HospitalInspections.org

Based on review of facility policy, ED (emergency department) medical records, inpatient medical records (MR), and staff interview, it was determined the facility failed to ensure the staff followed their own policy for use of restraints and:

1) Restrained areas were inspected every two hours and circulation checks performed and documented.

2) Performed and documented release of restraints at least every 2 hours.

3) Performed and documented ROM (range of motion provided) at least 2 hours.

4) Alternatives to restraints were considered.

This affected 1 of 1 records reviewed for restraint use and included MR # 9 and had the potential to negatively affect all patients placed in restraints.

Findings include:

Policy: Restraints
Policy #: XXIII 1a
Reviewed: 3/19

A restraint is defined as a device used to restrict freedom of movement. Restraints are used to provide a safe environment for patients (to prevent a patient from injuring self or others.

The RN will employ restraints when all alternatives have been exhausted...and/or assign patient to room in close proximity to nurses station, or mitten application to protect tubes/appliances....

General Information:

...Restrained areas are to be inspected every two hours and appropriated space (circulation checks) performed and documented...

Restraints are to be removed every two hours and more often as indicated, for ROM (range of motion) and ADL (activities of daily living) to be administered (fluids and bathroom privileges). This is to be documented on the Restraint Flow Sheet. Reason for restraint must be documented every shift in the nurses notes...

Policy: Alternatives to Restraint Use
Policy #: XXIII 1c
Reviewed: 3/19

A. Providing companionship and supervision...

B. Changing or elimination bothersome treatments...

C. Modifying the environment...

D. Reality orientation and psychosocial interventions...

E. Providing food...

F. Offer diversional and physical activities...

G. Designing creative alternatives...

1. MR # 9 presented to the ER on 2/8/17 at 2:27 PM with complaint of shortness of breath and admitted for inpatient care at 6:28 PM with diagnosis of Aspiration Pneumonia.

Review of the ER documentation revealed the CRNP (Certified Registered Nurse Practitioner) documented on 2/8/17 at 3:08 PM patient "is pulling at (his/her) gown and PEG (Percutaneous Endoscopic Gastrostomy) tube. Soft wrist restraints placed to prevent (his/her) medical equipment."

Review of the History and Physical dated 2/8/17 revealed "the patient was restless or agitated, pulling off his gown and trying to pull on his PEG tube; he was pulling (himself/herself) down in the bed. After arrival to the ER, soft wrist restraints were placed on (him/her) to keep medical equipment in place."

There was no documentation in the ER notes from 3:08 PM to 6:28 (3 hours, 20 minutes) that restraints:

a) circulation checks were performed and documented

b) were removed every 2 hours to allow for ADL or ROM

c) alternatives to restraint use were considered

An interview was conducted on 12/19/19 at 5:15 PM with EI # 2, Director of Nurses, who confirmed the above findings.

Based on observations Medical Record (MR) review, and staff interviews it was determined that the staff failed to follow the physician orders for telemetry and medication administration.

This deficient practice affected 1 of 1 charts reviewed with telemetry including Patient Identifier (PI) # 3, 1 of 4 of medication administration observations, including PI # 5. This had the potential to negatively affect all patients admitted to this facility.

Findings include:

1. PI # 3 was admitted to the facility on 12/18/19 with diagnoses including Upper GI (Gastrointestinal) Bleed, Abdominal Pain, Pancreatitis, Leucocytosis, Severe Sepsis, New Onset Diabetes, and Ketoacidosis.

Review of Physician order dated 12/18/19 at 7:21 PM revealed an order for the patient to be placed on telemetry for cardiac monitoring.

An observation of medication pass was conducted on 12/19/19 at 8:10 AM with Employee Identifier (EI) # 7, Licensed Practical Nurse (LPN).

During the medication pass observation the telemetry unit and wires were observed on top to the sheets at the foot of the bed and not connected to the patient.

EI # 7 was asked why the telemetry was not connected to the patient. EI # 7 responded that the patient was about to get a bath.

During a visit to the nursing station where the telemetry is monitored on 12/19/19 at 10:30 AM it was observed that PI # 3 was not on telemetry.

There was no documentation of an order to hold or discontinue the telemetry for the patient's bath.

An interview was conducted on 12/19/19 at 10:30 AM with EI # 2, Director of Nursing, who confirmed PI # 3 had not been on telemetry from 8:10 AM to 10:30 AM.


