be discolored with a white substance and spots of rust.

In Bay #8, the monitor "Quick Reference Guide" was heavily spattered with a brown fluid. The mattress of the cart was lifted and a large red/brown stain approximately 12"x18" was found to be present. Upon finding the stain on 7/10/2024 at 1030, Staff F exclaimed, "Be careful where you're putting your hands (on the mattress while lifting)!" Staff F identified the large stain as being blood. Tape was present on the end of the cart which appeared dingy and grayish in color. The tape edges were dark. The bedside table was found to large amounts of brown liquid stains present in 2 of the 3 interior compartments. There was rust present on the foot/stand area of the bedside table. There was a sharps box that was full and not dated which was also present in Bay #8.

In Bay #7, the sharps box was noted to have some sharps present in it. The date on the box was "3/24." Staff F was queried on 7/10/2024 at 1037 as to if the date on the sharps box was the date it was put out or the date of expiration. Staff F stated she thought it was the date it expired. It was later confirmed on 7/10/2024 at 1139 by Director of Nursing (DON) Staff C that the handwritten date on the sharps container was the date the container expired. Staff C was then queried as to if it were her expectation that the sharps boxes be identified with an expiration date when put into use to which she stated, "Yes."

In Bay #6, the cart underneath the mattress had rust present. The sharps bin was dated "3/24", and there was an open, unused abdominal pad (wound dressing) present, available for use.

The crash cart was present in Bay #5. It was opened and found to have expired lab tubes - green top expired 12/31/2023 and two yellow-tops expired 2/29/2024. The bottom of the cart and the side shelf, which had suctioning equipment available, was dusty. The finger-clip portion of the pulse oximetry unit had several pieces of tape present that appeared yellowish-gray in color. Each of the six drawers on the crash cart had tape adhesive residue present. Additionally, the paper towel dispenser had heavy dust present on the top of it.

In Bay #4, the velcro underneath the mattress had slid exposing the adhesive underneath. There was a large dent in the cart under the mattress that had rust present. Additionally, there was tape wrapped around the base of the bedside table multiple times. The tape appeared grayish in color.

In Bay #3, tape and tape residue was found under the mattress.

On 7/10/2024 at 1050, the storage area next to the sink cabinet in the pre-op/recovery area was opened. Multiple expired blood collection tubes were found that were available for use:
Red top - 6 tubes expired 11/30/2023; 1 tube expired 12/31/2023
Yellow top - 3 tubes expired 2/29/2024
Green top - 5 tubes expired 12/31/2023

On 7/10/2024 at 1110, the endoscopy room was entered. The middle drawer of the anesthesia machine appeared to have liquid streaks that had dried and were now gray in color. The bottom drawer was opened and black dirt stains along the right top corner. Supplies could be seen inside the drawer. A full sharps bin was present that was undated. Open packages of 2x2 and 4x4 gauze were present on top of the pyxis. A triangular positioning pad was present which had vinyl worn off at the edges and corners exposing the cotton mesh underneath. The bottom portion of the IV pole was rusty. The top of the cart which supported the scope machine had large patches of worn away/missing plastic from the top.

On 7/10/2024 at 1125, Director of Quality Staff F was queried as to the process once the procedure was completed. She stated the physician would hand the dirty scope to the technician who would suction water through the scope and wipe the scope down. The scope was placed on top of the cart and wrapped in a towel, then carried to the blue bin. Staff F was asked to show where the blue bin was located. She proceeded to walk through the previously identified clean scope/supply area to a small hallway where there were two blue bins. The blue bin would then be taken to the reprocessing area for cleaning and disinfection. The technician would then go back into the endoscopy suite and clean the top of the cart and set up for the next procedure.

