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Based on observation and staff interview it was determined the facility failed to ensure clinical staff monitor defibrillators in the Emergency Room (ER) to ensure the equipment is readily available for emergency cases. This failure was identified in one (1) out of three (3) defibrillators. This failure has the potential to place all patients at risk for lack of available equipment for emergency cases.

Findings include:

1. An observation conducted on 04/05/21 at approximately 2:30 p.m. of ER Exam Room #1 revealed a "Life Pak" defibrillator did not have a daily check log. When asked to review the log, Registered Nurse #1 verbalized it did not need to be checked because the defibrillator automatically self-checks every morning.

2. An interview was conducted with the Chief Nursing Officer on 04/07/21 at 9:00 a.m. She stated regarding the Automated External Defibrillator (AED) in ER Exam Room #1, "All AEDs should be checked and have a log, regardless of if they self-check." She confirmed there was no written policy.

Based on document review and staff interview it was determined the facility failed to maintain a preventive maintenance program to ensure the safe operation of all mechanical, electrical, and patient care equipment. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 3.

Findings include:

1. Document review on 4/6/21 at approximately 1:23 p.m. revealed no specific equipment maintenance inventories for all essential mechanical, electrical, and patient-care equipment was provided during survey.

2. Document review on 4/6/21 at approximately 1:25 p.m. revealed the equipment maintenance program was not based off of manufacturer recommendations or other generally accepted standards of practice for an alternate maintenance schedule.

3. Interview on 4/6/21 at approximately 1:27 p.m. with the Facilities Director verified these findings. The findings were also acknowledged by the Chief Executive Officer at the exit interview on 4/7/21 at approximately 2:35 p.m.

Based on observation, document review and staff interview it was determined the facility failed to ensure Registered Nurses (RN) #1 and 2 maintained security of the narcotic cabinet keys to ensure controlled medications are stored securely following facility policy. This failure was identified in one (1) out of one (1) observation. This failure has the potential to place the facility and nursing staff at risk for access to unsecured narcotic medications.

Findings include:

1. An observation conducted on 04/05/21 at approximately 1:45 p.m. in the Emergency Room revealed the keys to access the narcotic medication cabinet were stored in an accessible drawer in the medication room.

2. A review of hospital policy, "Narcotic Count," revised 06/09, states in part: "Narcotic keys must be accounted for at the change of shift. Keys must be personally handed to another RN or LPN {Licensed Practical Nurse}; never leave keys lying on the medication cart or in a drawer."

3. An interview was conducted with the Chief Nursing Officer on 04/07/21 at 9:00 a.m. When notified of the observation, she stated in part, "The nurses know what is expected of them. Two (2) nurses must be present for the narcotic count, and the keys should be kept on them at all times."

Based on observation, document review, and staff interview it was determined the facility failed to ensure that the premises were clean and orderly. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 3.

Findings include:

1. Observation on 4/5/21 at approximately 1:33 p.m. revealed the ceiling heating/cooling registers in the Infusion Room in the Physical Therapy Department were loaded with dust/debris.

2. Observation on 4/5/21 at approximately 3:11 p.m. revealed a floor model air conditioner and two (2) dehumidifiers in the Lab, which had no documentation of preventative maintenance or a filter change schedule provided during survey.

3. Observation on 4/6/21 at approximately 7:49 a.m. revealed hand sanitizer, facial tissues, and cleaning supplies stored under the sink of the Lab at the Coplin Clinic.

4. Observation on 4/6/21 at approximately 10:40 a.m. revealed ceiling heating/cooling registers in the Kitchen were loaded with dust/debris.

5. Observation on 4/6/21 at approximately 10:44 a.m. revealed the floor in the walk-in cooler in the Kitchen was extensively rusty and missing paint.

6. Observation on 4/6/21 at approximately 10:45 a.m. revealed a ceiling heating/cooling register above the freezer in the Serving Area of the Kitchen was loaded with dust/debris.

7. Observation on 4/6/21 at approximately 10:50 a.m. revealed the ceiling heating/cooling registers in the Kitchen Dish Room were loaded with dust/debris.

8. Observation on 4/6/21 at approximately 10:51 a.m. revealed the dish cabinet in the Kitchen Dish Room was extensively rusty.

9. Observation on 4/6/21 at approximately 11:06 a.m. revealed approximately sixteen (16) cardboard boxes of personal protective equipment that were stored on the floor of the Dietary/Materials Management Corridor.

10. Observation on 4/6/21 at approximately 11:11 a.m. revealed cleaning supplies and disposable gloves being stored under the sink in the Laundry area.