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5. PI # 5 was admitted to the facility on 12/17/19 with a diagnosis of Pyelonephritis Acute Cystitis with Hematuria.

Review of the Scheduled Medication Report dated 12/19/19 revealed a physician's order for Ciprofloxacin IV 400 mg (milligrams)/200 ml (milliliters) D5W (Dextrose) to be administered at 200 ml/hr every 12 hours.

During an observation, conducted on 12/19/19 at 8:52 AM with EI # 7 for observation of the Ciprofloxacin IV administration, EI # 7 administered the Ciprofloxacin using the IV pump at a rate of 150 ml/hr.

EI # 7 was able to verify the rate of 150 ml/hr to the surveyor prior to leaving PI # 5's room.

An interview was conducted on 12/19/19 at 9:26 AM with EI # 2, who walked down to PI # 5's room and confirmed the Ciprofloxacin was being administered at 150 ml/hr instead of the physician ordered 200 ml/hr.

Based on review of medical records (MR), facility policy and procedure, Potter and Perry Fundamentals of Nursing Study Guide 7th Edition, and interviews, it was determined the facility failed to ensure:

1. A policy was developed for the evaluation of patient problems and interventions.

2. The staff developed and updated a care plan with goals and treatments.

3. Patient interventions and goals were individualized and measurable.

This affected 2 of 8 inpatient MR's reviewed including PI # 5 and PI # 2 and had the potential to affect all patients admitted to this facility.

Findings include:

PP:III
9a
Review Date: 3/19

Subject: Nursing Problem List (Nursing Care Plan)

Policy: A nursing problem list (care plan) will be initiated by the admitting nurse on each admitted patient... Problem list must be updated/reviewed/addressed/resolved no less than every 24 hours or as indicated related to change in patient condition by the RN (Registered Nurse) on each shift.

Procedure:

1...All problem list, interventions, and goals can be revised/edited to individualize to the patient.

2. The RN on each shift will be responsible for updating/reviewing/addressing/resolving the patient problem list no less than every 24 hours or as indicated to any changes...

Potter and Perry Fundamentals of Nursing Study Guide 7th Edition
Chapter 18 - Planning Nursing Care

...Goals and Expected outcomes are: ... The goals and outcomes need to meet established intellectual standards by being relevant to patient needs, specific, singular, observable, measurable, and time limited...

1. PI # 5 was admitted to the facility on 12/17/19 with a diagnosis of Pyelonephritis Acute Cystitis with Hematuria.

Review of the History and Physical dated 12/17/19 revealed the chief complaint as: "flank pain, intractable N/V (nausea/vomiting)."

Further review of the History and Physical dated 12/17/19 revealed the following plan for hospitalization: "IVF (Intravenous Fluids) will be continued for hydration.... IV Cipro will be initiated BID (twice daily). She/He will be advised to strain all urine. IV Toradol and Zofran with Benadryl will be available prn (as needed) pain and n/v. Patient will be placed on a clear liquid diet due to intractable n/v, to be advanced as tolerated. She/He will be placed on fall precautions to be up with assist only for safety due to weakness..."

Review of the Problem Activity revealed the following nursing care plan:

Problem: Alteration in comfort r/t (related to) pain
Goal: Pain relief with meds, PO (oral) meds by discharge, and Minimal pain/discomfort.

There was no documentation of the nursing interventions to be performed to obtain goals and no individualized unit of measure to assess if the pain goal was met.

Problem: IV Therapy
Goal: No s/s (signs/symptoms) infection r/t IV and no undetected infiltration
There was no documentation of the nursing interventions to be performed to obtain goals and no individualized unit of measure to assess if the goal was met.

Problem: Urinary Tract Infection (UTI) - Actual or Potential
Goal: Pt (patient) will return to normal urinary function without symptoms of UTI, Patient's lab values will be within normal limits, and pt will be afebrile upon discharge.

There was no documentation of the nursing interventions to be performed to obtain goals, no documentation of what lab values would be within normal limits, and no individualized unit of measure to assess if the goal was met.

Further review of the Problem Activity revealed no documentation of a nursing care plan for the intractable N/V, patient hydration, the straining of the urine, diet tolerance and advancement, and fall precautions.

On 12/20/19 at 12:14, EI # 2 confirmed the above findings via email.

