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Based on observation, staff interviews, and review of maintenance records between September 20 and 21, 2022, Aspirus Eagle River Hospital, did not construct, install, and maintain the building systems to ensure life safety for patients.

Findings include:

The facility was found to contain the following deficiencies:
K222 Egress Door
K223 Doors with Self-Closing Devices
K321 Hazardous Area - Enclosure
K341 Fire Alarm System - Installation
K346 Fire Alarm Outage
K351 Sprinkler System - Installation
K363 Corridor - Doors
K372 Subdivision of Building Spaces - Smoke Barrier Construction
K511 Utilities - Gas and Electric
K923 Gas Equipment - Cylinder and Container Storage

Refer to the full description at the cited K tags.
The cumulative effect of environment deficiencies are not compliant with 42 CFR 485.623(c)(e) resulted in the Critical Access Hospital's inability to ensure a safe environment for the patients.

Based on observation, staff interviews, and review of maintenance records between September 20 and 21, 2022, Aspirus Eagle River Hospital, did not construct, install, and maintain the life safety systems for patients.

Findings include:

K222 Egress Door
K223 Doors with Self-Closing Devices
K321 Hazardous Area - Enclosure
K341 Fire Alarm System - Installation
K346 Fire Alarm Outage
K351 Sprinkler System - Installation
K363 Corridor - Doors
K372 Subdivision of Building Spaces - Smoke Barrier Construction
K511 Utilities - Gas and Electric
K923 Gas Equipment - Cylinder and Container Storage

Refer to the full description at the cited K tags.
The cumulative effect of environment deficiencies with 42 CFR 485.623(d)(1) resulted in the Critical Access Hospital's inability to ensure a safe environment for the patients.

Based on record review and interview the facility failed to ensure that vital signs (blood pressure, pulse, temperature and respirations) were taken as per physicians orders in 2 of 21 (Patient #'s 7 and 10) medical records, and that initial assessments were completed within the facility established time line when a patient was admitted to the medical floor from the emergency department in 1 of 21 (Patient #5) medical records reviewed out of a total universe of 21 open and closed records.

Findings include:

The facility document titled, "Nursing Documentation Process" #8745862 last revised 11/2/2020 was reviewed. This document revealed, "1. Initial Assessment: For patients admitted to the inpatient units..the Registered Nurse will complete an initial assessment within two hours of admission."

The facility document titled, "Nursing Documentation During Emergency Response" #10361239 last revised 9/2021 was reviewed. This document revealed, "II. INPATIENT: Initial Inpatient Admission:...Documentation of the following is required with initial assessment following admission (within...3-4 hours for med (medical) surg (surgical)...Ongoing Re-assessment for all patients: Vital signs (Temp, Pulse/Heart Rate, Respiratory Rate, BP (blood pressure)-as ordered."

Examples of vital signs not completed as per physician order:

Patient #7 was a current inpatient admitted on 09/06/2022 for increased weakness and had a physicians order to have vital signs completed every 8 hours. On review of "Vital Signs Flowsheet" on 09/06/2022 vital signs were completed at 8:00 PM and then again at 7:27 AM (11.5 hours later). On 09/07/2022 vital signs were completed at 10:30 PM, on 09/08/2022 at 7:10 AM (8.5 hours later) and at 10:45 PM. On 09/09/2022 vital signs were completed at 7:31 AM (8.5 hours later) and at 9:55 PM (14 hours later). On 09/10/2022 vital signs were taken at 3:59 PM and then on 09/11/2022 at 4:30 AM (12.5 hours later). On 9/11/2022 vital signs were taken at 7:34 AM and then again at 10:20 PM (15 hours later) and then on 09/12/2022 at 7:02 AM (9 hours later). On 9/12/2022 vital signs were taken at 2:52 PM and then again at 11:37 PM (9 hours later). On 9/13/2022 vital signs were taken at 1:00 PM and then again at 11:45 PM (10 hours later). On 9/14/2022 vital signs were taken at 6:51 AM and then at 3:03 PM (9 hours later) On 09/15/2022 vitals digns were checked at 6:47 AM (15 hours later) and at 2:28 PM and again at 11:30 PM (9 hours later). On 9/16/2022 vital signs were taken at 7:15 AM and then again at 5:00 PM (10 hours later) and at 7:50 PM and then again on 09/17/2022 at 6:52 AM (11 hours later). On 9/17/2022 vital signs were taken at 9:30 PM and then again on 09/18/2022 at 7:02 AM (10 hours later). On 9/18/2022 vital signs were taken at 9:15 PM and then again at 6:57 AM (9.5 hours later). On 9/20/2022 vital signs were taken at 7:15 AM and then again at 5:00 PM (9.5 hours later).

Patient #10's closed medical record was reviewed. Patient #10 was a swing bed patient from 8/14/2022 through 8/18/2022 after a fall at home and had a physician's order to have vital signs done every 8 hours. On review of "Vital Signs Flowsheet" on 8/14/2022 vital signs were completed at 6:00 PM and then again on 08/15/2022 at 7:07 AM (13 hours later). On 8/15/2022 vital signs were completed at 2:26 PM and then again at 11:45 PM (9 hours later). On 8/16/2022 vital signs were completed at 2:32 PM and then again at 11:00 PM (9 hours later). On 8/17/2022 vital signs were completed at 1:57 PM and then again at 7:45 AM on 8/18/2022 (17 hours later).

