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Based on observation, interview, and record review, the hospital did not have an effective governing body that was legally responsible for the conduct of the hospital, and did not ensure that the hospital was arranged and maintained to ensure patient safety and provide facilities for diagnosis and treatment (A0700); did not ensure that the hospital provided the services to meet the needs of patients in accordance with acceptable standards of practice appropriate to the needs of the community (A1151); and did not ensure that the hospital followed the requirements to be granted approval from CMS to provide post-hospital extended care services to be reimbursed as a swing-bed hospital (A1500).

The cumulative effects of these systemic practices resulted in the hospital's failure to comply and provide statutorily mandated services under the condition level of Governing Body.

Based on observation, interview, and record review the facility failed to ensure that patients receiving care in the Outpatient Adult Medical Clinic had their Personal Identifiable Information (PII) protected from being viewed and accessed by other patients and other healthcare practitioners in the clinic.

Findings included:

On 09/12/22 at approximately 10:17 a.m. during a tour of the Adult Outpatient Medical Clinic, an unattended laptop computer positioned on a rolling computer cart located in the hallway had its screen open and had the names of patients, medical diagnosis, and dates of birth viewable by anyone walking in the hallway. During the observation, there were patients in the hallway near the rolling computer cart, and various hospital staff passing by.

A review of the hospital policy titled 'HIPPA Privacy and Security (Code:1088)', (Section 9) stated, "All Employees Shall Follow: a. Reasonable safeguards and minimum necessary policies and procedures are expected such as : Turn computer monitors away to avoid public viewing access."

An interview with manager (OCM124) was done on 9/12/2022 at approximately 10:22 a.m.. She stated that laptop screens should be closed when not in use. "If the laptop is not being used, they should close the screen or lock the screen so patient information should not be viewable." She also added that the laptop should not be left unattended with the display being visible with PII. The OCM124 was unable to determine which hospital staff member had left the laptop display open or who had last used the laptop.

Based on observation, interview, and record review, the facility failed to ensure a safe environment for five patients on the inpatient psychiatric unit (sampled patients P2, P7, P8, and non-sampled patients NSP1, NSP2). Ligature points were identified throughout the psychiatric unit in patient rooms, corridors, and common areas. The presence of ligature risks in the physical environment of a psychiatric patient compromised the patient's safety. Psychiatric patients with suicidal ideation or self-harming behaviors are at very high risk for self-injury including strangulation.

Findings include:

BACKGROUND: A ligature risk (point) is defined as anything which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation. Ligature points include shower rails, coat hooks, pipes, radiators, bedsteads, windows and door frames, ceiling fittings, handles, hinges and closures. (CQC Brief Guide: Ligature points - Review date: June 2017). The most common ligature points and ligatures are doors, hooks/handles, windows, and belts or sheets/towels. The use of shoelaces, doors, and windows increased over time. (Hunt et al 2012; Ligature points used by psych inpatients.) The hospital Patient's Rights Condition of Participation (CoP) at § 482.13(c)(2) provides all patients with the right to care in a safe setting. Psychiatric patients receiving care and treatment in a hospital setting are particularly vulnerable.

There is no height requirement for a ligature risk. Information from various sources note that suicides as a result of asphyxiation can occur at any height. Specifically, suicides or suicide attempts have occurred during which patients fixed a ligature to a low pipe and around their neck and then spun their body ("alligator roll") to twist the ligature until it asphyxiated them. Thus, low-to-the-ground exposed piping (such as near toilets or under sinks, for example) or any other apparatus protruding from the wall or another structure is still considered a ligature risk if the patient is able to create a sustainable point of attachment with another material in order to inflict self-harm or cause loss of life.

OBSERVATION/INTERVIEW: An observational tour of the inpatient psychiatric unit was conducted on 9/12/22 from 9:05 AM to 10:15 AM with the Facilities and Maintenance Manager (F&MM), psychiatric nurse manager (Staff PNM), and psychiatric unit charge nurse (PCN1) and safety of environment was reviewed. The inpatient psychiatric unit was locked. A nurses station located just inside the door was secured with tempered glass and a locked door. The unit consisted of a single corridor with patient rooms and a locked exit door at the far end.

During the tour (walk-through observation), ligature points were identified at the following locations:

Patient room entry doors, (corridor doors): Metal 'scissor-action' bars, were attached to the top of the doors. F&MM stated the metal bars were not required for fire or life safety. F&MM explained that the bars were designed to hold the doors in the open position to provide visual privacy for the patient bathrooms within the resident rooms. The bathrooms had no doors and the patient room entry door (when fully open) blocked view inside the bathroom.

F&MM held onto the bar with both hands and confirmed the bar supported his body weight.
The hardware was inconsistently installed on patient room doors. The door handles were designed to be grasped and pulled up or pulled down to open the door. Some patient rooms had the handles either on the inside of the door or on the outside of the door installed so they pointed upwards creating ligature points.

F&MM, PNM and PCN1 confirmed the 'hold-open' bars on the patient room doors, and the door handles installed pointing upward were ligature points and posed a risk for hanging/strangulation.

The patient room doors were inset in an alcove and the ligature points on both the inside and on the outside of the doors were not visible (not in line of sight) from the nurse station.

Inside patient rooms: Patient rooms contained a wardrobe/storage unit with brackets that protruded from the side of the structure creating a ligature point. The observed storage units were empty. F&MM stated the storage units were not in use and confirmed the ligature points.

Patient bathrooms: The appliances and fixtures in patient bathrooms were inconsistent from room to room. Ligature points identified in patient bathrooms included: a towel hook installed approximately 5 feet 2 inches above the floor, a towel bar 3 feet above the floor and an angled grab bar in the shower 3 to 4 feet above the floor. F&MM confirmed the fixtures were not of a collapsible or "break-away" type and would support a person's body weight. F&MM called staff to remove the items.

Some patient sinks had goose neck spouts, and some patient bathrooms had exposed plumbing under sinks creating ligature points.

Multiple patient bathrooms had toilet plumbing that created ligature points where the water pipe exited the wall at a height more than 3 feet above the floor. The pipe made a 90-degree turn downward to the toilet resulting in a short run of pipe parallel to the floor. This exposed pipe was a ligature point capable of supporting body weight.

Common area, Day Room: The door to the Day Room was left in the open position and was directly across from the nurses station. The Day room was L-shaped and a large part of the Day Room was not in line-of-sight of the nurses station. In the area not visible from the nursing station, a sliding accordion partition opened in two directions. Each half of the partition had a handle that created ligature points capable of supporting body weight.

Seclusion rooms: The psychiatric unit seclusion rooms had a door knob inside the room creating a ligature point.

Corridor: Additional ligature points identified in the corridor included door knobs to include store rooms, office, and closets. Hardware above the exit door created a ligature point.
Except for the patient room doors, the strangulation risk in the corridor was mitigated (lessened) by direct field of view from the nurses station desk area. PNM stated there was usually a staff member at the nurses station with view of the corridor. However, PNM acknowledged, there may be periods of time when staff are required to assist with patient behaviors or staff may be in the nurse office/break room and staff may not always be present at the nurses station in the area with line of sight to the patient corridor.

Following the tour, F&MM stated the facility needed to go through the psychiatric unit room-by-room to develop a plan to remove as many ligature points as possible. PNM agreed.

PNM stated he conducted two ligature risk assessments. PNM said he provided a completed assessment to the Chief Nursing Officer in either March or May of 2021. PNM said he conducted a ligature risk assessment again in August of 2022 but had not yet submitted it to management. PNM confirmed the ligature points identified on the tour and stated he noted some of the same ligature points, but not all of them on the August 2022 assessment. PNM said he scored the ligature points according to the instructions on the ligature risk assessment tool, Appendix 1. PNM stated he did not complete Appendix 2 because according to his assessment the "risk was not high enough."

The hospital provided a copy of Operating Policy: Category: Safety Code: 4023, Subject: Ligature Risk Assessment, with an effective date of 10/2018. The policy listed Responsible departments as being Facility Maintenance, Nursing, and General Support Services.

The policy read, Purpose: 1). To ensure the care and safety of patients and the staff that provide psychiatric care as mandated by the Centers for Medicare and Medicaid Services (CMS) for Hospital's Patient's Rights Condition of Participation (CoP) §482.13(c)(2) - The patient has the right to receive care in a safe setting. 2). To address the environmental risks posed within a service that could enable a patient attempting suicide to use a ligature. 3). To provide guidance and instruction for identifying and assessing potential ligature points and ligature risks, regarding the findings and identifying mitigating actions as appropriate to the level of risk. Plan of actions to address ligature point risks can include reporting, management/operational/clinical solutions or physical solutions. 4). To ensure that there are regular assessments of ligature points and appropriate management thereafter.

POLICY: 1). It is (CHCC) policy and commitment to identify and manage all likely ligature points in inpatient wards specifically psychiatric unit and where psych patients access a service within CHC- such as the emergency room. 2). It is CHC - Hospital policy to describe the responsibilities for ligature risk identification, assessment, and management within CHC.
PROCEDURE: The procedure required annual (as a minimum) environmental ligature risk assessment for the psychiatric unit and emergency department. The policy read: 3). Environmental ligature risk assessments are required for Psychiatric Unit and Emergency Department. This is to ensure that where ligature risks are identified they are removed or managed. The Ligature Risk Identification Tool will assist staff in carrying out this task.

Completed Ligature Risk Assessments should be forwarded to Patient Rights and Grievance Committee. The Patient Rights and Grievance Committee will then report findings through their respective patient Rights and Quality Council meetings in order to highlight identified risk and seek approval for recommendations to manage unmitigated high risks. Approved recommendations to manage unmitigated risks, which require the investment of additional resources will then be escalated to the CHCC Chief Executive Officer (CEO) and the CHCC Board of Trustee.

The CHCC Risk Team (made up of Facilities and Maintenance Manager, Compliance Officer, CPQM Hospital Quality Coordinator, Ward Nurse manager or Supervisor, Director of Nursing and Director of Hospital Services) used an environmental Ligature Risk (Point) Identification Tool.

Ward nurse managers were responsible for identifying ligature points through the Ligature Risk Identification Tool (Appendix 1) and for completing the Ligature Risk Assessment (see Appendix 2) for any identified highest risks (those scoring 54 or 81).

The tool used four elements to identify the level of potential risk attached to a ligature point. Each element was scored from 1 to 3. A higher score denoted a higher likelihood of risk. The scores, when multiplied together gave a final rating from 1 to 81. Elements included: A. Room Type: rated based on amount of time most patients spend in the room without direct supervision from staff and rooms/areas with unobserved opportunity e.g. toilets. This rating indicted the opportunity to use a ligature point. Nurse managers scored room designation according to usual staff supervision. B. Patient profile: Mental health service users (psychiatric patients) are at greater risk for suicide than general population. C:Ligature Point: Managers scored potential ligature points in relation to height. The written instructions directed: Ligature points located between 2.3 feet and 13 feet above the floor must be scored at 3, because it is the most obvious in which a patient could hang him/herself. However, the same document gave conflicting instructions, as read, anything in the middle section of the room (2.3 to 5.6 feet) is rated at 2. D: Compensatory factors: things that reduce the risk. Must be common practice or related to room design, and must be permanent.

The tool provided an example: bedroom door handle of an Adult Acute Psychiatric Ward.
Room type - bedroom, patients spend significant time unsupervised, scored- high rating = 3
Patient profile: Psychiatric inpatient provides for a range of acute presentations including suicidal ideation, scored- a high rating = 3

Ligature Point: - (approx. 1m or 40 inches), Ligature point above 2.3 feet but below head height and therefore scored a moderate rating = 2
Compensatory factor - bedroom not easily observable, scored- high rating = 3
Room Type (3) X Patient Profile (3) X Ligature Point (2) X Compensatory factor (3) = overall rating 54 (high).