2. PI # 2 was admitted to the facility on 12/18/19 with a diagnosis of Right Lower Lobe Pneumonia, Leukocytosis (high white blood cell count), Hyperglycemia (high blood sugar), Glycouria (sugar in urine), Hyponatremia (low sodium), and Cocaine Use.

Review of the History and Physical dated 12/18/19 revealed a chief complaint of shortness of breath (SOB) and chest pain.

Further review of the History and Physical dated 12/18/19 revealed the following plan for hospitalization: "Patient is at risk due to leukocytosis and SOB...IVFs continued for hydration. Rocephin and Cleocin continued. Solumedrol continued. Duonebs scheduled routine. Lovenox for DVT (Deep Vein Thrombosis) prophylaxis...BGL (Blood glucose level) checked ACHS (before meals and at bedtime) with Humulin R for sliding scale coverage...Tylenol for prn pain.

Review of the Problem Activity revealed the following nursing care plan:

Problem: Cardiac Function
Goal: b/p (blood pressure) WNL (within normal limits) for pt, Pulse WNL for pt, and No ectopy/dyrhythmias.
There was no documentation of the nursing interventions to be performed to obtain goals and no individualized unit of measure to assess if the goal was met.

Problem: Chest Pain
Goal: no further chest pain
There was no documentation of the nursing interventions to be performed to obtain goals and no individualized unit of measure to assess if the goal was met.

Problem: Respiratory
Goal: Patent airway, BBS (bilateral breath sounds) clear, and no evidence of hypoxia.
There was no documentation of the nursing interventions to be performed to obtain goals and no individualized unit of measure to assess if the goal was met.

Problem: Alteration in comfort r/t (related to) pain
Goal: Pain relief with meds, PO (oral) meds by discharge, and Minimal pain/discomfort.
There was no documentation of the nursing interventions to be performed to obtain goals and no individualized unit of measure to assess if the pain goal was met.

Further review of the Problem Activity revealed no documentation of a nursing care plan for the patient hydration, Lovenox prophylaxis tolerance and education, and blood glucose levels and education.

On 12/20/19 at 12:14, EI # 2 confirmed the above findings via email.

Based on observation, review of facility policy, and interview the hospital failed to assure all controlled substances were locked to prevent tampering or diversion.

This affected the Medical Surgical Unit and had the potential to affect all patients served.

Findings Include:

Policy: Controlled Drugs
Revised: 3/19

Storage: Nursing Units

Each nursing unit or department that has controlled drugs is provided either a lockable unit dose cart with lockable drawers for controlled drugs or a wall cabinet that is lockable and suitable for controlled drugs...

1. An observation of the nursing unit medication room was conducted on 12/17/19 at 9:00 AM to assess medication storage.

The refrigerator in the medication room containing vials of Ativan, a Schedule IV controlled substance, was unlocked.

Upon further examination, the medication room had two entry doors, one on each side of the nurses station. Door number 2 had a rack for storing telemetry units hung over door preventing the door from closing properly. Door number 2 was not locked or fully closed at time of observation.

An interview with EI # 8 on 12/17/19 at 9:30 AM confirmed the above findings.

Based on observations, review of Policy, and interview it was determined that the facility failed to ensure that outdated medications and Intravenous Fluids (IV) were not available for patient use.

Findings include:

Policy: Refrigerated Medication Stock
Revised: 3/19

All vials must be dated when opened and discarded 28 days after open date, also note expiration date...

1. An observation of the nursing unit medication room was conducted on 12/17/19 at 9:00 AM with Employee Identifier (EI) # 8, RN (Registered Nurse) to observe medication storage and expiration dates.

The following expired medications were observed opened and dated in the refrigerator of the medication room:

1. Folic acid 50 mg (milligram) 10 ml (milliliter) vial expired on 12/4/19
2. Lantus insulin 100 units/ml expired on 12/1/19
3. Novolog insulin 70/30 10 ml vial expired on 12/11/19
4. Thiamin 200 mg/2 ml, opened but no label with expiration date
5. Levemir 100 units/ml 10 ml vial expired on 12/2/19
6. Levemir 100 units/ml 10 ml vial expired on 11/31/19
7. Novolog 100 units/ml 10 ml vial expired on 12/3/19

An interview conducted on 12/17/19 at 9:30 AM with EI # 8 confirmed the the expired and open unlabeled medications.

Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety. This had the potential to negatively affect all patients served by the facility.

Findings include:

Refer to Life Safety Code violations

Based on observations and interviews it was determined the facility failed to provide the patients with a method of alerting staff for needs while being treated in the Emergency Department (ED) due to not having operable Call System.

This had the potential to affect all patients served by the facilities ED.

Findings include:

1. A tour of the ED was conducted on 12/17/19 at 1:32 AM, during the tour the surveyor observed 2 private treatment rooms and 3 semi-private treatment bays within the ED with a door or curtain to close for privacy. The patients' beds were not visible from the nurses' station.

The 2 private treatment rooms and the 3 semi-private treatment bays contained no operational call lights at the bedside.

An interview was conducted on 12/17/19 at 2:27 AM with Employee Identifier # 2, Director of Nursing, who confirmed there was no method for the patient's to alert staff of needs.

Based on observations, review of facility policies and procedures, Centers for Disease Control and Prevention (CDC) Frequently Asked Questions (FAQ's) regarding Safe Practices For Medical Injections and interviews with the staff, it was determined the facility failed to ensure the staff:

a) Followed the facility policy and procedure for proper hand hygiene and gloving.

b) Cleaned the septum of medication vials prior to piercing the vial per CDC guidelines.

c) Cleaned contaminated Computer on Wheels between patient interactions.

d) Followed sanitary handling of pots and pans

This deficient practice was observed in 5 of 10 patient care observations and 1 of 2 dietary observations and had the potential to negatively effect all patients admitted to the facility.

Findings include:

Hand Hygiene for all Healthcare Workers

PP: XXXXI
1a
Reviewed Date: 03/19

Purpose

To prevent the transmission of microorganisms from patient to patient and from inanimate surfaces to patients by the hands of all healthcare providers.

Audience

All employees of LMCH (Lake Martin Community Hospital) hospitals, clinics, LMCH outpatient care and surgical center, contract workers, volunteers, and students

Policy

Hand Hygiene shall be practiced before and after each patient contact (even if gloves are worn). All employees are required to wash, rinse, and dry their hands or apply an alcohol hand rub before beginning work, after using the rest room and prior to leaving work.

Antiseptic (antimicrobial) handwashing products or alcohol hand rub shall be used for hand hygiene.

An alcohol hand rub, may be used for hand hygiene in place of an antimicrobial soap handwash...

Routine handwashing procedure:

...Dry well with paper towel and use the paper towels to turn off the faucet...

Hand Antiseptics

An alcohol hand rub may be substituted for antimicrobial soap. The following technique should be used:

If hands are visibly soiled, wash hands with lotion soap prior to application of alcohol hand rub.

Apply enough alcohol hand rub to cover the entire surface of hands and fingers.

Rub the solution vigorously into hands until dry...

PP: XXXIV
5a
Revised Date: 3/19

Subject: Cleaning of non-critical, reusable patient care equipment

Policy: In accordance with existing infection prevention and control policies and procedures, implement and maintain processes to ensure all non-critical equipment is routinely cleaned before and after reuse.

Procedure:

...B. Patient care equipment should be dedicated to the use of a single patient and cleaned, disinfected and/or reprocessed before reuse with another patient or before placed in storage...
...K. All horizontal and frequently touched surfaces shall be cleaned daily and immediately when soiled....

CDC Frequently Asked Questions (FAQ's) regarding Safe Practices For Medical Injections

"Medication Preparation Questions

1. How should I draw up medications?

Parenteral medications should be accessed in an aseptic manner. This includes using a new sterile syringe and sterile needle to draw up medications while preventing contact between the injection materials and the non-sterile environment. Proper hand hygiene should be performed before handling medications and the rubber septum should be disinfected with alcohol prior to piercing it."

Dietary Safety and Sanitation
Title: Pot and Pan
Revised Date: 3/19

Policy: Procedures guaranteeing safe and sanitary handling of pots and pans shall be followed.

Procedure:
...4. The sink is clean. The pots and pans will be washed in a hot detergent...
5. The pots and pans are sanitized in the third compartment according to the protocol...

Protocol: Sanitizer Sink

...4. Water/sanitizer mixture should be tested by using a 3-4 inch piece of the QT-10 test strip provided. Test strip should be submerged into the water for 10 seconds. The test strip should read 200 ppm (parts per million).