11. Observation on 4/6/21 at approximately 11:13 a.m. revealed ceiling tile, which appeared to be stained/water damaged in the Laundry Clean Linen Storage Room.

12. Observation on 4/6/21 at approximately 11:19 a.m. revealed supplies in cardboard boxes were stored on the floor in the Materials Management area.

13. Observation on 4/6/21 at approximately 11:20 a.m. revealed missing and drooping ceiling tile in the Materials Management area.

14. Observation on 4/6/21 at approximately 11:21 a.m. revealed ceiling tile which appeared to be stained/water damaged in the Materials Management area.

15. Document review on 4/6/21 at approximately 1:37 p.m. revealed no documentation of a water management program to reduce Legionella was provided during survey.

15. Observation on 4/7/21 at approximately 1:54 p.m. revealed ceiling mounted negative pressure isolation units in Patient Rooms #402, 404, 406, and 408 and a floor model negative pressure isolation unit in Exam Rooms #3, 4, and 5 of the Emergency Department, which had no documentation of testing, preventative maintenance, or a filter change schedule provided during survey.

17. Interview on 4/7/21 at approximately 1:56 p.m. with the Environmental Services Coordinator verified these findings. The findings were also acknowledged by the Chief Executive Officer at the exit interview on 4/7/21 at approximately 2:35 p.m.

A. Based on document review and staff interview it was determined the facility failed to ensure the Emergency Room (ER) nursing staff monitored refrigeration storage temperatures to maintain medication integrity following the United States Food and Drug Administration (USFDA) guidelines. This failure was identified in four (4) out of four (4) months of refrigerator logs in the ER. This failure has the potential to place patients at risk for receiving ineffective medications.

Findings include:

1. An observation of the medication contents of the refrigerator in the ER revealed four (4) trays were stored containing insulin medications.

2. A review of the "MHHS ER Refrigerator Temperature Log" from 01/01/21 through 01/31/21 revealed the temperature was not checked ten (10) days out of thirty-one (31) days (01/01, 01/02, 01/12, 01/13, 01/25, 01/26, 01/27, 01/28, 01/29 and 01/30/21).

3. A review of the "MHHS ER Refrigerator Temperature Log" book revealed the pages for 02/2021 and 03/2021 were not present. When Registered Nurse (RN) #2 was asked to review the dates, she concurred they were not present.

4. A review of the "MHHS ER Refrigerator Temperature Log" from 04/01/21 through 04/05/21 revealed the temperature was not checked four (4) days out of five (5) days (04/02, 04/03, 04/04 and 04/05/21).

5. A review of the USFDA guidelines "Information Regarding Insulin Storage and Switching Between Products in an Emergency," dated 09/19/17, stated in part: "According to the product labels from all three U.S. insulin manufacturers, it is recommended that insulin be stored in a refrigerator at approximately 36°F to 46°F. Unopened and stored in this manner, these products maintain potency until the expiration date on the package ... Note: Insulin loses some effectiveness when exposed to extreme temperatures. The longer the exposure to extreme temperatures, the less effective the insulin becomes. This can result in loss of blood glucose control over time."

6. An interview was conducted with the Chief Nursing Officer on 04/07/21 at 9:00 a.m. When notified the ER medication refrigeration logs were incomplete and missing temperature logs for February and March 2021, she stated in part, "They had been done, but we cannot find them anywhere."


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B. Based on document review and staff interview it was determined the facility failed to ensure proper ventilation in patient care areas. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 3.

Findings include:

1. Document review on 4/6/21 at approximately 1:54 p.m. revealed no documentation of monitoring of the temperature, humidity, air changes, or appropriate air pressure relationships for critical areas throughout the facility was provided during survey.

2. Interview on 4/6/21 at approximately 1:56 p.m. with the Facilities Director verified this finding. This finding was also acknowledged by the Chief Executive Officer at the exit interview on 4/7/21 at approximately 2:35 p.m.

Based on document review and staff interview, the facility failed to provide safety from fire and meet the provisions applicable to Existing Healthcare Occupancies of the 2012 edition of the Life Safety Code of the National Fire Protection Association (NFPA) 101. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 3.

Findings include:

1. In reference to Federal Life Safety Code citation K 211 the facility failed to maintain the means of egress to full use in case of emergency.

2. In reference to Federal Life Safety Code citation K 300 the facility failed to maintain fire barriers within the facility.

3. In reference to Federal Life Safety Code citation K 321 the facility failed to ensure that hazardous areas were appropriately separated.