The tool directed; once assessment was completed, the highest risks (those scoring 54 to 81) should be copied into Appendix 2 with a description of the hazard, ligature point scale, risk findings & controls in place, recommended action, lead person, progress, and date.

CHC policy 4023 page 8 of 12 read: The tool aims to not only identify the highest risks but evaluate whether there are any control measures already in place that would adequately mitigate the risk. Where such control measures are not in place or deemed inadequate then recommendations should be identified to mitigate the risk.

The hospital policy did not address removal or mitigation of ligature risks (ligature points) in the moderate to low scoring range. This is not consistent with the policy statement: "To identify and manage all likely ligature points in inpatient wards specifically psychiatric unit."

Hospital policy and practices are not in keeping with the intent of the regulations to ensure a psychiatric unit environment is as ligature "resistant" or ligature "free" as possible.

Appendix 1 Ligature Point Identification Tool for the Psychiatry Ward dated 8/30/22 and completed by PNM was reviewed with the following findings for rooms A02, A04, A06, A10, and A12:

Ligature points: Shower head and shower curtain were listed but did not indicate which rooms and did not indicate the shower curtain or shower head with a ligature point. The rooms and ligature points were rated 3; Compensatory factor rated 2; patient population was incorrectly coded as 2 (should be 3 for psychiatric unit). The total score recorded was 36 for each. However, the score should have been 54 for each. Additionally, towel hanger, sprinkler, and light fixtures were scored at 36 but all should have been 54. The "bar handle" (resident room door handle) patient profile was scored at 2 but should have been 3; compensatory factor rated 2 but should be 3 because patient room doors were not visible from the nurse station, the total was 24 but should have been 54.

Ligature points identified on tour but not identified on the Ligature Point Identification Tool included the hold-open bars on the patient room doors and projections on wardrobe/storage units in patient rooms which would score 84 and plumbing above toilet would score 54.
Appendix 2 of the ligature Point Identification Tool- listed only one item; the towel hangers in regular rooms. The towel hangers were documented with a score of 36 and not break-away type. The recommended action: replace with weight limited break away towel holders.

The psychiatric unit policy titled; Patient Unit Safety, Number 5:1, revised February 2018.
PURPOSE: To provide a therapeutic and safe environment --- and by ensuring patient's safety in the use of personal belongings, hospital supplies, and equipment. RESPONSIBILITIES: all psychiatric unit employees. PROCEDURE: addressed B. Personal belongings: regarding responsibility for belongings and conditions under which belongings would be searched. Personal items that may be used as ligatures were not addressed. C. Sharp Items D. Contraband: addressed illegal drugs, alcohol, and medications. E. Environment: 2. No wire clothes hangers are allowed. The policy did not address potential ligature points.

During an interview at 9/13/22 on 1:00 PM with Plant Operations Administrative Assistant (POAA), Quality Compliance Officer (QCO), and F&MM, QCO said the hospital conducted an assessment for ligature risk and noted nursing staff and facilities and maintenance staff conducted the ligature assessment on the psychiatric unit.

F&MM recalled the assessment and stated; At that time, the only change made to psychiatric unit patient rooms was the sprinkler head in the isolation/seclusion room. F&MM said the patient room door handles were not changed due to the criticality rating stated on the assessment. F&MM stated tempered glass and a lockable door were added to secure the nurse station. A copy of the ligature risk assessment was requested.

On 9/14/22 at 9:00 AM, QCO provided a document and stated it was the most current hospital ligature risk assessment. QCO confirmed the assessment was reviewed by "Quality Assurance." When asked about hospital plans to remove ligature risks/ligature points from the psychiatric unit, QCO stated; "The ligature risks were scored and mitigating factors were in place so no plans were put in place for removal." The ligature risk assessment did not identify mitigating factors. QCO stated the hospital did not identify need for removal of ligature points.

Interview: 9/14/22 at 11:00 AM with Director of Nursing (DON). The DON stated the hospital conducted a ligature risk assessment every year. When asked her expectation regarding ligature points on the psychiatric unit, DON stated it was her expectation that ligature risks be removed immediately when identified. DON said she received email/text informing her that the ligature points on the psychiatric unit were removed as of yesterday 9/13/22. The DON accompanied to observe the psychiatric unit. DON confirmed ligature risks/ligature points remained on the psychiatric unit to include door handles, sink and bathroom plumbing, etc.

Based on interview and record review, the hospital failed to follow its Medical Staff By-Laws as it related to the appointment of a non-physician to be the Department Chair of a medical service (obstetrics/gynecology).

Findings included:

During a review of the medical staff roster and listing of medical service Chairpersons, it was identified that a Certified Nurse Midwife (a non-physician, advanced practice nurse/mid-level practitioner) had been voted as the Chairperson for the obstetrics/gynecology department/service at the hospital effective January 2022.

Review of the current Medical Staff Bylaws and Standards (effective 2019) revealed that" Medical Staff Oversight: The Medical Staff shall oversee all clinical services provided within the Commonwealth Healthcare Corporation to ensure that patients receive care of the highest possible standard. Oversight responsibilities include staff supervision and staffing recommendations, conducting and participating in continuing education, skills testing, proctoring, and performance evaluations as well as proactively ensure compliance with all Centers for Medicare and Medicaid Services Conditions of Participation...The individual ultimately responsible for overseeing clinical services must be doctors of medicine or osteopathy." (page 23). Further, "a non-physician practitioner exercising privileges at the Commonwealth Healthcare Corporation will be supervised and/or directed by a physician member of the Medical Staff (page 11).

An interview was done on 9/16/22 at approximately 7:47 a.m.with CNM39. She stated that she was the current Chairperson overseeing the clinical services of the obstetrics/gynecology department/service. "I took the position earlier this year." She described the various roles associated with being the Chairperson, as described in the Medical Staff Bylaws and Standards document. "As far as evaluations, skills testing, and proctoring I will usually have one of the physicians in the department (obstetrics/gynecology) be involved, and they will let me know and keep me in the loop of any issues or concerns involving other physicians or midwives in the department."

An interview was done on 9/16/22 at approximately 10:47 a.m. with P30 who was the Acting Chief Medical Officer (CMO) during the time of the survey. He confirmed that the appointment of the obstetrics/gynecology took place in January 2022. He stated that CNM39 should not be conducting evaluations of physicians. "We have had ongoing discussions about this this summer at the hospital. We had a situation where a Chairperson in another department departed, and the hospital decided to have a senior person in that department (FCC) who was a PA (physician's assistant' assume that vacated Chairperson role. There was resistance in that department in having PAs being a department head." He added, "We discussed the Bylaws and determined that the Bylaws did not clearly stipulate a non-physician could not be the Chairperson of a department. So we wanted to have a vote to clarify this to amend the Bylaws, but it failed. I think our current policy in the Bylaws is not clear."

Based on interview and record review the facility failed to follow their procedure to ensure a hospital licensed nurse (LN), LN188's current and valid licensure was verified. Verifying current licensure is a basic patient protection to ensure staff caring out nursing functions are qualified.

Findings include:

Four (4) LN employee files were reviewed for compliance with current licensure. LN188's employee file revealed the most current copy of an RN license expired on "11/21/20."

Facility Policy titled "Nursing Professional Qualifications and Requirements for Employment" with revision date 02/21 read, "It is a Standard of Care policy to employ nurses that are competent and qualified to ensure quality of care and patient safety during a life-threatening emergency situation." It further read, "NO LICENSE/CERTIFICATION, NO WORK." Point 3 under procedure read, "The nursing administration office will maintain a database of filing system that will ensure that each nursing employee has an active license and certification." Point 4 read, "The nursing administration office will monitor the database or filing system on a monthly basis and provide 2 month notification for upcoming renewal requirements."

On 09/16/22 at 1:00 PM Nursing Admin Assistant (NAA) 187 confirmed the nursing department maintained the data base of current nursing licenses. LN223 was assigned to do this, and LN223 confirmed she managed the database during a concurrent review. She accessed the database and opened the most current license on file for LN188. The license's expiration date read, "11/21/20". She stated it is the employee's responsibility to bring in the new license when it is renewed. NAA187 stated nursing management was expected to follow the same procure for current licensure as any other nurse.

Based on observation, record review, and interview, the facility failed to develop an active treatment plan for competency restoration for Sampled Patient 2; and failed to develop treatment/care plan for Sampled Patients P7 and P8 on the psychiatric unit..

Findings include:

1. Patient-P2
On 9/13/22 at 10:15 AM, Psychiatric Nurse Manager (PNM) stated P2 was admitted to the inpatient psychiatric unit under the department of corrections court order for competency restoration. PNM said P2 was noncompliant with his medications and at first, he stayed in his room. He spoke aggressively to a "non-person" but denied visual and auditory hallucinations. PNM said currently P2 was verbally aggressive when he wanted to leave. PNM said P2 spoke Chinese and understood English only for simple things he wanted. PNM said the staff attempted to use the telephone translator with P2 but he would not cooperate. PNM said he knew one staff in Pediatrics who could speak with P2 in his language.

When asked to describe the active treatment program for P2, PNM stated there was a court order for him to take his medications. PNM said the nursing staff administered medications intramuscular (shot in muscle) if P2 refused the oral medications. When asked about counseling, education, or other interventions to restore competency. PNM said, "For him- no, just taking medications, no counseling."

PNM was asked to describe P2's daily treatment routine. PNM stated the patients knew the routine, it was the same for all patients on the psychiatric unit. 5:00 to 5:30 AM wake up and vital signs, then ADLs and assist with shower. Breakfast 7:00 to 7:30 AM. Medications at 8:00 AM. Depending on the weather, staffing, patient's ability to manage stairs, and satisfactory behavior- outside time 8:30 to 9:30 AM. Phone time 10:00 to 11:00 AM (only P7 makes phone calls). 11:00 to 11:30 lunch. 12:00 PM to 2:00 PM slow time usually naps. 3:00 to 5:00 PM try to do coloring, games, or outside time (P7 engages with staff). 5:00 to 5:30 dinner in day room then watch television. About 6:00 PM patients are in bed, some may stay up and hang out.

PNM said P2 was seen monthly by a psychiatrist. PNM stated Dr. 72 had a background in criminal psychology and tried to speak through an interpreter with P2 about what a judge did in court. PNM said the use of interpreter did not go well. PNM said P2 did not like speaking through an interpreter.

Record review: Patient (P2) was admitted to the hospital inpatient psychiatric unit on 5/6/22 on an involuntary 72-hour civil commitment. P2 remained in the psychiatric unit involuntarily admitted by court order to restore competency. The court determined P2 was incompetent to stand trial for criminal charges.

Dr. 72 wrote admission progress notes documenting a court-ordered psychiatric consult and noted diagnosis of behavior disorder- assault with a dangerous weapon and battery. Dr. 72 documented limitations of the hospital; P2 refused use of telephonic interpretation by certified language interpreters. A Mandarin-speaking staff member was not consistently able to leave clinical duties to interpret and use of court certified Mandarin interpreter required 5 days advance notice which was not adequate to provide restoration education.

Dr. 72 wrote that P2 had not been an acute risk for harm to self or others and was occupying 1 of 4 acute care beds on the psychiatric unit. P2 refused medications and was on court order for involuntary medication administration. Dr. 72 noted the likelihood of restoration was poor and may take years.