5. Document reading on the Ph log sheet and sign your initial...

...8. The Ph level should be checked each time you refill the sanitizing sink and findings shall be documented on the Ph log sheet.

1. An observation of care provided by Employee Identifier (EI) #7 LPN (Licensed Practical Nurse) occurred on 12/18/19 at 4:40 PM. EI # 7 entered hospital room and applied hand sanitizer from the wall mounted dispenser then wiped hand sanitizer from hands on uniform.

EI # 7 failed to follow facility policy by not rubbing the hand sanitizer solution vigorously into hands until dry.


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2. An observation was conducted on 12/17/19 at 3:13 PM with EI # 11, Registered Nurse (RN), to observe administration of oral medication.

EI # 11 entered the patient exam room and performed hand hygiene using the sink in the exam room. After performing hand hygiene, EI # 11 used bare hand to turn the sink faucet off.

An interview was conducted on 12/19/19 at 9:16 AM with EI # 2, who confirmed the above finding.

3. An observation was conducted on 12/18/19 at 1:06 PM with EI # 3, RN, to observe an Intravenous (IV) placement and IV medication administration.

During the observation, EI # 3 prepared Solu-Medrol 125 mg (milligrams), Zofran 4 mg, and Diphenydramine 50 mg in 3 syringes for IV administration. EI # 3 failed to disinfect the rubber septum of the Solu-Medrol, Zofran, and Diphenydramine bottle prior to piercing it.

An interview was conducted on 12/19/19 at 9:16 AM with EI # 2, who confirmed the above finding.

4. An observation was conducted on 12/19/19 at 8:19 AM with EI # 7, LPN, to observe IV, oral, and topical medication administration.

EI # 7 entered room 218 with a computer on wheels, identified the patient, and performed documentation on the computer then proceeded to prepare Rocephin 1 gm (gram) in Normal Saline 100 ml (milliters) for administration without performing hand hygiene.

After preparing the Rocephin, EI # 7 administered oral medications then removed a pair of scissors from right uniform pocket, cut the pouch that contained Nicoderm 21 mg Transdermal patch, replaced scissors in right uniform pocket and obtained pen from uniform pocket, wrote on the Nicoderm patch, then placed patch on the patient's left arm. EI # 7 failed to clean scissors and pen prior to and after use.

EI # 7 then exited room 218 and obtained IV tubing and a stethoscope.

As EI # 7 returned to room 218 the computer on wheels scanner dropped on the ground inside the door frame of the patient's room. EI # 7 reached down, picked up scanner, and placed the scanner on the computer on wheels without cleaning the scanner.

After performing hand hygiene, EI # 7 primed IV tubing with Rocephin and reached onto the computer on wheel, picking up several objects including contaminated scanner, then connected the IV tubing primed with Rocephin to existing IV tubing (piggy back) without hand hygiene after contact with a contaminated object or cleaning the port of the existing IV tubing prior to connection of the Rocephin.

EI # 7 performed an assessment of the patient lungs using stethoscope. EI # 7 failed to clean stethoscope prior to and after use on the patient.

EI # 7 returned to the nurses station, entered the medication room, obtained IV and oral medication for the next observation on another patient using the computer on wheels. EI # 7 failed to clean the contaminated computer on wheels.

An interview was conducted on 12/19/19 at 9:18 AM with EI # 2, who confirmed the above findings.

5. An observation was conducted on 12/19/19 at 8:52 AM with EI # 7 for observation of oral and IV medication administration.

EI # 7 obtained IV Cipro 400 mg in 200 ml of dextrose bag inside of packet from medication room IV storage and oral Norvasc 5 mg from the medication dispense system.

EI # 7 entered room 200 with the computer on wheels, scanned the patient's armband and medications with computer scanner, documented on the computer, then administered the oral medication without performing hand hygiene.

EI # 7 removed scissors from right uniform pocket and cut the IV Cipro bag out of packet. EI # 7 failed to clean scissors prior to or after use.

EI # 7 removed used Cipro bag from IV pole, placed used Cipro bag on top of computer on wheels, then administered new Cipro with tubing left from used Cipro bag.

EI # 7 performed hand hygiene then exited the patient's room, returned to the nurses station, removed used Cipro bag from computer on wheels, documented on the computer, then entered medication room and prepared another patient's medications.