4. In reference to Federal Life Safety Code citation K 345 the facility failed ensure that the fire alarm system was appropriately tested.

5. In reference to Federal Life Safety Code citation K 353 the facility failed to ensure that the sprinkler system was appropriately tested.

6. In reference to Federal Life Safety Code citation K 355 the facility failed to ensure that fire extinguishers were appropriately tested.

7. In reference to Federal Life Safety Code citation K 511 the facility failed to ensure that electrical wiring and equipment was installed appropriately.

8. In reference to Federal Life Safety Code citation K 521 the facility failed to ensure the appropriate installation and testing of fire dampers.

9. In reference to Federal Life Safety Code citation K 914 the facility failed to ensure that patient bed location receptacles were appropriately tested.

10. In reference to Federal Life Safety Code citation K 920 the facility failed to ensure that power strips were used appropriately.

11. In reference to Federal Life Safety Code citation K 921 the facility failed to ensure that patient care equipment was appropriately tested.

12. Interview on 4/6/21 at approximately 1:57 p.m. with the Facilities Director verified these findings. The findings were also acknowledged by the Chief Executive Officer at the exit interview on 4/7/21 at approximately 2:35 p.m.

A. Based on observation, document review and staff interview it was determined the facility failed to ensure Registered Nurses (RN) #1 and 2 maintained security of the narcotic cabinet keys to ensure controlled medications are stored securely following facility policy. This failure was identified in one (1) out of one (1) observation. This failure has the potential to place the facility and nursing staff at risk for access to unsecured narcotic medications.

Findings include:

1. An observation conducted on 04/05/21 at approximately 1:45 p.m. in the Emergency Department revealed the keys to access the narcotic medication cabinet were stored in an accessible drawer in the medication room.

2. A review of hospital policy "Narcotic Count," revised 06/09, states in part: "Narcotic keys must be accounted for at the change of shift. Keys must be personally handed to another RN or LPN {Licensed Practical Nurse}; never leave keys lying on the medication cart or in a drawer."

3. An interview was conducted with the Chief Nursing Officer on 04/07/21 at 9:00 a.m. When notified of the observation, she stated in part, "The nurses know what is expected of them. Two (2) nurses must be present for the narcotic count, and the keys should be kept on them at all times."

B. Based on document review and staff interview it was determined the facility failed to ensure the Emergency Room (ER) RN's and LPN's verified and maintained a complete narcotic count each shift to record tracking, distribution and integrity of controlled medications following facility policy. This failure was identified in one (1) out of two (2) narcotic count logs in the facility. This failure has the potential to place the facility, all patients, and staff at risk for access to uncontrolled medications.

Findings include:

1. A review of the "Narcotic/Controlled Substance Count" logs in the ER from 02/10/21 through 04/05/21 revealed nurses failed to document two (2) nurses' signatures verifying controlled medication counts were accurate in eleven (11) shifts (02/11/21, 7:00 p.m.; 02/17/21, 7:00 p.m., 02/18/21, 7:00 a.m.; 02/22/21, 7:00 a.m.; 02/22/21, 7:00 p.m.; 02/23/21, 7:00 a.m.; 02/23/21, 7:00 p.m.; 03/30/21, 7:00 a.m.; 03/30/31, 7:00 p.m.; 04/04/21, 7:00 a.m.; 04/04/21, 7:00 p.m.). Nurses failed to document the count was correct on the log on eight (8) shifts (02/11/21, 7:00 p.m., 02/17/21, 7:00 p.m.; 02/18/21, 7:00 a.m.; 02/18/21, 7:00 p.m.; 02/19/21, 7:00 a.m.; 02/19/21, 7:00 p.m.; 02/20/21, 7:00 a.m.; 02/20/20, 7:00 p.m.).

2. A review of facility policy "Narcotic Count," revised 06/09, states in part: "At the end of each shift a nurse from the on-coming shift and a nurse from the off-going shift will make the narcotic check together. Both nurses will sign the narcotic check sheet stating the count is correct ... When you sign the narcotic sheet, you are stating that you know the count is correct at that time ... All RN's and/or LPN's are to remain on duty until narcotic check is completed."

3. An interview was conducted with the Chief Nursing Officer on 04/07/21 at 9:00 a.m. When notified of the observation, she stated in part, "The nurses know what is expected of them. Two (2) nurses must be present for the narcotic count, and the keys should be kept on them at all times."

A. Based on observation, document review, and staff interview, it was determined the facility failed to maintain a sanitary environment to avoid sources and transmissions of infection in the radiology department in two (2) out of three (3) locations. This failure has the potential to negatively impact all patients receiving radiology services.