Dr. 72 entered a physician order into P2's medical record on 6/29/22 that read; 'Hospital" informed court that it lacked the capacity or resources to assist defendants who were referred to this 'hospital' for competency restoration treatment. The physician order directed staff to check to see if P2 could be referred to Guam.

In a brief discussion on 09/14/22, Dr. 72 said staff were not trained to do competency restoration. Regarding referral to another psychiatrist, Dr. 99, a staff psychiatrist treated patients on the psychiatric unit but was not trained/experienced in competency restoration.

In an interview on 9/15/22 at 12:30-1:15 PM, the Director of Nursing (DON) said she was not aware Dr. 72 documented that the hospital lacked capacity to provide competency restoration for P2. The DON said she did not know if a referral was requested to transfer P2 to Guam. DON said social services would handle referrals.

During an interview on 9/16/22 at 8:30 AM social service (SS) staff, social workers SW430, SW431, and SW432, when asked about the doctor's order requesting referral of P2 to Guam. SW430 said SS arranged for referrals but it was her understanding that it was up to the courts to make referrals for DOC (department of corrections) patients. When asked if SS explored possible community resources such as a Mandarin-speaking attorneys or legal aides who could provide competency education to P2, SW430 and SW431 said they did not do any such research. SW 430 said she needed guidance and direction as to what sort of community resources to explore because she had no experience with competency restoration.

2. Patient- P8
Record review: A monthly inpatient psychiatry progress note by Dr. 72 documented that P8 was admitted voluntarily by a family member/legal guardian since 04/2012. Following the closure of the Living Center, P8 continued to reside in the hospital due to placement issues and lack of alternative safe housing such as group home or nursing home. Diagnoses included chronic schizophrenia, dementia, TBI (traumatic brain injury), and diabetes. P8 exhibited intermittent behaviors: wandering halls, moaning/yelling at times, disorganized behaviors, repetitive purposeless motions, and shuffling gait. She required assistance with ADLs including spoon-feeding, dressing, bathing, and incontinence care.

During an interview, PNM was asked to describe P8's primary diagnosis resulting in need for inpatient psychiatric care on the locked unit and to describe the active treatment plan. PNM stated P8 was a long-time patient of the psychiatric unit. PNM said P8 spoke mainly Chamorro but understood some English. Staff who spoke Chamorro told PNM, when P8 spoke Chamorro, she was not coherent.

PNM stated P8 sometimes talked out loud to herself and paced around back and forth but exhibited no harm behaviors to self or others. PNM stated P8 received medications and did not have individual counseling or group therapy. P8 was seen monthly by a psychiatrist.
PNM stated P8 had worsening dementia and required assistance from the unit staff with ADLs such as feeding, dressing, personal hygiene, and incontinence care. PNM said P8 did not need inpatient psychiatric care and "could go to a nursing home if there was one available."

When asked how the psychiatric unit met P8's psychosocial needs, PNM said they followed the unit routine. When asked about recreational or social activities for P8; PNM stated P8 had the same routine as described above for P2. PNM said P8's leisure activities included television, music, and sometimes she "colored." PNM acknowledged that P8 could not ambulate down stairs and did not participate in the outdoor time. PNM stated staff used to walk P8 to the elevator and then outside but since COVID, more than two years now, P8 had not been outdoors or off the locked psychiatric unit.

When asked about community-based programs, PNM stated there was a Day Program off the hospital grounds that patients used to attend. PNM said it was a staffing issue. At least one staff had to accompany the patients to the Day Care Program and the psychiatric unit did not have enough staff to send staff out with patients.

During social services interview on 9/16/22 at 8:30 AM with social workers SW430, SW431, and SW432, SW432 said social services role in treatment plans for patients on the psychiatric unit included assisting with discharge planning and assisting with specific tasks when asked. SW430 said the patients on the psychiatric unit were "chronic patients" and did not need a locked psychiatric unit. SW430 they tried to work with families to get them discharged. SW431 said the families either did not want them to return home or were not able to provide the needed care in the home. SW430 said for the patients currently on the psychiatric unit; "SS exhausted resources for discharge."

When asked how often SS updated assessments or made changes to the active support and treatment plans, SW430 said social services did not have ongoing active support plans for the psychiatric patients. "They (referring to psychiatric staff) call us when needed." SW430 said SS did not update SS assessments on a scheduled basis. SS were involved on admission and for discharge planning only. SW430 said the TLC (Transitional Living Center) caseworker attended psychiatric unit discharge planning meetings. SW430 said the facility did not regularly schedule discharge planning update meetings because they were "chronic" patients.

When asked about social services role in recreational activity and quality of life for the patients on the psychiatric unit, SW430 said SS was not involved in quality of life for psychiatric patients. When asked about community programs, recreational activities, and off-unit activities to help prepare patients for discharge from the locked psychiatric unit should a placement become available, SW431 said "They used to have all those activities for psychiatric patients, they went bowling and on other outings." The staff person who coordinated the activities and outings left and there had been nothing since.

SW430 said the community had programs. TLC has a Day Program, it closed during the COVID pandemic, but it was reopened now. SW430 said TLC required a referral from a psychiatrist.

Interview 9/15/22 12:30 PM: Regarding active treatment, The DON said most psychiatric patients "were chronic so hardly have acute psychiatric cases and no active treatment plans." The DON added that before COVID the psychiatric unit used to send patients out into the community for programs but one of the patients got agitated during Day Program, so they don't go there anymore. DON said the Tender Loving Care (TLC) program handled behavioral issues and the Senior Center was also an option.

DON agreed with social services that except for P2 who was court ordered, the patients (four) on the psychiatric unit did not require care on the locked psychiatric unit. When asked if the hospital considered placement in a less restrictive area of the hospital such as a hospital swing bed. [Hospital Swing Beds are beds used by hospitals to serve individuals needing the type of care generally provided at a Skilled Nursing Facility (SNF) when the hospital beds are not needed for acute care patients.] The DON stated the hospital had swing beds, but did not consider placement of patients from the psychiatric unit in swing beds.

Based on interview and record review the hospital failed to assign nursing staff with qualifications and competence to provide care of patients on the locked inpatient psychiatric unit. This failure placed patients on the psychiatric unit at risk for unmet psychiatric needs.

Findings include:

During an interview on 9/13/22 to 10:15 AM with the Psychiatric Unit Nurse Manager (PNM) regarding qualifications, education and training related to psychiatric nursing care, PNM stated he graduated from nursing school in 2017 and worked at the hospital for five years, since he graduated. PNM said he was assigned to be the psychiatric unit nurse manager a little over a year ago. PNM stated he had no specialized psychiatric nursing experience or education and did not receive any training regarding psychiatric nursing when he was assigned the role of nurse manager for the psychiatric unit. PNM said he supervised nursing staff on the psychiatric unit.

PNM stated he was "not really trained" or familiar with the role of nursing staff in psychiatric nursing skills such as competency restoration or development of active psychiatric treatment plans.

Regarding training of staff who provided nursing care on the locked psychiatric unit, PNM said staff received no "regular training" meaning no ongoing or regularly scheduled training. PNM said no training was conducted on the psychiatric unit since he became manager. PNM stated he planned to do the Pro-Act training program with the staff but he had not set it up yet because he waited for approval from management. Pro-ACT is a commercial training program (information at proacttraining.com) that taught skills to reduce or avoid restraint. PNM stated the Pro-Act training taught staff how to handle violent or aggressive patients.

When asked what resources were available to him for consultation, PNM said he would refer to the Director of Nursing if he had questions.

On 9/15/22 at 12:30 PM, the Chief Nursing Officer (CNO) stated she had a masters degree in nursing leadership and management but did not have masters degree level training in psychiatric nursing. The Director of Nursing (DON) stated she did not have a masters degree in psychiatric nursing, had no specialized psychiatric nursing training, and did not have psychiatric experience.

When asked to describe how the facility trained and evaluated staff knowledge and competency of skills regarding development and implementation of psychiatric active treatment plans, unit programs such as therapeutic groups, and competency restoration; DON stated all new employees attended general orientation regarding personnel and facility-wide policies. The nurse manager was responsible for orientation to the nursing units.

The six-page document titled Psychiatric Unit Orientation Checklist included patient chart content, forms, charting, oxygen and charting medication administration, crash cart log sheet, x-ray request form, and numerous other nursing duties. Skill competencies included basic skills such as oxygen and medication administration. The only psychiatric unit-specific skills competencies listed were regarding use of restraint and seclusion.

When informed Dr. 72 documented that staff were not trained and the hospital was not capable of providing competency restoration for which P2 was admitted to the psychiatric unit, DON sad she was not aware.



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Based on interview and record review, the hospital failed to ensure that hospital personnel (a registered nurse) had the specialized qualifications and training to conduct cardiac-related medical diagnostic tests on patients.

Findings included:

During an interview with RN126 on 9/13/20 at approximately 11:50 a.m., she stated that she conducted cardiac stress testing on cardiac patients. "I have been doing cardiac stress testing on patients for the last two months." She stated that she and another nurse had been asked to conduct cardiac stress testing on patients, but the other nurse declined. "The other nurse chose not to do it, so I am the only one doing cardiac stress testing. I haven't received any technical training, but they are teaching me as I go." She stated that she had no previous cardiac arrhythmia monitoring or training, as well as no electrocardiogram (ECG) abnormality recognitions training. "I do get a little nervous sometimes, but I think I do okay."

According to Tabers Medical Dictionary (online), a cardiac stress test is "a stress test, also called an exercise stress test, shows how your heart works during physical activity. Because exercise makes your heart pump harder and faster, an exercise stress test can reveal problems with blood flow within your heart." Further, it says that risks include, "Possible complications of an exercise stress test are: Low blood pressure - blood pressure may drop during or immediately after exercise, possibly causing you to feel dizzy or faint. The problem should go away after you stop exercising. Abnormal heart rhythms (arrhythmia's) - Arrhythmia's that occur during an exercise stress test usually go away soon after you stop exercising. Heart attack (myocardial infarction) - it's possible that an exercise stress test could cause a heart attack." (www.tabers.com)

Review of the hospital policy titled "Stress/Exercise Tolerance Testing (Code: 9710), page 4 stated, "Personnel administering the test should possess experience and knowledge in exercise physiology and testing, including arterial blood gas sampling and analysis, cardiopulmonary resuscitation (BCLS certified), ECG abnormality recognition, oxygen therapy, and blood pressure monitoring."

Review of the training record for RN126 reveled that she had not taken ECG abnormality recognition training, and did not have training in arterial blood gas sampling and analysis.

Based on observation, interview, and record review, nursing services failed to ensure strict intake and output (I & O) was monitored for 1 of 30 sampled patients, Patient 1, as ordered by the attending physician. Patient 1 required strict I & O's due to a fluid restriction related to dialysis and a history of pulmonary edema (Fluid in the lungs). Additionally, Patient 1 was dependent of staff to provide fluids to maintain hydration due to medically necessary restraint of his wrists.

Finding includes:

The facility admitted Patient 1 on 08/17/22 for treatment of a heart attack and a stroke. During the hospital stay Patient 1's kidney function declined and he required new and on-going dialysis treatments.

On 09/12/22 at 10:05 AM, observed staff Certified Nursing Assistant (CNA297) sitting outside of Patient 1 and Patient 2's room. He stated "I am watching them ... they are on restraints." He explained and demonstrated the routine monitoring he provided for the medically required restraints. Observed Patient 1 was not able to reach the water pitcher or bring a cup to his mouth due to the restraints. CNA297 stated Patient 1 asks for what he wants and he (CNA297) provides it. Observed a breakfast tray on the bedside table with cups of liquid, 10 - 25 % of the fluid had been consumed. When asked if Patient 1's fluid intake was documented, he stated, "We have a sheet for monitoring we write it down. I just haven't started the one for today."