The facility's Infection Control Plan for 2024 states, "Scope: The infection prevention program is comprehensive in that it addresses detection, prevention, and control of infections among patients and personnel. The scope of services is based on our patient population, function, and specialized needs of the facility... There are ongoing efforts to maintain a sanitary hospital environment... There are continued efforts to develop and implement infection control measure related to hospital personnel and hospital staff, for infection control purposes including all hospital staff, contract workers, and volunteers... Goals: 1. To identify and reduce risks of infections in healthcare workers, students, volunteers, patients, staff and physicians: a. Monitor for occurrence of infection and implement appropriate control measures b. Identify and correct problems relating to infection prevention practices c. Minimize the risk associated with procedures, medical devices, and medical equipment d. Limit unprotected exposure to pathogens through the hospital 2. To improve clinical outcomes using a multidisciplinary approach... c. To improve the healthcare environment of the healthcare worker and the patient in recognizing risks, controlling outbreaks/infections within the organization. d. Maintain compliance with state and federal regulations relating to infection prevention e. To adopt and monitor on an on-going bases compliance with CDC (Center for Disease Control) handwashing guidelines to reduce the risk of infection... Hand Hygiene... Healthcare personnel shall use alcohol-based hand rub or wash with soap and water following clinical indications including: 1. Immediately before touching a patient, 2. Before performing an aseptic task or handling invasive medical devices, 3. Before moving from work on a soiled body site to a clean body site on the same patient, 4. After touching a patient or the patient's immediate environment, 5. After contact with blood, bodily fluids, or contaminated surfaces, and 6. Immediately after glove removal... All hospital staff will adhere to maintaining 1/4 inch natural nails... Glove Use and Requirements 1. Wear gloves, according to Standard Precautions, when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, non-intact skin, potentially contaminated skin or contaminated equipment could occur. 2. Gloves are not a substitute for hand hygiene..."


45246

During the initial tour of the facility on 7/09/24 from 1055 to 1230, with Director of Nursing, Staff C, nursing staff and patients were observed on 6S unit. Nursing station was observed to have floors with black streaks, dust, and debris. Walls had pilled/chipped areas without paint covering. Facility's tubing station (pneumatic tube system for sending/receiving within the facility) was observed to have old, stained, dirty carpet lining the bottom of it. Several tubes were observed in the tube station. When Staff C was asked if this system was still in use, she stated "yes".

During the tour of the facility on 7/15/24 at 1505 nursing staff and patients were observed on 6S unit. New patient was observed transported by an emergency services team on a stretcher to the unit. After patient was situated into the examination room, nursing staff was handed all the linen sheets from the stretcher. She took the linen to the soiled utility room and disposed of it into the collection bin. Staff did not wear gloves. In the soiled utility room staff proceeded to collect items from the floor and disposed of them. Nurse did not perform hand hygiene, neither did she don gloves. After finishing in a soiled utility room, she opened the door, went to the nurses' station, opened the gate, walked in, picked up a soda bottle, opened nurses' station gate and left on her break. No hand hygiene was observed during this encounter. During the same tour several nursing staff was observed wearing long braided hair with the length below their waist, untied, and brushing against the surfaces. Several female nursing staff had long artificial fingernails embellished with rhinestones. Staff G was present during the tour and confirmed these findings.

During interview with Infection Control RN (registered nurse), Staff T, on 7/10/24 at 0955, he stated that the facility is conducting consistent hand hygiene audits and staff are monitored on an on-going bases for compliance with CDC (Center for Disease Control) handwashing guidelines. He also stated that it had been a challenge to hold female nursing staff accountable to adhere to maintaining 1/4-inch natural nails.


50585

On 7/10/2024 from 0930 to 1030, during a tour of the pharmacy medication preparation areas with the Director of Pharmacy Staff II, at least 19 elements of debris were observed in the two overhead lights above the laminar airflow hood in the sterile products area where intravenous solutions were prepared. In the Unit Dose area, black and brown substances were observed on two pull out drawers located beneath the counter and on a shelf below another counter in the medication storage area. Dirty tape residue was observed above the handle of one of the drawers located below the counter.

