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Based on observation and interviews the hospital failed to ensure emergency respiratory supplies were not expired and available for emergency patient use as evidenced by having expired respiratory supplies in the supply room that were available for patient use.

Findings:

On 08/22/2022 at 12:30 p.m. a tour of the supply room revealed the following expired items:
a) 7- Max Cap Reg expired 08/17/2022;
b) 1 -37 Fr. Esophageal Trach Airway expired -5/04/2022.; and
c) 2 - 28 Fr. NP Airways expired - 05/2022

In an interview on 08/22/2022 at 12:30 p.m. S1ADM and S2DON verified the expired respiratory items.


30984

Based on observation and interviews the hospital failed to ensure the hospital is sanitary and maintained in good repair, to ensure the safety and well-being of patients. This deficient practice is evidenced by peeling paint in the laundry room and inpatient rooms; cob webs noted in the corner of the laundry room walls and ceiling; a dirty laundry room air vent and dirty floor grate (located on the floor of the washing machine room of the laundry); and uncovered stored linens.

Findings:

On 08/22/2022 at 11:30 a.m. a tour of the laundry room revealed:
a) Peeling paint on the wall and ceiling,
b) Cobs webs were noted in the corners of the walls and ceiling,
c) The vent was covered in a grey fuzzy substance.
d) The floor grate, located on the floor of the washing machine room, was coated in dark grey grime and a grey fuzzy substance.

In an interview on 08/22/2022 at 11:30 a.m. S1ADM verified the above findings.

On 08/22/2022 12:07 p.m. observation of the linen storage for the emergency department and inpatient areas revealed the linen was not properly covered to protect from dust.

In an interview on 08/23/2022 at 3:15 p.m. S2DON verified the linen was not properly stored.

On 08/22/2022 at 1:00 p.m. a tour of patient rooms 27 and 28 revealed raised and peeling paint on the exterior wall.

In an interview on 08/22/2022 at 1:00 p.m. S1ADM verified the raised peeling paint in the exterior walls of the inpatient rooms.


30984

Based on observation and interview the hospital failed to ensure all electrical equipment was maintained in safe operating condition as evidenced by 6 of 15 licensed beds failing to have operational bed side-rail nurse call bells.

Findings:

On 08/23/2022 at 9:40 a.m. a tour of the inpatient beds revealed 6 beds with non-operational side rail nurse call buttons.

In an interview on 08/23/2022 at 9:40 a.m. S5Maint verified the bed side rail nurse call buttons were non-operational on 6 inpatient beds.

Based on record review and interview the hospital failed to develop and implement policies and procedures to ensure all staff are fully vaccinated for COVID-19. This deficient practice was evidenced by failure to ensure 100% vaccination rate, excluding those staff who have been granted exemptions to the vaccination requirements, 60 days after implementation of CMS Omnibus COVID-19 Health Care Staff Regulations.
Findings:

Review of hospital policy HR.06.014, "Mandatory COVID-19 Vaccination" effective 08/15/2021, revealed in part, "Policy: As a condition of employment, residency, contract or agency staff, or access to perform services or engage in student activities at FMOLHS facilities, Covered Individuals must receive the complete dosing regimen of one of the COVID-19 vaccines currently authorized by the U.S. Food and Drug Administration (FDA) or possess an approved exemption."

Review of the COVID vaccination records for the facility on 08/22/2022 at 2:30 p.m. revealed a list of 92 people who worked at the facility with 83 fully vaccinated and 8 religious exemptions. S8MD was marked as na. The calculated vaccination rate was 98.8%.

In interview on 08/23/2022 at 8:54 a.m. S3IC verified S8MD worked in the facility and did not have documentation of vaccination or exemption. S3IC verified the vaccination rate was not 100% as required by CMS.