On 09/13/22 at approximately 09:00 AM, observed CNA333 sitting outside of Patient 1's room. A breakfast tray was again observed partially consumed in the room. CNA333 stated Patient 1 "calls every minute, but he is on fluid restriction." When asked if she monitored and documented Patient 1's intake, she stated today was her first day on this assignment and she was not sure if she was supposed to or not and stated, "The nurse didn't give one [I & O documentation sheet]."

During an interview on 09/13/22 at 10:00 AM, Patient 1's assigned nurses, RN339 and orientee Graduate Nurse (GN292), explained Patient 1 was on a fluid restriction of 1500 cc per day. RN339 described Patient 1 had, earlier in his hospital stay, shortness of breath when flat on his back and developed "flash pulmonary edema". RN339 described Patient 1 did not usually drink his entire cup of fluid. When asked how I & O were monitored, he stated the CNAs gave a verbal report to the nurse who recorded them on the flow sheet.

A concurrent review of the flow sheet in the paper chart revealed, "0" intake for the 7-3 shift on 09/12/22. The 24-hour total for all days reviewed (9/7 - 9/12) were blank, as were several of the shift totals.

During the record review, the surveyor described the observation on 9/12/22 where some of the breakfast fluids were observed to have been consumed and CNA297 stated he had not started a I & O sheet for the day. RN297 stated the CNA should be monitoring. When notified that CNA333 this morning did not know if she should be monitoring I & O's, RN297 stated he had since provided direction.

Additional review of the daily flow sheet I & O recording multiple blanks for the shift totals on the following dates: 09/10/22 on the 11-7 shift; 09/09/22 on the 11-7 Shift, 7-3 shift, and 3-11 shift; 09/08/22 on the 11-7 shift, and the 3-11 shift; 09/07/22 on the 3-11 shift. All of the 24-hour totals were blank.

Review of physician orders revealed an order dated 08/18/22 for "Strict" I & O's and to document.

Interviewed the Unit Manager (RN286) on 09/13/22 at 2:43 PM. RN286 described that Patient 1 was under constant supervision, and not allowed to take in too much fluid, due to having too much fluid in the past. He stated they tried to maintain 1 pitcher of water in the room, and the CNA assigned is aware of how much fluid Patient 1 can have. Surveyor described observations and concurrently reviewed the I & O documentation. RN286 stated there was "Inconsistency in the monitoring if the order is strict I & O. And we should be following it."

Facility policy titled "Patient Flowsheet & Fluid Balance" revised on 01/20 read under purpose, "To ensure adequate documentation of patients' hourly activity including intake and output ... in the flowsheets." Under procedures it read, "Fluid Intake and Output - patient fluid intake and output record must reflect every 8 hours and every 24 hours total balances; such as from 11 to 7, 7 to 3, 3 to 11. Nursing Assistants that is (sic) providing oral fluids or collecting urine from patient/s should document them in the flowsheet, and endorsed to the incoming staff. Intake and output balances should be calculated at the end of every shift."

On 09/15/22 at 03:18 PM the Director of Nursing confirmed she had reviewed the concerns related to the I & O monitoring and stated "The I & O monitoring was not consistent there will be education provided to staff on this."

Based on observation, interview, and record review the facility failed to ensure that patient medical records were stored in a manner to prevent access by unauthorized individuals and protect Patient Identifiable Information (PII).

Findings included:

During a tour of the Adult Outpatient Medical Clinic on 09/12/20 at approximately 10:10 a.m. with the OCM124, a 6-drawer filing cabinet was observed in the clinic hallway located across the office of a clinic medical practitioner. The cabinet was unattended, and was unlocked. Upon opening the drawers in the presence of the OCM124, 3 of the 4 cabinet drawers contained approximately 75 medical records (in each drawer). The medical records contained the names and medical/treatment notes, and other PII for patients seen fn the clinic.

The OCM124 was interviewed next to the cabinet on 9/12/20 at approximately 10:12 a.m., and said that the cabinet was being stored in the hallway temporarily, and that she did not know medical records were being stored in the cabinet. "The cabinet is being stored here while we renovate one of the medical offices. I did not know there were medical records being stored inside." OCM124 stated that these types of records should be stored in a secured manner to protect access. She also agreed that the medical records being stored in the unattended and unlocked cabinet could potentially be viewed by staff or unauthorized individuals.

On 9/12/22 at approximately 10:40 a.m., RN126 was interviewed regarding the cabinet. She stated that she stored medical records of cardiac patients seen in the clinic in the cabinet. "I have been storing medical records inside the cabinet for a few months. When I come to the clinic in the morning, I unlock the cabinet and leave it unlocked until I end my shift at the end of the day." She stated that she leaves the cabinet unlocked and unattended to her entire work shift in the clinic.

On 9/14/22 at approximately 2:15 p.m., AMRM480 was interviewed. She stated that "Medical records kept outside of the medical records department need to be stored in a secure area. If the records are kept at the nurses station, they should be secured." When asked about the medical records being stored in an unsecured cabinet in the hallway of the Adult Outpatient Clinic, the DIRECTOR stated "I didn't know there were records being stored in there. They need to be secured and locked, and not left unattended."

Review of the hospital policy titled, 'HIPPA Privacy and Security (Code:1088)' stated (page 60), "(Medical) Records must not be left in open areas where the record may be viewed by unauthorized personnel."

Based on interview and record review, the facility failed to ensure an Informed Consent document in Resident 1's chart was complete, dated, timed, and consistent with hospital policies and procedures. The facility failed to ensure accuracy of Patient 8's medical record; and physician orders did not accurately reflect cardiac resuscitation status. Incomplete and inaccurate medical records can potentially lead to inappropriate care and services.

Findings include:

1. The facility admitted Patient 1 on 08/17/22 for treatment of a heart attack and a stroke. During the hospital stay Patient 1's kidney function declined and he required new and on-going dialysis treatments. A surgery consult dated 08/29/22 revealed under Assessment and Plan, Patient 1 required vascular access for dialysis due to acute renal failure. It read, "Procedure an (sic) risks explained. Consent by thumb print." The consult was signed by Dr. 35.

A review of forms in Patient 1's medical record revealed a document titled "Consent for Bedside Procedure." The document identified the procedure was the insertion of type of vascular access called "Vascath". It indicated that Dr. 35 would perform the procedure. In place of a patient signature was a thumb print. The form lacked completion of the following items: patient name, date, signature of the physician, and signature of the witness nurse. The documentation section for emergency procedure was also blank.

An addendum to the 08/29/22 nursing note revealed the addendum was created on 9/13/22 (two weeks later). It indicated "[Patient 1] was oriented to self and location, but with unusual responses, when signing consent form for vascath patient was alert and oriented, able to answer questions and follow commands, thumbprint was taken in place of signature because the patient was unable to hold a pen, [Dr. 35] shown the consent form. [Dr. 35] began explaining procedure to patient and after acknowledgement he began procedure." (sic)

During an interview on 09/13/22 at 10:00 AM, Registered Nurse (RN)339 confirmed the consent with the thumb print was incomplete.

On 09/15/22 at 2:15 PM, the Acting Medical Records Manager (AMRM480) was interviewed. She stated records in the medical chart should have two identifiers on them, name and date of birth. Ideally forms will also include the medical record number. After a concurrent review of the bedside procedure consent form she was asked if the nursing addendum was sufficient for completing the form. She stated, "No. We should have him (the doctor) fill this out again." She added the physician and the nurse should sign the form in the area designated for that. She confirmed the document did not conform to the standards and policy of the medical records.



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2. Record review: The EHR (electronic health record) indicated Patient 8 was admitted to the psychiatric unit on 10/30/21 under voluntary commitment. A family member served as Patient 8's guardian/representative per court order.

The current physician orders included an order updated 7/25/22 that read "full code." [Full code indicated the hospital should perform cardiopulmonary resuscitation, (CPR) in the event Patient 8's breathing and heart stopped.]

The record contained contradictory information. A document in the hard chart (paper chart) dated 7/26/22 and signed by Patient 8's representative indicated: DNR/DNI. DNR means Do not resuscitate, and DNI means do not intubate (insert breathing tube).

On 9/14/22 the psychiatric unit nurse manager (PNM) reviewed both the EHR and the paper chart. PNM confirmed the records contained inconsistencies regarding CPR orders. PNM stated it appeared that the CPR status for Patient 8 was updated during care conference on 7/26/22 but the order was missed, never processed, so the DNR/DNI order was never entered in the physician orders.

When asked where he would expect the nurse to look for DNR orders, PNM said the nurse could look in either place, in the paper chart for DNR forms, or in the EHR for physician orders. PNM said the EHR would be the quickest and most likely place the nurse would look. PNM stated the EHR was not accurate and could result in staff performing CPR and intubation against the wishes of the patient and the physician order.

Based on observation, interview, and record review the hospital did not ensure that all drugs and biologicals were kept in a secured area and locked when appropriate.
a). The fully stocked medications draw in the crash cart [A wheeled container carrying medicine and equipment for use in emergency resuscitations] was found unlocked in the Intensive Care Unit (ICU).
b). Ativan [Controlled Substances] 2 mg [Milligram] 32 bottles and five tablets [Controlled Substances] 50 mg in the ICU medication room.
This failure could result in unmonitored access by unauthorized individuals, loss, and potential tampering of medications and biologicals inside the medication room.

Findings include:

1). On 9/14/22 at 10:30 a.m., the medication room on the surgical unit located across from the nursing station was observed with the door wide open. There was no licensed staff inside the room. While unit staff were in the hallway and were passing by the room, none noticed that the door was open. It was not until 10:36 a.m. when another licensed staff who was in the nursing station told another staff member who was in the hallway to close the door.

During a subsequent interview at 9/14/22, the nurse manager (NM206) stated that the medication room door was equipped with a device that slowly closed the door until it locked. To demonstrate, NM206 opened the door fully, released the door and allowed it to close. The door, however, stopped midway and did not close. NM206 stated that he would inform maintenance staff to have the device checked.

NM206 added that the medication room door was to be closed and locked at all times.




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2). During the initial tour of the ICU unit concurrent with interview on 9/12/222 at 10:00 AM with the Charge Nurse Staff 68. The surveyor observed the medication draw of the crash cart [A wheeled cart carrying medicine and equipment for use in emergency resuscitations] unlocked. The medication crash cart draw was fully stocked per checklist on the crash cart. The unlocked crash cart medication draw is accessible to unauthorized personnel and visitors. The surveyor entered the medication room with the Charge Nurse Staff 68 and found 32 bottles of Ativan 2 mg inside the unlocked refrigerator. An unlocked draw surveyor found five tablets of Tramadol 50 mg. The Charge Nurse Staff 68 indicated the expectation is for the medication draw of the crash cart and storage area for controlled substances always to remain secured and locked.

Interviewed the ICU acting manager Staff 69, on 9/13/2022 at 09:00 AM; she acknowledged the unsecured medications storage areas were against facility policy. She further explained the nursing staff should ensure the medication storage areas are secured and locked.