An interview was conducted with Quality Registered Nurse I on 9/21/2022 at 8:45 AM. When reviewed the times between vital signs being obtained on the above medical records Quality Registered Nurse I stated "Yes. I agree with you they are done later than the amount of time ordered."

Example of in patient admission assessment not completed as per facility policy:

Patient #5's closed medical record was reviewed. Patient #5 was an inpatient 07/29/2022 through 08/7/2022 for COVID-19. Patient #5's medical record documented that on 07/29/2022 at 10:15 PM the ER (Emergency Room) nurse transferred Patient #5 to an inpatient room and gave report to the nurse assuming care for the patient. The first documented assessment completed by the Registered Nurse (RN) once the patient was on the medical floor was documented on 07/30/2022 at 5:00 AM (7 hours later).

An interview was conducted with Quality Registered Nurse I on 09/21/2022 at 8:45 AM. When shown the times of Patient #5 being admitted to inpatient floor in relation to the first documented assessment on inpatient floor Quality Registered Nurse I stated "Yeah, it should have been done sooner than 7 hours."

Based on record review, observation and interview, staff at this facility failed to maintain a sanitary environment free of potential contamination to patients and staff by not adhering to infection prevention policies in 1 of 8 patient care areas (Laboratory), in a total sample of 8 patient care areas observed.

Findings include:

Review of facility policy "Hand Hygiene Policy (System) #11291421 dated 03/2021 revealed, "General Instructions I. Hand hygiene is the single most important means of preventing spread of infection. II. Perform hand hygiene with soap and water or alcohol based hand rub for at least twenty (20) seconds when: ...D. After contact with a patient's intact skin (e.g. when taking a pulse or blood pressure..) G. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. H. After removing gloves."

On 9/20/2022 at 10:44 AM while on tour in the Laboratory, Phlebotomist E was observed to don a pair of gloves, draw blood from Patient #21, take the blood sample and place it in the Laboratory area, clean the area after Patient #21 left, take off gloves and bring back Patient #22 to the Laboratory area and put on new gloves without completing hand hygiene.

During an interview on 09/21/2022 at 3:50 PM, Quality Director C was asked about expectations of hand hygiene for staff when providing patient care, Quality Director C stated the staff should be completing hand hygiene every time gloves are removed.

Based on observation and interview the facility failed to ensure the patient care areas (patient rooms) had smooth, cleanable surfaces in 9 of 9 in patient rooms (Room #'s 108, 109, 112, 113, 114, 115, 117, 119 and 120) observed out of a total of 8 patient care areas observed.

Findings include:

A policy was requested from facility in regards to environmental standards and as of exit none was provided.

On 09/20/2022 at 9:20 AM a tour was completed of the inpatient nursing area, accompanied by Director of Nursing A. The following was observed: Room #'s 108, 109, 112, 113, 114, 115, 117, 119 and 120 had areas in the drywall at the head of the bed that were dented and scraped (not allowing for a smooth, cleanable surface). Room #'s 108, 109, 113, 114 and 120 had white ceiling tiles with approximately 7 to 8 inch brown spots from water damage. Room #'s 112, 113, 115, 117 and 120 had vertical seams of wallpaper not adhered to wall, exposing the porous drywall underneath.

During a concurrent interview and confirmation of the above infection control issues in patient rooms on 09/20/2022 at 9:20 AM, Director of Nursing A confirmed the above areas and stated "We look at and talk about those things on environmental rounds I don't know why we haven't fixed them."

Based on record review and interview the facility failed to ensure that patients were being sent home with discharge instructions for home health agency information to provide them with prescribed services in 1 of 16 (Patient #4) closed records reviewed out of a total universe of 21 medical records.

Findings include:

A record review for Patient #4 revealed that Patient #4 was an inpatient from 07/29/2022 through 08/7/2022 for COVID-19. A "Care Coordination Progress Note" dated 08/02/2022 documented "Currently on 3L nasal cannula (oxygen). Would benefit from Home Health when he returns home...Status of Referrals: none made at this time. Need to determine preference for Home Health agency." A "Discharge" Nursing Note on 08/07/2022 documented that "Patient given discharge instructions...He has his O2 (oxygen) concentrator and is taking it home." The "After Visit Summary" (AVS) provided to the patient at discharge on 08/07/2022 documented follow up appointments with lab, ultrasound, office visits with providers, home oxygen use including risks, supplies, how to use, clean and care for supplies and safety tips.

There was no evidence in the medical record that a referral was made to a home health agency for Patient #4 to contact for oxygen and/or supplies.

An interview was conducted with Quality Registered Nurse I on 9/21/2022 at 9:45 AM. When asked the expectation of the AVS Quality Registered Nurse I stated "It should list on there the agency that services were arranged with and it doesn't."