Findings:

1. An observation was conducted on 04/06/21 at approximately 8:37 a.m. of the radiology diagnostic room in the outpatient department at the facility's off-site location. One (1) lead apron was stored in the closet and one (1) lead apron was lying on top of a large container in the room. When Radiology Technician #1 was asked how the lead aprons are cleaned, he stated in part, "To be honest, I rarely clean them." When asked if they are used on patients, he concurred the aprons are used on patients to reduce radiation exposure.

2. An observation was conducted on 04/06/21 at 10:28 a.m. of the radiology department at the main facility campus. The department had one (1) lead apron hanging in the Energetic High-Frequency Electromagnetic Radiation (X-ray) room, and two (2) half shield lead aprons on the X-ray table. The Computed Tomography (CT) scanner room had one (1) lead apron. During the tour, the Radiology Assistant Supervisor stated regarding the cleaning of the lead aprons, "Unless the aprons or shields are visibly soiled or exposed to COVID-19, they only get cleaned once a month when maintenance checks them."

3. A review of policy titled "Standard Precautions and Isolation Precautions," last reviewed June 2020, was conducted. It states in part: "Procedure. Standard Precautions.5. Patient Care Equipment. Make sure reusable equipment has been cleaned and reprocessed appropriately prior to use on another patient."

4. An interview was conducted with the Chief Nursing Officer on 04/07/21 at 9:00 a.m. She stated regarding the lead aprons, "I would expect them to be cleaned after every use. I do not know why they are not being cleaned."


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B. Based on observation, document review and staff interview it was determined the facility failed to ensure nursing staff provided a sanitary environment to reduce sources and transmission of infections and communicable diseases in the Emergency Room (ER). This failure was identified in three (3) out of three (3) observations. This failure places all patients at risk for infections.

Findings include:

1. An observation conducted on 04/05/21 at approximately 1:45 p.m. in ER Trauma Bay #3 revealed a linen cart was left stored, unattended and uncovered with exposed clean linens and a supply cart was left stored, unattended, unlocked and accessible which contained needles in drawers #1, 2, and 5. The bed was not covered with linens. When Registered Nurse (RN) #2 was asked if this room had been cleaned after the last patient, she verbalized it was not cleaned yet. When asked if the linen cart should be covered, she stated in part, "The linen cart should be covered, and the cloth should be down over the cart. When asked if the supply cart should be locked, she stated in part, "The cart should be locked at all times."

2. An observation conducted on 04/05/21 at approximately 1:45 p.m. in ER Trauma Bay #5 revealed a portable container containing intravenous needles and supplies was stored on the patient bedside table next to the bed.

3. A review of facility policy "Standard Precautions and Isolation Precautions," approved 08/19/11, states in part: "It is the policy ... to provide standard precautions and isolation precautions to protect the staff and patients from the spread of potentially infectious agents ... It is the purpose of this policy to reduce the risk of transmission of blood borne, contact, droplet and airborne pathogens by applying the appropriate and necessary precautions to all patients receiving care in this facility ... Environmental Controls: Ensure the facility has adequate procedures and they are followed for the routine cleaning of all surfaces including bed, bed rails, bedside equipment and other frequently touched surfaces ... Linens: Used linen soiled with blood, body fluids, secretions and excretions will be handled, transported and processed in a manner which prevents skin and mucous membrane exposure, contamination of clothing, and the transfer of microorganisms to the other patients and the environment."

4. In an interview with the Chief Nursing Officer (CNO) on 04/07/21 at 9:00 a.m., she stated regarding the linen cart in the Emergency Department exam room, "The linen cart should be kept covered at all times unless someone is actively retrieving linens from it. We do not have a policy, but that is expected." Then, she stated regarding the supply cart being unlocked, "The supply cart should be kept locked at all times, this is a nursing standard."

C. Based on observation, document review and staff interview it was determined the facility failed to ensure the wound care nurse provided a sanitary environment to reduce sources and transmission of infections and communicable diseases in the wound care room. This failure was identified in one (1) out of one (1) observation. This failure places all patients at risk for infections.

Findings include:

1. An observation conducted on 04/05/21 at approximately 2:50 p.m. of the wound care room bathroom revealed patient care supplies and a pair of worn sneakers with soil embedded in the soles were stored together on the shower floor across from the toilet. The supplies consisted of two (2) packages of wound care boots, five (5) boxes of cohesive bandages, a packaged metal surgical tray, three (3) packages of gowns and three (3) boxes of procedure drapes.