Reviewed the facility policy titled "Storage and Security of Pharmaceutical Material" dated 9/2013 and it revealed.
Purpose:
To ensure pharmaceutical product integrity and safe and secure practices associated with these substances throughout the entire Health Center.
Administration:
All areas where pharmaceutical items are kept shall be under the advisory supervision of the Department of the Pharmacy. This shall encompass areas where medications are kept that are not directly managed by the Department of the Pharmacy (i.e. emergency
carts, nursing units1 clinics1 emergency rooms, operating rooms, recovery rooms and treatment rooms).
Security:
All areas where pharmaceuticals are kept shall be secure and accessible only to designated and authorized personnel.
2. Areas where pharmaceuticals are kept within the nursing units and patient care areas shall be accessible and restricted to authorized personnel as designated by the unit managers responsible for the area, generally limited to registered
nurses, physicians, and pharmacy personnel. Unit managers of these areas shall comply with the advisory supervision from the department of pharmacy with regards to the appropriate storage of pharmaceutical materials.
3. All federal and local laws as they pertain to pharmaceutical materials storage will be complied with.
4. Drug preparation and storage areas throughout the health center shall be locked. This includes pharmacy areas, and all drug storage areas on the nursing units and in-patient care areas.
5. Emergency medications stocked within the patient care areas shall be maintained in kits or carts secured by a breakable or evidence of entry locks.
6. Controlled substance medications within the health center including all patient care areas shall be stored in a lockable cabinet and the key maintained in a secure place.
7. Department of Pharmacy and general pharmaceutical storage area shall have limited access restricted to designated and authorized personnel, who are selected and supervised by the Director of Pharmacy.

Based on observation, interview, and policy review, the facility failed to ensure that only authorized personnel had access to locked areas where drugs and biologicals were stored. This failure placed drugs and biologicals at risk for theft and adulteration from pharmaceutical product tampering. This failure placed patients at risk for suboptimal therapeutic effect, adverse reactions, and/or injury from altered drugs.

Findings include:

An observational tour of the hospital was conducted on 9/13/22 with Facilities and Maintenance Manager (F&MM) and the unit manager from each unit.

While touring the Medical-Surgical Unit, Pediatric Unit, Surgical Unit, Recovery rooms, and other areas of the hospital where care was provided and medications were prepared and administered, FM&M opened medication supply rooms with a master key carried on his key ring. No staff in any of the areas questioned FM&M when the medication rooms were opened and did not provide supervision while the medication rooms were inspected for fire and life safety concerns.

FM&M stated he had access with either his keycard or with keys to all areas of the hospital but did not have access to controlled medications in Pyxis (proprietary name-automated drug dispenser) or locked storage cabinets within medication supply rooms.

Interview: 9/14/22 at 11:00 AM with hospital Director of Nursing: When discussing medication storage security, DON stated only nurses, doctors, and pharmacists should have keys to access medication storage areas. DON said housekeeping and other ancillary staff may enter the areas to conduct work duties but must be observed by nursing staff authorized to access the room.

The hospital Operations/Management policy titled: Storage and Security of Pharmaceutical Material, revised 09/2013 stated PURPOSE: To ensure pharmaceutical product integrity and safe and secure practices associated with these substances throughout the entire Health Center. POLICY: All areas where pharmaceutical materials are kept throughout the health center including general storage, pharmacy areas, ancillary areas, and patient care areas (nursing units, outpatient clinic, emergency rooms, operating rooms, recovery room, and treatment rooms). PROCEDURES: III. Security: 1. All areas where pharmaceuticals are kept shall be secure and accessible only to designated and authorized personnel. 2. Areas where pharmaceuticals are kept within nursing units and patient care areas shall be accessible and restricted to personnel authorized by the unit managers responsible for the area, generally limited to registered nurses, physicians, and pharmacy personnel.

Based on observation and interview, the hospital did not ensure that outdated, mislabeled, or otherwise unusable drugs and biologicals must not be available for patient use. This failure could potentially result in ineffective use of the drugs or biologicals.

Findings include:

1. During observation of the medication storage room in the emergency department on 9/13/22 at 10:15 a.m., the following were noted:

a. A vial of Lidocaine 2% 100 mgs/ml was observed on top of the medication cart inside the medication room. The vial was not dated when it was first opened.

b. A vial of Cetacaine topical anesthetic spray which was primed with the metal dispenser was found on top of the same medication cart. While the label on the vial indicated an expiration date of "02/23," and that it was "For single patient use only," the name of the patient was not noted on the vial to prevent use by other patients.

When the observations were conveyed, the nurse manager (NM268) was unable to comment.

2. During the medication storage observation on the surgical unit at 2:45 p.m. on 9/14 /22, the following were noted:

a. An open vial of Dexamethasone 20 mgs/5 ml was observed in a tray (C18) inside the medication cart. The vial was not dated as to when it was first opened.

In an interview during the observation, NM206 explained that multidose vials were to be discarded 28 days after the first-open date.

b. Another multidose vial of Labetelol Hydrochloride injection 100 mgs/20 ml was observed in a tray (C22) inside the medication cart. The vial which was not dated as to when it was first opened also had a note attached to "Note dosage strength."

Review of the hospital's policy (effective 05/2017) for the use of multiple dose vials revealed that beyond-use date for opened "multidose vials with antimicrobial preservatives shall be 28 days," unless otherwise specified by the manufacturer. (No manufacturer's specification was noted on the vial.)

The policy further indicated that the "healthcare provider shall write the expiration date on the vial, when it is opened."

Based on interview and record review, the facility failed to ensure proper safety precautions were maintained against radiation hazards when it did not have documented evidence that all patient and staff personal protective shielding used in the facility was inspected annually.

This failure increased the risks for radiation exposure to patients and staff.

Findings include:

During an interview on 9/14/22 at 2:05 pm with radiology technician (RT388) and Acting radiology manager (ARM), RT388 listed the number of aprons and shields used but was not sure of the full inventory. RT388 stated that under the previous manager shields and aprons went through x-ray and fluoroscopy machine every Jan/February to check for cracks but that was a couple of years ago and was not sure when aprons and shields were last checked. When asked if there was a list or inventory of all aprons and shields with dates of last inspections, ARM stated that she was unsure something like this existed but would check. ARM later provided surveyor Radiology Radiation Protection Equipment Inspection Program Log, dated 2020, which documented 26 protective shielding (for example, lead aprons, lead collars, lead gonadal shields, lead gloves) that were inspected on 1/17/2020 and next inspection due on 1/18/21.

During an interview on 9/16/22 at 8:22 am, the Chief of Ancillary Services (CAS) confirmed that there should be a comprehensive list of all shields and aprons used throughout the facility, including Radiology and Operating Room (shielding used for C-arm) with last inspection dates and inspections should occur annually. CAS reviewed Radiology Radiation Protection Equipment Inspection Program Log, dated 2020, and confirmed protective shielding had not occurred annually and was overdue. CAS stated that he will check with previous radiology manager.

During an interview on 9/16/22 about 11:00 am ARM provided surveyor with Radiology Radiation Protection Equipment Inspection Program Log, dated 2021 which documented 26 protective shielding (for example, lead aprons, lead collars, lead gonadal shields, lead gloves) that were inspected on 7/17/21 and next inspection due on 7/17/22. ARM stated that inspection was not completed on 7/17/22 and was overdue. ARM stated that inspection was done yesterday and provided surveyor with Radiology Radiation Protection Equipment Inspection Program Log, dated 2022 which documented 21 protective shielding (for example, lead aprons, lead collars, lead gonadal shields, lead gloves) that were inspected on 9/15/22 and next inspection due on 9/15/23. ARM also provided Radiology Radiation Protection Equipment Inspection Program Log, Operating Room, dated 2022 which documented 11 protective shielding (for example, lead aprons and lead collars) that were inspected on 9/15/22 and next inspection due on 9/15/23. ARM stated protective shielding used in the Operating Room was previously not inspected but would be conducted in the future.

Based on interview and record review, the facility failed to ensure the radiologist who supervised the ionizing radiology services met the qualifications established and was granted privileges by the medical staff.

This failure increased the risks for poor quality of radiology services delivered to patients.

Findings include:

During an interview on 9/13/22 at 8:27 am Acting radiology manager (ARM) stated that previous manager resigned in May and she assumed acting role two months ago. ARM stated that supervising radiologist, who had been onsite, resigned two weeks ago and the role was currently covered by the two contracted tele radiologists.

During an interview on 9/14/22 at 8:53 am, the Chief of Ancillary Services (CAS) stated that the previous supervising radiologist's last day was 9/2/22 and his replacement will start in December 2022. Currently during the interim period tele radiologist#1 (acting radiology medical director, MD475) is the supervising radiologist. CAS was unsure if the medical staff appointed MD475.

During an interview on 9/15/22 at 2:58 pm MD475 stated that he was informed a couple of days ago that he was the supervising radiologist.

Review of the credentialing and privileging file showed that the medical staff had not granted MD475 privileges as a radiologist.

Based on observation, interviews, and record review the hospital failed to maintain the overall hospital environment to ensure the safety and well-being of all patients, staff, and visitors. The hospital failed to ensure a ligature resistant psychiatric unit, failed to inspect/maintain safety equipment, failed to ensure secure and safe storage of medications and pharmaceuticals, and failed to comply with the life safety code.

The cumulative effects of these systemic practices resulted in the hospital's failure to comply with the statutorily mandated Condition of Participation under Physical Environment.

Findings:

The hospital:

-failed to identify and mitigate ligature risks (ligature points) on the inpatient psychiatric unit (A0144);

-failed to conduct required inspections of radiology protective equipment to ensure safety of radiology staff and patients and operating room staff and patients (A0536);

-failed to ensure that drugs (medications), biologicals, and medical supplies were stored in a manner to ensure safety and quality of the products; that unusable drugs were not available for use and not available beyond expiration date; and that open single-dose medications were not available for use (A0505);

-failed to ensure that medications, biologicals, and supply storage areas were secured (A0502, A0504, A0724); and

-failed to ensure that staff were knowledgeable and competent to respond to fire emergencies A0709).

The facility also failed to meet the requirements of the Life Safety Code as adopted by CMS; NFPA 101 Edition 2012 and NFPA 99 Edition 2012. Refer to LSC survey report for details related to:

K211 and K271: failure to maintain clearance of egress corridors and exit pathways for emergency evacuation.

K321, K363, and K374: failed to maintain doors for: protection of egress corridors, smoke barriers, and separation of hazardous areas from rest of hospital.

K352 and K353: failed to maintain fire sprinkler system.

K920: failed to maintain electrical wiring, unsafe use of extension cords and powerstrips.

K923: failed to ensure safe storage of oxygen cylinders.

Based on interview and record review, the facility failed to develop and implement systems to ensure staff had the knowledge and competence to respond to fire emergencies. This failure placed patients on the Obstetrics (OB) unit, newborn nursery, and neonatal intensive care unit (NICU) at risk for injury during a fire emergency.

Finding includes;

The Life Safety Code NFPA 101 requires the hospital to conduct a fire drill at least quarterly on each shift to ensure staff are familiar with procedures. NFPA 101 19.7.1.2; requires that all employees shall be periodically instructed and kept informed with respect to their duties under the evacuation and relocation plan.

On 9/13/22 at 11:45 AM, General Support staff (GSP1) provided the past 12 months of fire drill reports for review. Fire drill report dated 6/30/22 conducted at 9:43 PM documented that most of responders on OB/NICU/Nursery were not aware of their specific responsibilities during a fire drill.

When asked for documentation to show how the facility responded to the fire drill findings, GSP1 said there was no documented follow-up. GSP1 said he did not provide educational materials and did not do training with the OB/NICU/Nursery staff following the fire drill.

GSP1 stated the hospital used to do fire training on a monthly basis but that practice was stopped more than a year ago. GSP1 stated he provided a report of the number of fire drills conducted to the QAPI committee.