During the observation, EI # 7 failed to clean the contaminated computer on wheels at any time or the scissors used for multiple patients and stored in uniform pocket.

An interview was conducted on 12/19/19 at 9:18 AM with EI # 2, who confirmed the above findings.

6. An observation was conducted on 12/17/19 at 11:45 AM with EI # 10, dietary cook, to observe the sanitization of the lunch pots and pans.

During the observation, EI # 10 placed the lunch pots and pans to soak inside of the third compartment of a 3 compartment sink for sanitation that had previously used water and Quat Ammonium solution for sanitation. While placing the pots and pan in the sanitizing solution, EI # 10 added more solution and water to the compartment. EI # 10 failed to check the parts per million (ppm) of the sanitizing solution prior to adding more solution and water and also after the addition.

An interview was conducted on 12/17/19 at 12:08 PM with EI # 4, Dietary Director and Dietician, who confirmed the wash water temperature and ppm of the Quat Ammonium solution should have been tested prior to use.

Based on review of the facility's Emergency Medical Treatment and Labor Act (EMTALA) related policy, medical records, and interviews, it was determined the facility failed document a patient consent for a transfer to a different facility in 1 out of 2 transferred patient, including Patient Identifier (PI) # 22.

Findings include:

Subject: Documentation requirements for Emergency Room Transfers (EMTALA Law)
Reviewed date: 3/19

Policy: In the event of transfer, the Emergency Room Medical Record.... There shall be documentation that the patient or his/her responsible party agreed to the transfer...

1. PI # 22 presented to the Emergency Department (ED) on 11/1/19 with a chief complaint of a head injury.

Review of the nursing assessment dated 11/1/19 at 7:16 PM documented the patient was oriented, attentive, appropriate and provided the information for the assessment.

Review of the Certified Registered Nurse Practitioner (CRNP) assessment dated 11/1/19 at 7:16 PM documented the patient had no alteration in mental status, was alert, not confused, and was not exhibiting a decreased level of consciousness.

Review of the ED Record revealed documentation the patient was transferred to another facility due to need for higher acuity care and the "transfer form was completed." There was no documentation the transfer was discussed with the patient and that the patient agreed to the transfer.

Review of the ED Transfer Summary revealed no documentation the patient signed to acknowledge and agree to the transfer to another facility.

An interview was conducted on 12/19/19 at 5:15 PM with Employee Identifier # 2, Director of Nursing, who confirmed there was no documentation the patient had acknowledged and agreed to the transfer to another facility.

Based on interview with staff it was determined the facility failed to ensure the Condition for Certification 491.12 - Establishment of the Emergency Program was initiated and put into practice.

Findings include:

Refer to E 0004, E 006, E 009, E 0013, E 0020, E 0025, E 0029, E 0032, and E 0036

Based on review of Emergency Preparedness (EP) documentation and interviews with the staff it was determined the facility failed to ensure a comprehensive EP Program was developed and implemented which complied with State, Federal and local emergency preparedness requirements.

Findings include:

Review of the EP documentation provided to the surveyor revealed the emergency plan failed to include:

a. EP plan reviewed and updated at least every 2 years

b. The facilities ability to collaborate with local emergency preparedness officials in an emergency situation.

b. Emerging infectious diseases such as Influenza, Ebola and Zika Virus.

On 12/19/19, Employee Identifier (EI) # 1, Assistant Administrator, provided the surveyor with an EP Plan.

Review of the EP documentation provided to the surveyor revealed documentation of an Disaster Plan, External with no date and a Disaster Plan, Fire with a date of 5/3/07.

Review of the Disaster Plan, External and Disaster Plan, Fire both failed to document the facilities ability to collaborate with local EP officals in an emergency situation and a plan for emerging infectious diseases.

An interview was conducted on 12/19/19 at 3:11 PM with EI # 1, who confirmed the above findings.

Based on review of the Emergency Preparedness (EP) plan, and interview with staff, it was determined the facility failed to document a facility based all hazards risk assessment. This had the potential to affect all persons served by the facility.

Findings include:

Review of the EP plan revealed no documented facility or community based risk assessment for all hazards.

An interview was conducted on 12/19/19 at 3:11 PM with Employee Identifier # 1, Assistant Administrator, who confirmed the above findings.