2. A review of facility policy "Standard Precautions and Isolation Precautions," approved 08/19/11, states in part: "It is the policy ... to provide standard precautions and isolation precautions to protect the staff and patients from the spread of potentially infectious agents ... It is the purpose of this policy to reduce the risk of transmission of blood borne, contact, droplet and airborne pathogens by applying the appropriate and necessary precautions to all patients receiving care in this facility ... Environmental Controls: Ensure the facility has adequate procedures and they are followed for the routine cleaning of all surfaces including bed, bed rails, bedside equipment and other frequently touched surfaces ... Linens: Used linen soiled with blood, body fluids, secretions and excretions will be handled, transported and processed in a manner which prevents skin and mucous membrane exposure, contamination of clothing, and the transfer of microorganisms to the other patients and the environment."

3. An interview was conducted with the CNO on 04/07/21 at 9:00 a.m. She stated regarding the supplies in the wound care bathroom shower, "We use the bathroom as a storage closet and not a bathroom. The shoes belong to the wound care nurse who changes his shoes when arriving to work. I agree this is not a good place for the supplies or shoes."

D. Based on observation, document review and staff interview it was determined the facility failed to ensure the laboratory staff in the facility's off-site location provided a sanitary environment to reduce sources and transmission of infections and communicable diseases in the laboratory draw room. This failure was identified in one (1) out of one (1) observation. This failure places all patients at risk for infections.

Findings include:

1. An observation conducted on 04/06/21 at approximately 8:37 a.m. at the facility's off-site location for the outpatient laboratory revealed the refrigerator contained approximately five (5) bottles of oral glucose, three (3) apple juice cups and two (2) bottles of water stored on the top shelf and fifteen (15) opened items consisting of salad dressing, chik-fila sauce, whipped topping, coffee delight creamers and three (3) plastic and metal personal drink containers stored on the bottom shelf. When asked if the refrigerator was used for storing patient nutrition and staff's food storage, Phlebotomist #1 confirmed the items on the top shelf were for patients and the bottom shelf was the staff's food. When asked to review the refrigerator temperature logs, she verbalized there were not any temperature logs for the refrigerator.

2. A review of facility policy "Patient Refrigerators," approved 09/14, states in part: "The purpose is to ensure proper and safe storage with appropriate handling and discarding of materials to decrease the risk of cross contamination and food borne illness ... Only patient food may be stored in patient refrigerators."

3. An interview was conducted with the CNO on 04/07/21 at approximately 2:35 p.m. When discussing the refrigerator not being monitored and patient and staff items were stored in the same refrigerator, she concurred the temperatures should be monitored daily and staff food should not be stored with patient food.

E. Based on observation, document review and staff interview it was determined Radiology Technician (RT) #1 failed to ensure sandbags used for patient positioning for radiographs are cleaned and maintained in accordance with infection control standards. This failure was observed in two (2) out of (2) stored sandbags. This failure places all patients at risk for infections.

Findings include:

1. An observation was conducted on 04/06/21 at approximately 8:37 a.m. at the facility's off-site outpatient radiology department. One (1) sandbag was lying on the floor in the corner to the left of the entry door of the radiology diagnostic room and one (1) sandbag was lying on the floor in front of the office door and being used to prop open the office door. When asked if the sandbags were used for patient care, RT #1 stated the sandbags were used to help place patients in position for radiographs when they were holding them. When asked if the sandbags were cleaned and disinfected, he stated in part, "They don't get cleaned."

2. A review of facility policy "Standard Precautions and Isolation Precautions," approved 08/19/11, states in part: "It is the policy ... to provide standard precautions and isolation precautions to protect the staff and patients from the spread of potentially infectious agents ... It is the purpose of this policy to reduce the risk of transmission of blood borne, contact, droplet and airborne pathogens by applying the appropriate and necessary precautions to all patients receiving care in this facility ... Environmental Controls: Ensure the facility has adequate procedures and they are followed for the routine cleaning of all surfaces including bed, bed rails, bedside equipment and other frequently touched surfaces ... Linens: Used linen soiled with blood, body fluids, secretions and excretions will be handled, transported and processed in a manner which prevents skin and mucous membrane exposure, contamination of clothing, and the transfer of microorganisms to the other patients and the environment."

3. An interview was conducted with the CNO on 04/07/21 at approximately 2:35 p.m. When notified of the equipment not being cleaned and disinfected in the off-site radiology department, she concurred it should be cleaned and disinfected."