In an interview on 9/13/22 at 1:20 PM, Quality Assurance Staff (QA1) said she was a quality compliance officer. When asked how the facility determined staff were knowledgeable and competent to respond to fire emergencies QA1 said they were informed about fire safety during orientation. When asked about review and analysis of fire drills, QA1 stated Quality Assurance (QA) did not review fire drills. QA1 said QA monitored to ensure drills were conducted at the prescribed interval but did not review fire drill findings.

QA1 was advised of the fire drill findings described above and of the absence of documented follow-up, QA1 said that was concerning. When asked the expectation, QA1 said there should be a process to correct the staff after a bad drill.

During an interview on 9/15/22 at 12:30 PM, when asked about fire drills, the DON said yes the facility had fire drills. The DON said the "safety department" took care of the drills. When informed of the findings from the fire drill conducted 6/30/22 on the OB/NICU/Nursery, DON said she was not aware of this and stated it "was not good." When informed there was no documented follow-up for this drill and asked her expectation, DON said she was not responsible for the fire drills.

Based on observation and interview, the hospital did not ensure that supplies and equipment must be maintained to ensure an acceptable level of safety and quality. This failure could potentially result in cross-contamination and affect the accuracy of laboratory test results.

Findings include:

During the initial tour of the emergency department (ED) at 9:15 a.m. on 9/13/22, the following observations were made:

1. Four blue top vacutainer tubes (specimen collection tubes) were observed in two gray plastic trays with other supply items. The trays were on a shelf against the wall along the hallway from the nursing station to the PCAP (primary care access point) rooms. The vacutainer tubes had an expiration date of 5/31/22.

2. An open vial of Hemoccult developer 15 ml solution with a yellow top cover was found inside a blue plastic tray on another shelf that was on the same narrow hallway. The expiration date on the vial was illegible and noted only "09" on the label. NM268 stated that the vial should have been discarded.

3. Eight other blue plastic trays were observed containing an assortment of supplies including stacks of vacutainers tubes of different colors and sizes, specimen containers, blood culture bottles, band aids, syringes, assorted needles of different gauges, boxes of gauzes including opened 2x2 gauzes, irrigation syringes, test kits for chlamydia, boxes of gloves, ID tags, and allergy bracelets. Two phlebotomy trays were also noted on one of the shelves that contained more items including skin prep pads, vacutainer tubes, tapes, needles, and tourniquets.

All these supply items were uncovered and unsecured and were on the same shelves where paper supplies such as laboratory requests, prescription pads, application forms for leave, illness certification slips, discharge summary slips, admission and consultation forms, and neurological checklists were stored.



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Based on observation, interview, and record review the facility failed to ensure that all medical equipment used directly on patients was inspected prior to use on patients to ensure the equipment was safe for use on patients.

Findings included:

During a tour of the Adult Outpatient Clinic on 9/12/22 with the OCM124 at approximately 10:51 a.m., an observation of a blue medical device shaped like a briefcase labeled "Boston Scientific" was observed on the desk in a physician office within the clinic. The UM stated that the box was a device used by the cardiologist (heart physician) to use on patients that have pacemakers. She stated that the hospital had just received the device "about 3 weeks ago" on behalf of the physician for his use on patients. She states that "it has not been used yet on patients, the physician is just getting familiar with it right now." Further, she said that the device had not been checked by the hospital's bio-medical department since she said the device was not being used on patients, "It has not been checked yet because it is not being on patients yet."

On 9/14/22 at approximately 11:47 a.m., the cardiologist (MS98) was interviewed and said he was currently using the "Boston Scientific" device on patients. He stated that he had been using the device on heart patients for the last 2 months. "We were able to get this device from Boston Scientific, and I have been using on many of our cardiology patients for the past few months..."

On 9/14/22 at approximately 2:14 p.m, a representative from the hospital bio-medical department (BT25) was interviewed. He stated that all electrical medical equipment used on patients need to inspected upon initial receipt (by the hospital) and before being used on patients, and then periodically thereafter. "Equipment needs to be inspected before it is used on patients." He added, he had no record or awareness of the Boston Scientific device being used on patients in the Outpatient Adult Clinic. "I don't know about that one, usually the hospital unit will tell me when they receive a new piece of equipment. I should have inspected it before it was put into use on patients. We are in the process of developing a new tracking system."

Review of the hospital policy titled "Medical Equipment Management Plan (Code: 4007)" was reviewed. The policy stated (page 6 of 16) in Section E, Number 2, "All mechanical and electrical patient care equipment will be evaluated prior to use...The primary purpose of the incoming inspection is to verify that the equipment is safe for patient use, is in good working order, and meets the manufacturer's specifications."

Based on observation, interview, and record review, the hospital failed to ensure that its infection prevention and control program included maintaining a clean and sanitary environment to avoid sources and transmission of potential food borne infections in the kitchen; and that supplies and equipment for patient use were protected from cross-contamination.

1. Scooper handles were stored in food storage bin and were observed touching food.
2. Pots, pans and other food containers were stacked wet.
3. Cutting surface of cutting boards had cracks and crevices.
4. Staff did not immediately clean and disinfect surface area after preparing and handling raw chicken.
5. Items brought to the patient's care area was not cleaned or disinfected before being returned to a clean storage area.
These failures had the potential to cause cross-contamination of patient care supplies and of food items when unclean surfaces or utensils spread germs to food and can potentially cause foodborne illness and infections.
6). Operating Room [OR] Registered Nurse [RN] Staff and Environmental Services [EVS] did not clean the Intravenous [IV] pole and discard a single-use epinephrine irrigation container and tubing post-procedure before starting a new procedure.
7). OR RN Staff should have discarded the suction tubing with the canister post-procedure before starting a new procedure.
These failed practice can create transmission of infections to patients in the OR.

Findings include:

1. Scooper handles in rice bin

Concurrent observation and interview during initial kitchen with Dietary Director (DD451) on 9/12/22 at 9:34 am showed brown rice bin with scooper inside the bin with handle touching rice. DD451 confirmed scooper should not be present in the bin.

United States Public Health Service Food Code, dated 2017, documented "In-Use Utensils, Between-Use Storage: Food preparation and dispensing utensils shall be stored ....in food ....with their handles above the top of the food within containers ....such as bins of sugar, flour, or cinnamon ...."

Pots/pans stacked wet and cutting boards

2. Concurrent observation and interview on 9/13/22 at 10:19 am with Dietary Supervisor/Kitchen Staff (KS443) showed pots, pans and dishware ready for use were stacked wet; specifically more than two large 3 inch perforated shallow pans, four large 3 inch non-perforated shallow pans, four large 4 inch perforated pans, four large 4 inch non-perforated pans, 4 medium pans and a large plastic measuring container were stacked upside down on the shelves in the storage area with beads of water observed on the outside and inside surfaces of the pans and containers. One stack of pans that was inverted had multiple large beads of water observed on the inside food contact surface of the pan. KS443 stated that the pans and other dishes on the shelf should be dry, and not stacked wet, as the items on the shelves were ready for use. KS443 stated that dishes/pans/pots flowed from washing, rinsing, and then drying which all takes place on the same side of the wall. After being dried, the dishes/pans/pots are placed on these shelves. In addition to multiple pans/dishes being stacked wet, a 1.5 to 2 inch orange dried substance was observed on the side of one of the pans. KS443 acknowledged the orange substance and stated that it was probably food that should have been removed during the dishwashing process, but wasn't. KS443 also acknowledged the pots/pans/dishes should not be stacked wet, should be dried first and then stored but there was not enough drying space.

3. Several different colored plastic cutting boards were also observed to be stored in this area, a blue cutting board was observed to have six to eight 1.5 to 2 inch groves or crevices in the board and the red cutting board was observed to have two or three 1 to 1.5 inch groves or crevices in the board with part of the plastic hanging off the board which was subsequently pulled off the cutting board. KS443 stated that the blue cutting board was used for seafood and the red cutting board was used for meats/pork and acknowledged the groves/crevices present were present. KS443 stated that the knife leaves tiny little cuts in the plastic which makes a nice home for the bacteria to grow in and can't sanitize the board with the crevices. KS443 stated that the cutting boards should have been replaced.

Facility policy Dishwashing Machine Operations, revised 10/2020, documented "Before touching newly cleaned items, the dietary employee must wash their hands. Then they are to remove dishes and place them on the drying rack to allow items to air dry ... If employee notices food particles or other signs of inadequate cleaning, they are to clean the item again. Some items may require soaking in order to remove all food particles prior to running it through the machine."

United States Public Health Service Food Code, dated 2017, documented "Items must be allowed to drain and to air-dry before being stacked or stored. Stacking
wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow."

Facility policy Chipped or Cracked Items, revised 12/2020, documented "Chipped or damaged, china, glassware, trays, and other service ware can be both a sanitation and safety hazard, and must be removed from use."

4. Raw chicken
Observation on 9/13/22 at 11:04 am showed Cook/Kitchen Staff (KS459) holding a package of raw chicken and a knife in the other hand. KS459 sliced open the plastic using the knife and then placed the knife on the food preparation counter surface across the ovens and grills. KS459 moved the raw chicken into two large pans and then placed the pans into the oven. Head chef approached the counter and moved the knife to the other side of the cutting board. Cook #1 and Head Chef left the counter area and helped, along with most of the other dietary staff, to prepare and plate meals on the tray line. The knife was left on the counter for more than 10 minutes while staff attended to tray line.

During an interview on 9/13/22 about 11:30 am DD451 stated that preparation areas should be cleaned and wiped down between uses and during prep. When informed of observation of knife used for raw chicken being left on the prep area for an extended period of time while staff attended to other tasks, DD451 stated that knife used for raw chicken should have been immediately removed from the prep area to the dishwashing area given it was used for raw chicken and other staff may not know what knife was used for or prep area was exposed to raw chicken.

Facility policy Infection Prevention and Control for Nutritional Services, revised 10/2020, documented "Food prep tables, work areas, cooking, serving utensils and cutting boards shall be washed and sanitized after coming in contact with food."



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5. At 9:40 a.m. on 9/13/22, a licensed staff member (LS277) was observed taking a phlebotomy tray from one of the shelves where emergency department supplies were maintained. LS277 then brought the tray to a patient who was in a gurney in the man ED hallway. LS277 placed the phlebotomy tray directly on top of the gurney without using a protective barrier. LS277 then proceeded to insert a heparin lock (a venous access) on the patient for medication administration.

After the procedure, LS277 took the phlebotomy tray and brought it back to the same place on the shelf without cleaning or disinfecting the tray.

In an interview at 9:55 a.m. after the observation was conveyed, LS277 stated that he should have disinfected the phlebotomy tray before putting it back on the shelf where other supplies were stored.

In a separate interview on 9/14/22, NM268 verified that the phlebotomy tray should have been disinfected before it was returned to the shelf to prevent cross-contamination.



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6). On 09/13/2022 at 10:30 AM observed the OR RN Staff 71 and EVS Staff cleaning OR room 1 post-procedure. OR RN Staff 71 and EVS failed to clean the IV pole and remove the single-use epinephrine irrigation bottle with tubing and the suction tubing with the canister. In addition, the OR RN Staff 71 began the new procedure without changing the single-use epinephrine irrigation bottle with tubing, suction tubing with the canister, and clean the IV pole.

On 09/13/2022 at 11:00 AM, interviewed the EVS Staff 70. EVS Staff 70 questioned why he did not clean the IV pole post-procedure; EVS Staff answered, "The RN staff is supposed to clean the pump and remove the tubing's."