Based on review of the Emergency Preparedness (EP) Program it was determined the agency failed to ensure the collaboration and the cooperation with local, regional, state and federal emergency preparedness officials.

Findings include:

On 12/19/19, Employee Identifier (EI) # 1, Assistant Administrator, provided the surveyor with an EP Plan.

Review of the EP documentation provided to the surveyor revealed documentation of an Disaster Plan, External with no date and a Disaster Plan, Fire with a date of 5/3/07.

Review of the Disaster Plan, External and Disaster Plan, Fire both failed to document the facilities ability to collaborate with local EP officials in an emergency situation and a plan for emerging infectious diseases.

An interview was conducted on 12/19/19 at 3:11 PM with EI # 1, Assistant Administrator, who confirmed the above findings.

Based on review of the facility's Emergency Preparedness (EP) policy, and interview with agency staff, it was determined the agency failed to ensure policies and procedures had been updated and/or reviewed at least every 2 years.

This had the potential to negatively affect all persons served by the agency.

Findings include:

On 12/19/19, Employee Identifier (EI) # 1, Assistant Administrator, provided the surveyor with an EP Plan.


Review of the EP documentation provided to the surveyor revealed documentation of an Disaster Plan, External with no date and a Disaster Plan, Fire with a date of 5/3/07.

An interview was conducted on 12/19/19 at 3:11 PM with EI # 1, Assistant Administrator, who confirmed the above findings.

Based on review of the Emergency Preparedness (EP) plan, and interview with staff, it was determined the facility failed to document a plan for the safe evacuation from the facility, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s); and primary and alternate means of communication with external sources of assistance.

This deficiency had the potential to negatively affect all patients served by the facility.

Findings include:

On 12/19/19, Employee Identifier (EI) # 1, Assistant Administrator, provided the surveyor with an EP Plan.

Review of the EP documentation provided to the surveyor revealed no documentation of a plan for the safe evacuation from the facility.

An interview was conducted on 12/19/19 at 3:11 PM with EI # 1, who confirmed the above findings.

Based on review of the Emergency Preparedness plan and interview with staff, the facility failed to provide policies and procedures for arrangements with another hospital(s).

This deficiency had the potential to negatively affect all patients served by the agency.

Findings include:

On 12/19/19, Employee Identifier (EI) # 1, Assistant Administrator, provided the surveyor with an EP Plan.

Review of the Emergency Preparedness Plan revealed no documentation addressing arrangements with another hospital to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients during an emergency.

An interview was conducted on 12/19/19 at 3:11 PM with EI # 1, who confirmed the above findings.

Based on review of an Emergency Preparedness (EP) Program and interviews with the staff it was determined the facility failed to ensure a communication plan for the Emergency Preparedness Program had been updated and/or reviewed at least every 2 years. This had the potential to negatively affect all patients served by the facility.

Findings include:

On 12/19/19, Employee Identifier (EI) # 1, Assistant Administrator, provided the surveyor with an EP Plan

Review of the EP documentation provided to the surveyor revealed no documentation of an emergency preparedness communication plan that complies with Federal, State and local laws.

An interview was conducted on 12/19/19 at 3:11 PM with EI # 1, Assistant Administrator, who confirmed the above findings.

Based on review of the Emergency Preparedness Program it was determined the facility failed to provide an emergency preparedness communication plan.

This had the potential to negatively affect all patients served by the facility.

Findings include:

On 12/19/19, Employee Identifier (EI) # 1, Assistant Administrator, provided the surveyor with an EP Plan.

Review of the EP documentation provided to the surveyor revealed no documentation of a communication plan for the primary and any alternate means of communication with the staff or the local or state agencies during an emergency.

An interview was conducted on 12/19/19 at 3:11 PM with EI # 1, who confirmed the above findings.

Based on review of an Emergency Preparedness (EP) Program and interviews with the staff it was determined the facility failed to ensure a training and testing plan for the Emergency Preparedness Program had been updated and/or reviewed at least every 2 years. This had the potential to negatively affect all patients served by the facility.

Findings include:

On 12/19/19, Employee Identifier (EI) # 1, Assistant Administrator, provided the surveyor with an EP Plan

Review of the EP documentation provided to the surveyor revealed no documentation of an training and testing plan that complies with Federal, State and local laws.

An interview was conducted on 12/19/19 at 3:11 PM with EI # 1, Assistant Administrator, who confirmed the above findings.