On 7/9/2024 at 1055, during a tour of the 6 North (6N) medication room with Pharmacy Technician Staff H, a container of apple sauce was observed on a shelf in the medication refrigerator. When queried Staff H if this was appropriate, she responded "they may mix with other medications."

On 7/12/2024 at 1430, during a tour of the 6 South (6S) medication room with Director of Quality Staff F, a glass bottle of spring water was observed inside the freezer component of the medication refrigerator. The freezer section had ice present on the freezer shelf and on the sides of the freezer.

On 7/15/2024 at 1430, the facility's policy "Medication Management and Administration," dated 3/20/2024 was reviewed and the policy indicated that "Medication dispensing adheres to law, regulation, licensure, professional standards of practice, including record keeping" and the policy also indicated for storage of medication, "Medications are stored under necessary conditions to ensure stability and in the most ready-to-administer forms available, when feasible."





On 7/9/24 at 11:05 AM, during an inspection of the kitchen, assisted by the Director of Food and Nutrition (DFN) "TTTT," a container of raw chicken, located in the walk-in cooler, was observed to have standing liquid on the lid as well as accumulation on the floor. At this time, DFN "TTTT" picked up the container, and liquid poured onto the floor. DFN "TTTT" proceeded to remove and discard the chicken. The source of the liquid was undetermined.

On 7/9/24 at 11:05 AM, two wire racks, and one sheet pan rack, located in the walk-in cooler, were observed to be accumulating a white, mildew-like substance. At this time, DFN "TTTT" stated that they will clean the racks.

On 7/9/24 at 11:08 AM, a container of deli turkey was observed to be date marked 7/1 - 7/4. At this time, DFN "TTTT" stated that the turkey was out of date and proceeded to remove and discard the product.

On 7/9/24 at 11:11 AM, a box of raw eggs, located in the walk-in cooler, was observed to be stored over a pan of cooked sausage. At this time, DFN "TTTT" confirmed the sausage was cooked and ready-to-eat, then proceeded to move the eggs to a lower shelf away from ready-to-eat foods. Additionally, a container of diced tomato was observed to be improperly date marked 7/2 to 7/9, not counting the preparation date as day one of the allowable holding time of 7 days, resulting in the diced tomato being held for 8 days, in turn, being expired. Lastly, a container of shredded mozzarella cheese was observed to have no date marking.

On 7/9/24 at 11:16 AM, bulk containers of rice and flour, located in the dry storage area, were observed to have the scoop handle in the bulk containers, touching the food product, allowing for potential transfer of bacteria from the handle to the food product. At this time, DFN "TTTT" stated they will keep the scoops out of the bulk containers to prevent contamination.

On 7/9/24 at 12:00 PM, a used wet mop, located in the wash station area, was observed to be stored in an empty mop bucket, not allowing the mop head to properly air dry. At this time, DFN "TTTT" removed the mop from the bucket and hung it up to dry.

On 7/9/24 at 12:09 PM, the ice scoop holder, attached to the ice machine, was observed to have biofilm and mineral deposit accumulation on the bottom interior surface. At this time, DFN "TTTT" was queried on the frequency of the ice scoop holder cleaning and stated it was daily. DFN "TTTT" attempted to remove the ice scoop holder from the side of the ice machine but was unable to. DFN "TTTT" proceeded to wipe the interior of the ice scoop holder, and the wiping cloth came out with gray coloration from the biofilm and mineral deposits.

On 7/9/24 at 12:11 PM, approximately 15 wet chaffing pans, located on the drying rack across from the three-compartment sink, were observed to be stacked, not positioned in a way to air dry. Additionally, a large wet pot was on the rack, not positioned upside down to properly air dry. At this time, DFN "TTTT" moved all of the pans to be re-washed.