On 09/14/2022 at 2:30 PM interviewed with OR manager. Surveyor questioned the OR manager on the infection control risk to other patients in OR room 1. The OR manager acknowledged that not following the OR cleaning process may contribute to cross-contamination infectious risk to other patients. OR manager indicated that the OR RN staff should have cleaned the surfaces and discarded and changed all tubing post-procedure.

On 09/13/2022 at 2:45 PM, interviewed OR RN Staff 71, she verbalized forgetting to change the suction and irrigation bottle with tubing's. She further explains that the expectation per policy is to clean all IV pumps and surfaces and discard all tubing's before starting a new procedure.

Received a facility memorandum dated September 14, 2022
Subject: Ophthalmology Cases
"Effective immediately: This is to inform you that all BSS bottled tubing canisters used in ophthalmology surgical procedures are to be changed and removed before the following ophthalmology procedure commences. This may occur after the ophthalmology surgical procedure is completed or before turnover.

On 09/14/2022, reviewed the facility "Operating Room Cleaning Procedure; Operating Room Cleaning Checklist: Between Procedures" the undated form revealed:
Cleaning the OR between procedures can be a challenging task. Below is the checklist of OR environmental surfaces that EVS staff should clean and disinfect based on policies
Anesthesia cart and equipment (including IV poles and IV Pumps)

Infection Control: Operating Room Cleaning Procedure revised on 05/2019.
PURPOSE
To provide guidance to personnel performing environmental cleaning in operating and
procedure rooms. The expected outcome is that the patient is free from signs and
symptoms of infection.
End of Procedure Cleaning
1.Reestablish a clean environment after the patient is transferred from the OR.
2.Clean and disinfect reusable noncritical, nonporous surfaces (e.g., mattress covers, pneumatic tourniquet cuffs, blood pressure cuffs) according to the manufacturer's written instructions for use after each patient use.
a) Discard single-use items after each patient use.
3.Clean any soiled surface and frequently touched area of a high-touch object in the OR after each patient use.
4.Clean operating and procedure rooms after each patient has left the area.
a)Do not begin environmental cleaning, including trash and contaminated laundry removal, until the patient has left the area.
b) Remove trash and used linen from the room.
c) Clean and disinfect items used during patient care after each patient use, including
o anesthesia carts and equipment (e.g., IV poles, IV pumps),
o anesthesia machines,
o patient monitors,
o OR beds,
o reusable table straps,
o OR bed attachments (e.g., arm boards, stirrups, head rests),
o positioning devices (e.g., viscoelastic polymer rolls, vacuum pack positioning devices),
o patient transfer devices (e.g., roll boards),
o overhead procedure lights,
o tables and Mayo stands, and
o mobile and fixed equipment (e.g., suction regulators, medical gas regulators, imaging viewers, viewing monitors, radiology equipment, electrosurgical units, microscopes, robots, lasers).
5.Clean and disinfect floors and walls of operating and procedure rooms after each surgical or invasive procedure if soiled or potentially soiled (e.g., by splash, splatter, or spray).
6.Clean and disinfect patient transport vehicles, including the straps, handles, side rails and attachments, after each patient use.
a) Discard single-use straps after one use according to the manufacturer's instructions.

Based on interview and record review, the facility failed to meet patients needs in accordance with acceptable standards of practice related to respiratory services (A1152); and failed to have adequate number of respiratory therapists currently on staff to meet the needs of patients and provide the scope of services specified by medical staff and hospital policy (A1154).

The cumulative effects of these systemic practices resulted in the hospital's failure to comply and provide statutorily mandated services under the condition level of Respiratory Care Services.

Based on record review and interview, the facility failed to implement respiratory care services policy to document ventilator checks and care assessments for an intensive care unit patient (Patient 15) as required by current hospital policy. The failure which could potentially impact all patients requiring respiratory services in the hospital could lead to inaccurate assessments and unmet respiratory needs.

Findings include:

1. Record review and interview was conducted concurrently on 09/14/2022 at 9:00 AM with the Nurse Manager, Staff 69. The surveyor reviewed the adult ventilator record for Patient 15 the ventilator checks documented assessments every four hours on 9/12/2022, 9/13/2022, and 9/14/2022. Staff 69 confirmed that Patient 15's ventilator care notes and flowsheets needed to have documented assessments every two hours per the current policy.

Interview concurrent with record review on 9/18/22 at 8:00 AM with the RT manager revealed that adult ventilator records for Patient 15 documented assessments every four hours on 9/12/2022, 9/13/2022, and 9/14/2022. RT Manager acknowledged that the current respiratory policy is not meeting the ventilator check services provided in the ICU unit. The RT manager explained that since the pandemic, ventilator checks and documenting assessments have changed from every two hours to every four hours. He further explained that the policy did not reflect the time change implementation due to the extreme RT shortage. When asked how many RT staff currently worked in the hospital, he stated, "Currently, the hospital only has two RT staff which includes me, and the hospital is short three RTs to meet the needs of the patients. In addition, because of the RT shortage, all outpatient services are on hold."

In another interview on 9/18/22 at 8:00 AM, the RT Director confirmed that the hospital is experiencing a severe RT staff shortage. RT Director explained that the assessment documentation frequency was changed during the pandemic and has not adjusted the policy. A few hours later, the RT director provided a copy of an unsigned RT policy titled, "Patient- Ventilator System Checks" dated 9/2022.

Review of the facility polity titled "Patient- Ventilator System Checks," dated 5/2018 and signed and approved by the hospital leadership team revealed the following:

a). A patient-ventilator system check is a documented evaluation of a mechanical ventilator and of the response to mechanical ventilatory support.

b). All data relevant to the patient ventilator system check must be recorded on the appropriate hospital form at the time of performance.

c). A patient ventilator system check must be performed on a scheduled basis (Department Standard is every 2 hours) for any patient requiring mechanical ventilation for life support.



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2. Review of the work schedule for the last month of the Respiratory Department revealed that there were 2 full-time respiratory therapists working 12-hours shifts, 7 days per week. There was also 1 part-time respiratory therapist working one to two shifts per week (who also held another full-time non-respiratory therapist position at the hospital).

Review of the hospital policy titled "Respiratory Care Scope of Service (Code 3190)" revealed that the purpose of the Respiratory Care Department "serves and cares for all patient age groups in all stages of diseases."

Further review of this policy at section titled "Services Provided" (by the Respiratory Department) included:

DIAGNOSTIC SERVICES - obtaining sputum specimens, blood for arterial gases, outpatient testing (Exercise Stress Test, Pulmonary Function Test, Holter Monitoring) oximetry, capnography, and metabolic measurements.

TREATMENT - the department intimates and maintains all patients supported with mechanical ventilation, oxygen therapy, other types of gas therapies, and administers aerosol drugs when ordered. The department is also responsible for ensuring that artificial airway in place and secured post intubation of all ventilated patients. Routinely transport all mechanically ventilated patients in the hospital when they have to leave the intensive care unit..."

During an interview with DCOO28 on 9/12/22 at approximately 1:11 p.m., he stated that there are two-current full-time respiratory therapists on staff, "the two therapists work 12-hour shifts, one at night and one during the day, to cover the department for 24-hour daily coverage. Then I will work a couple of part-time shifts myself to give them relief so they can have a day off." He stated that the hospital has been challenged in recruiting and retaining respiratory therapists because of their location, as well as some past vendors "not wanting to work with us anymore because of payment delays and other payment issues." DCOO28 stated that they are currently hoping to effectuate 6-month contracts with two respiratory therapists to come work at the hospital "sometime in late September," and also part-time contract for a third. "We have made all three of the therapists offers, and we hope they will accept the positions." He added that the current staffing of two full-time respiratory therapists has been going on 'for the last 3-4 weeks."

An interview was done on 9/13/22 at approximately 1:22 p.m. with RT419 who is a full-time respiratory therapist at the hospital. He stated that the current staffing of 2 full-time therapists has been going on for "4 weeks." He added that prior to the current staffing "there were 3 of us for about a month prior to where we are now, and we still could provide outpatient services. When asked about being able to provide the scope of services outlined in the hospital policy, he stated "we are not doing anything for outpatient services. We don't have the time or resources to do cardiac stress testing, pulmonary function tests, or Holter (cardiac) monitoring." RT419 provided a folders of physician order requests for cardiac stress testing, pulmonary function tests, and Holter monitors that had physician orders dating back to December 2021. "The patients have called to ask when they can be scheduled or come in to have the test and I have had to tell them we cannot do it because we don't have the staff or resources at the present time." He said that "sometimes one of the nurses in the Outpatient Clinic will do a couple here and there, but we have way more that we just can't do. I tell patients they need to either go to Guam or get a medical referral." RT419 said there has been "minimal impact" on inpatient services, but it is "exhausting and demoralizing" that the hospital isn't providing the resources we needed. When asked if the Medical Director for the Respiratory Department was aware of the lack of staffing and not being able to provide outpatient services, RT419 stated that "yeah, I think he is aware, but I am not sure what is being done."

An interview was done with RT418 on 9/15/22 at approximately 7:55 a.m. He stated that the Respiratory Department has been challenged with staffing for "almost 2 years." He added, "I have been communicating for the last 2 years that we need more staff, but nothing has happened." He stated that outpatient services have stopped because they do not have the staffing. "We have to focus on inpatients, and even then, there are near misses in terms of covering all that we need to do. Whether it is covering a code to responding to something else in the ICU or ER, it can be challenging because we can only be at one place at once since there is only one of us (respiratory therapists) at any one time. We should have at least 7 of us, at minimum in our department to provide adequate coverage and have normal time-off. Right now we work back-to-back 12-hour shifts with no day off. That's crazy. I had three codes (an incident requiring cardiopulmonary resuscitation due to a patients becoming pulsess, non-breathing, and/or non-responsive), fortunately that happens once in a blue moon, but I had to pick which one I would respond to, and fortunately I picked the right one." He stated a monthly report titled "RT (Respiratory Therapy) Division Monthly Report" goes to the administration on a monthly basis.

Review of the "RT (Respiratory Therapy) Division Monthly Report" from January 2022 included the following, "Challenges: Maintaining 24/7 coverage and continuing outpatient testing."

Review of the "RT (Respiratory Division Monthly Report" from February and March 2022 included the following, "Challenges: Maintaining 24/7 coverage and continuing outpatient testing. Workload has suddenly dramatically increased due to COVID in December 2021...Unable to hire staff due to low salary."

Review of the "RT (Respiratory Division Monthly Report" from April and May 2022 included the following, "Challenges: Maintaining 24/7 coverage and continuing outpatient testing...3 staff leaving in less than 3 weeks and I don't see a plan. We need to address staffing now. There are travelers (temporary staff) who would stay but it's about price (salary)."

Review of the "RT (Respiratory Division Monthly Report" from June and July 2022 included the following, "Outcomes: 2 more staff leaving in less than 3 weeks. We need staffing now."

Review of the "RT (Respiratory Division Monthly Report" from August 2022 included the following, "Highlights: We only have 2 staff. All outpatient testing is canceled. We are in CMS COP violation. Services are not being provided."

Based on interview and record review, the dacility failed to have an adequate number of respiratory therapists on staff to meet the needs of patients receiving care at the hospital.

Findings included:

The hospital did not have sufficient respiratory staff to meet the needs of its patients.

Cross-refer to A1152.

Based on observation, interview and record review, the facility failed to put systems and processes for residents placed in "Swing Beds" to address Resident Rights; Admission, Transfer and Discharge Rights; Social Service needs; and Activities and Dental needs. These failures had the potential for all residents in "Swing Beds" to have their resident rights violated, and not reach their highest practicable well-being.