A review of the facility's policy titled "SANITATION AND INFECTION PREVENTION / CONTROL," date revised 1/20, it notes, "PROCEDURES: Dish Handlers, Trayline Area Associates
- Air dry all food contact surfaces, including pots, dishes, flatware, and utensils before storage, or store in a self-draining position. Do not stack or store when wet.
- Store all pots, dishes, flatware, and utensils 6" above the floor.
- Store all pots, glasses, and cups in an inverted position on a clean storage surface. Invert the top plate, bowl, or dish of any stacks of dishes.
- Store utensils vertically, in a bucket with handles pointing up, to reduce the opportunities for contamination.
- Cooling wands should be placed in a clean, covered pan or wrapped in sanitary plastic or food-grade bag before placing them in the freezer.
- Flatware:
- Wash hands before touching clean flatware.
- Ensure that handles are in the upright position extending toward the customer, ready for service.
- To bag or roll flatware:
- be sure flatware is dry;
- use clean flatware only;
- touch handles only OR wear disposable gloves"

On 7/9/24 at 12:18 PM, multiple ants, located at the cookline with kettles, were observed to be congregating around food debris. Additionally, gnats were observed to be accumulating and swarming around the yellow floor drain grates at the cookline. The floor drain grates were observed to be caked with grease, and attracting the gnats. At this time, DFN "TTTT" was queried about pest control and stated that a pest control operator comes to the kitchen and treats the drains for gnats.

On 7/9/24 at 12:29 PM, food and grease were observed to be accumulating on the floor at the cookline. At this time, DFN "TTTT" was queried on the frequency of cleaning under/behind the cookline and stated it is done once a week.

On 7/9/24 at 12:32 PM, five bins of utensils, located on a rack adjacent to the cookline, were observed to have food debris accumulating and touching the food contact portions of the utensils. At this time, DFN "TTTT" wheeled the rack to the dish machine area to re-wash the utensils.

On 7/9/24 at 12:39 PM, the commercial stand mixer, located in the preparation area of the kitchen, was observed to have encrusted food debris on the splash shield and wire guard. At this time, Dietary Staff "UUUU" stated the mixer was used the previous evening. DFN "TTTT" proceeded to instruct Dietary Staff "UUUU" to clean the mixer.

A review of the facility's policy titled, "SANITATION AND INFECTION PREVENTION / CONTROL Subject: CLEANING OF FOOD AND NONFOOD CONTACT SURFACES," revised 1/21, it notes, "POLICIES: FOOD CONTACT SURFACES1
- Food contact surfaces are in good condition, made of non-toxic materials and are easily cleanable.
- Flatware is run through the dish machine three times. Place flatware on flat tray for initial washing. Run through dish machine. Separate forks, knives and spoons and place with handles facing down in flatware cylinders. Run through dish machine again. Place forks, knives and spoons in new cylinder with handles facing up and run through dish machine for a third time.
- To prevent cross-contamination, kitchenware and food-contact surfaces of equipment shall be washed, rinsed, and sanitized after each use and following any interruption of operations during which time contamination may have occurred.
- Where equipment and utensils are used for the preparation of potentially hazardous foods on a continuous or production-line basis, utensils and the food-contact surfaces of equipment shall be washed, rinsed, and sanitized before and after each use with raw animal products; when changing from raw to ready-eat products; between uses with raw fruits and vegetables and with potentially hazardous food; at any time contamination is suspected; or at least every 4 hours during continuous use (example: can opener).
- Iced tea dispensers and self-service utensils such as tongs and scoops used with non-potentially hazardous foods, such as bulk candy must be cleaned and sanitized at least once a day.
- Utensils that are used to serve potentially hazardous foods must be cleaned and sanitized at least every four hours.
- The food-contact surfaces of all cooking equipment shall be kept free of encrusted grease deposits and other accumulated soil.
- Each kitchen that serves gluten-free diets and toasts bread should contain a toaster dedicated and labeled for use for gluten-free breads.
- Discard any food contact surfaces with chips, nicks or broken pieces, such as fryer baskets or skimmers that have damaged, loose or broken wires, strainers, pans, skillets, and knives, which cannot be cleaned properly.
- Ware washing sinks must be equipped with detergent and sanitizer. When a three compartment sink is used, the first compartment must contain the cleaning solution, the second must contain clean rinsing water and the third must contain sanitizer solution at the proper concentration. The sinks must be large enough to accommodate immersion of the largest equipment and utensils.
NONFOOD CONTACT SURFACES2
- Nonfood contact surfaces of utensils and equipment must be made of materials that are safe, corrosion resistant, nonabsorbent, smooth and easily cleanable, and maintained in good condition.
- Nonfood contact surfaces of equipment, such as handles on reach-in units, sides of sinks, gaskets on cooler and freezer doors, tracks of sliding doors on equipment, and the exterior of ice machines, shall be cleaned as often as is necessary to keep the equipment free of accumulation of dust, dirt, food particles, and other debris. It is not necessary to sanitize nonfood-contact surfaces; however, in-use wiping cloths must be kept in sanitizing solution between uses regardless of their intended use.
- The cavities and door seals of microwave ovens shall be cleaned at least once a day."

Based on interview and record review, the facility failed to provide the correct core privileges to 1 (Physician Staff JJJ) of 1 gastroenterologists and failed to delineate what the granted core privileges were, resulting in the potential for staff to perform procedures outside of their scope of practice and cause harm to all patients receiving services from this physician. Findings include:

On 7/11/2024 at 0955, review of the credentialing file for Physician Staff JJJ revealed on 1/16/2023 he was reappointed to the Medical Staff and was granted "Core Surgery Privileges", signed by CEO Staff A on 1/16/2023, the reappointment period to end 1/24/2025. Further review of the file revealed Staff JJJ was board certified in internal medicine and his specialty was gastroenterology. Core medical privileges and core gastroenterology privileges were granted on 1/31/2012 and core gastroenterology privileges were granted on 7/8/2016. On a form titled "Appointment to Medical Staff: (Staff JJJ)", it was marked that he was qualified for "Core Surgery Privileges" and approval was granted on 1/10/2023.

On 7/11/2024 at 1019, Director of Medical Records/Registration/Credentialing Staff PPPP was queried as to what procedures were part of core surgery privileges to which he stated that core privileges were "in the bylaws or maybe in a policy somewhere." He later recalled on 7/11/2024 at 1022 that it was on the reappointment information.

On 7/11/2024 at 1027, Staff PPPP confirmed the list of procedures for core surgery privileges was not present. He stated, "There is no review for reappointment... Sometimes privileges do roll over. It looks like the most recent privilege sheet is wrong. It should be gastroenterology, not surgery."

Based on observation, interview, and record review, the facility failed to maintain a clean environment for endoscopy services resulting in the potential to spread infectious agents to all patients receiving endoscopy services in the facility. Findings include:

On 7/9/2024 at 1155, the endoscopy area was entered. The anesthesia machine had streaks present on the second and third drawers where fluids had run down them and dried. The streaks were now gray in color. The third (bottom) drawer was partially opened. Black and dark gray dirt was present on the right top edge of the drawer. The floors had dirt and debris (dead insects and dust) present.

Facility policy for surgical services #E-1 titled "Environmental Cleaning of the Surgical Suites and Department" last reviewed 11/2023 states, "1. A safe, clean environment in the surgical setting should be provided for all patients and staff. 2. Environmental cleaning is a team effort involving surgical personnel and environmental personnel. 3. The ultimate responsibility for ensuring a clean environment lies with the Perioperative or Circulating Nurse... Conclusion of the Daily Schedule: a. Surgical procedure and endoscopy rooms and scrub/utility areas will be cleaned daily at the end of the day. b. Facility approved agents will be used to clean equipment and other areas, including surgical lights, fixed and ceiling mounted and furniture and equipment, including wheels and casters, door handles, hallways and floors, cabinet handles and push plates, ventilation grids and grills. c. Terminal cleaning of the OR (operating room) rooms includes, but is not limited to: Equipment, furniture (including wheels, castors and foot pedals), walls, doors, doorknobs, surgical lights and tracks, phones, horizontal surfaces, scrub sinks, and hallways."