The cumulative effects of these systemic practices resulted in the hospital's failure to comply and provide statutorily mandated services under the condition level of Swing Beds.

(Cross reference to A1562, A1564, A1567, A1573.)

Findings include:

During an initial tour of the Medical Unit on 9/12/22 at 9:52 AM, The Unit Manager (RN286) and Acting Manager (RN287) explained that some patients on the unit were in "Swing Beds" and agreed to provide the census data.

Hospital "Daily Census Report" dated 9/12/22 revealed 4 Residents were admitted to "Swing Beds."

During an interview on 09/13/22 at 12:20 PM, RN339 described the swing beds as a "new concept" and stating "Patients are put on swing bed status when they are not able to be discharged right away." When asked about some of the regulatory requirements such as activities being provided, he stated, "As far as I know it is only Physical Therapy."

During an interview at approximately noon on 9/14/22, the Social Work Manager described residents were placed in swing beds when there is an issue that keeps them from discharging. She confirmed she was not familiar with the swing bed regulations. When asked about provisions for activities, dental services, and social work counseling, she stated "We don't."

An interview with the Director of Nursing (DON) and the Chief Nursing Officer (CNO) was held on 09/15/22 at 3:18 PM. They described the swing bed use was implemented "about a month ago" as part of the COVID-19 Emergency Declaration. "We did not have a place to discharge them." When asked if they had a policy or procedures for the swing beds they said "We don't have a policy on that yet."

When asked how the residents were included in the Care Planning Process, they described the care planning process for the swing bed residents and the hospital bed patients was "no different."

When asked what the process was for helping residents to personalize their space, obtain their personal clothes and items, they admitted they had not considered that.

They confirmed there was not a written notification to residents, when they are admitted, of the items and services provided that are included in their stay, and will not be charged for.
Conversely, they did not have written notification of items and services offered they may be charged for.

When asked if they provided a written notice of discharge to the resident with their right to appeal, and was that sent to the Ombudsman, they said they did not.

When asked to describe their activities program, they said there was not one.

When asked if there was a system to evaluate the dental needs of residents in swing beds, they confirmed that it had not been planned or implemented.

The facility did not have a policy related to swing beds. The DON and CNO provided 2 memos that were distributed when they implemented the swing beds. Facility Memo dated 9/12/22, Subject "Update: Extension of Public Health Emergency - Swing Bed Services;" and an earlier Memo dated 6/17/22, Subject "Hospital Swing - Bed Services under Public Health Emergency: Documentation for Skilled Level Nursing Care" were reviewed.

The first Memo (6/17/22) outlined the criteria, or requirements for placing a patient/resident in a swing bed, and that the service must be clearly delineated in the medical record. The second Memo (9/12/22) further clarified the criteria that must be met for swing bed service, and the "Process for Clinical-Nursing."

The process for Clinical-Nursing read:

-"Knowledge of Swing Bed Service availability
-Once orders are received. Verify patient's understanding of plan of care, notify next of kin if patient is not competent to receive and acknowledge plan.
-Review orders for Swing bed Service. Should have Delayed Orders pending transfer.
-Notify Nursing Supervisor On Duty to communicate with Admission & Discharge personnel.
-Patients that have been successfully transferred to Swing Bed Service will have a dash (-) next to their room assignment such as D99-3
-Documentation of care of patients - no charge."

The Memo did not address how nursing or any other discipline would address all of the regulations relating to Swing Beds.

Based on observation, interview and record review the facility failed to consider Resident's right to have and use personal belongings while residing in a facility swing bed. The right to retain and use personal possessions promotes a homelike environment and supports each resident in maintaining their independence.

Findings include:

Observed Resident (R) 3 ambulating in the hallway, in a hospital gown, assisted by therapy staff on 09/12/22 at 09:56 AM. They returned to Resident 3's room. Observed no personal belonging in the room. The medical record revealed R3 was admitted to a swing bed on 08/31/22.

Observed R2 in bed on 09/12/22 at 10:14 AM, staff were sitting outside of his room. Observed no personal belonging in the room. The medical record revealed R2 was admitted to a swing bed on 07/25/22.

During an interview on 9/13/22 at approximately 09:30 AM, Certified Nursing Assistant 33 (CNA33) did not know if R2 had any personal belongings.

Registered Nurse 339 (RN339) confirmed on 09/13/22 at 12:20 PM that R3 did not have personal belongings in his room.

The Unit Manager (RN286) was asked about Resident's Rights related to personal belongings on 09/14/22 at approximately 09:00 AM. He stated being personal items from home would not be allowed. When asked if he was familiar with the Resident Rights' regulations concurrently reviewed, he confirmed he was not. When asked if a policy was provided by the hospital to address the Swing Bed Residents' Rights he said he was not aware of any.

An interview with the Director of Nursing (DON) and the Chief Nursing Officer (CNO) was held on 09/15/22 at 3:18 PM.
- When asked how the residents were included in the Care Planning Process they described the care planning process for the swing bed resident and the hospital bed patient was "no different."
- When asked what the process was for helping residents to personalize their space, obtain their personal clothes and items, they admitted they had not considered that.

The facility did not have a policy related to creating a homelike environment, or the use of personal belongings and clothing for the swing beds. They provided 2 memos that implemented the swing beds. Facility Memos dated 9/12/22, Subject "Update: Extension of Public Health Emergency - Swing Bed Services" and 6/17/22, Subject "Hospital Swing - Bed Services under Public Health Emergency: Documentation for Skilled Level Nursing Care" did not address creating a homelike environment for the Residents.

Based on interview and record review, the facility failed to provide discharge notices to three of three Residents (R) reviewed for discharge from swing beds (Residents R27, R28, and R29). This had the potential for Residents to not be informed of their appeal rights, to be notified timely, and for the Ombudsman to be unaware of discharge practices.

Findings include:

An interview with the Director of Nursing (DON) and the Chief Nursing Officer (CNO) was held on 09/15/22 at 3:18 PM regarding the implementation of swing beds in the facility. They described the swing bed use was implemented "about a month ago" as part of the COVID-19 Emergency Declaration. "We did not have a place to discharge them." When asked if they had a policy or procedures for the swing beds they said, "We don't have a policy on that yet." During the interview when asked if they provided a written notice of discharge to the resident, with their right to appeal, and that was sent to the Ombudsman, they said they did not. Requested a list of residents discharged from swing beds since it was implemented. A list of 7 residents was provided.

A review of R27, R28, and R29's medical record revealed a lack of discharge notification.

During a concurrent review of the medical records and the discharge notice regulations with Acting Medical Records Manager (AMRM480) on 09/15/22 at approximately 3:00 PM, AMRM480 confirmed they did not develop a discharge notice for swing bed residents. She stated, the swing beds were implemented before we were ready.

Based on interview and record review the facility failed to implement processes and structures to ensure that Residents' medically-related social service needs, beyond discharge, were met.

"Medically-related social services" means services provided by the facility's staff to assist residents in attaining or maintaining their mental and psychosocial health.

Examples of medically-related social services include, but are not limited to the following:

-Advocating for residents and assisting them in the assertion of their rights within the facility
-Making arrangements for obtaining items, such as clothing and personal items
-Making referrals and obtaining needed services from outside entities (e.g., talking books, absentee ballots)
-Providing or arranging for needed mental and psychosocial counseling services
-Meeting the needs of residents who are grieving from losses and coping with stressful events.

Finding includes:

Resident 2 (R2):
Observed R2 in bed on 09/12/22 at 10:14 AM, staff were sitting outside of his room. Observed no personal belonging in the room. Certified Nursing Assistant 297 (CNA297) stated he sat outside of R1 and R2's room because they required supervision related to restraints. Registered Nurse 338 (RN338) walked out of R2's room and stated "There was an order to discontinue [restraints] since he was no longer agitated."

Observed R2 on 09/13/22 at approximately 09:30 AM sitting cross legged on the bed. The side rails were up. A picture of a falling star was posted by the doorway. Certified Nursing Assistant 333 (CNA333) sat outside the room. She stated R2 was a fall risk and required close observation so he did not fall. When asked if the resident received Activity services she stated, "If they can walk we may walk them, but if not, they just stay in there."

The hospital discharge summary revealed R2 was admitted to the facility on 03/05/22 and discharged from acute care to a swing bed on 07/25/22. Diagnosis included Korsakoff's psychosis (Korsakoff psychosis is a late complication of persistent Wernicke encephalopathy (a degenerative brain disorder caused by the lack of thiamine (vitamin B1) and results in memory deficits, confusion, and behavioral changes), alcoholism, and dementia. It read, "Psych consult noted. Pt not felt to be of benefit for transfer to [in patient] psych."

Interviewed the Medical Social Services Manager (MSSM430) on 09/14/22 at approximately noon. She was asked if she participated in the comprehensive assessment used to assess long term care residents, the Minimum Data Set (MDS) assessment. She was not familiar with the MDS (used for assessment, care planning and payment) and did not participate in the care planning for R2's dementia. She explained her role was primarily discharge planning. She confirmed the social service department may get involved if a resident needed supplies such as diapers, she would contact the family to provide them, however that was not a usual part of their services.

An interview with the Director of Nursing (DON) and the Chief Nursing Officer (CNO) was held on 09/15/22 at 3:18 PM regarding swing bed services. During the interview the DON described the care for residents in swing beds did not differ from the care for acute care hospital patients. They confirmed the use of swing beds began "about a month ago" and was implemented with 2 memos.

Facility Memos dated 9/12/22, Subject "Update: Extension of Public Health Emergency - Swing Bed Services" and Memo dated 6/17/22, Subject "Hospital Swing - Bed Services under Public Health Emergency: Documentation for Skilled Level Nursing Care" were reviewed. They did not address how the facility would assist residents in attaining or maintaining their mental and psychosocial health.

Based on interview and record review the facility failed to assess and/or assist all swing bed residents with routine dental care. This had the potential for residents in need of routine dental services to not receive needed services.

Findings include:

During an initial tour of the Medical Unit on 9/12/22 at 09:52 AM, The Unit Manager (RN286) and Acting Manager (RN287) explained that some patients on the unit were in "Swing Beds" and agreed to provide the census data.

Hospital "Daily Census Report" dated 9/12/22 revealed 4 Residents (R) were admitted to "Swing Beds." R2, R3, and R4 were selected as part of the sample.

A review of their medical records revealed that R2 had resided in a swing bed for 7 weeks (admitted on 07/25/22); R3 was admitted to a swing bed on 08/31/22 (2 weeks prior to the survey); and R4 resided in a swing bed for 7 weeks (admitted on 07/26/22). The medical records lacked an assessment of their dental health or needs.

During an interview with the Unit Manager, Registered Nurse 286 (RN286) on 09/14/22 at approximately 9:00 AM, he was asked about services for swing bed residents. He stated he was not familiar with the regulations addressing routine dental needs for swing be residents. He confirmed they did not have a process to assess and address residents' routine dental needs upon admission.

An interview with the Director of Nursing (DON) and the Chief Nursing Officer (CNO) was held on 09/15/22 at 3:18 PM. When asked if there was a system to evaluate the dental needs of residents in swing beds, they confirmed that had not been planned or implemented.

The facility did not have a policy related to dental assessment/needs for the residents in swing beds. They provided 2 memos that implemented the swing beds. Facility Memos dated 9/12/22, Subject "Update: Extension of Public Health Emergency - Swing Bed Services" and 6/17/22, Subject "Hospital Swing - Bed Services under Public Health Emergency: Documentation for Skilled Level Nursing Care" as the documents implementing the swing beds. They did not address routine dental needs for the Residents.