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Based on interview and record review the facility failed to ensure a check of the Missouri Employee disqualification list (EDL) was done prior to hire for 52 staff hired since March of 2022. The facility census was one Acute Care patient and five Swing Bed patients for a total census of six.

Findings included:

1. During an interview on 07/26/23 at 3:30 PM, Staff L, Human Resources, stated all employees hired since she started with the facility in March of 2022 did not get a check of the EDL prior to hire. An EDL check was done after hire.

2. Review of the list of employees hired after March of 2022 showed 52 staff.

3. Review of the facility policy titled "Selection and Hiring," dated 06/22/99 showed as a post offer process, employees in Home Health and nursing will be verified through the Family Care Safety Registry which will include searches in the following databases:
- Criminal history by the MO State Highway Patrol
- Sex Offender Registry by the MO State Highway Patrol
- Child Abuse /Neglect Registry by the MO Dept of Social Services
- Foster Parent Licensure Records maintained by the MO Dept of Social Services
- Child Care Licensure Records maintained by the MO Dept of Health and Senior Services
- Employee Disqualification List maintained by the MO Dept of Health and Senior Services
- Employee Disqualification Registry maintained by the MO Dept of Mental Health

Based on observation, interview and policy review, the hospital failed to ensure that staff removed expired medications and ensured they were not available for use. These failures had the potential to affect the quality of the medications and potentially cause an increase of complications. The hospital census was one Acute Care patient and five Swing Bed patients for a total census of six.

Findings included:

1. Observation on 07/24/23 at 10:30 AM, in the patient medication refrigerator, in the pharmacy, showed one Acetylcysteine (used to relieve thick or abnormal mucous secretions in people with lung conditions) with an expiration date of 04/2021 (two years and two months expired) and five Pneumovax (a vaccine indicated for the immunization for the prevention of pneumococcal disease) with expiration dates of 01/2023 (six months expired).

2. Observation on 07/26/23 at 9:20 AM, inside the medication cart in the Endoscopy suite, showed one Succinylcholine [muscle relaxant used as a first-line paralytic used frequently for intubation (process of insertion of a tube through a person's mouth or nose, then down into their airway to connect to a breathing machine when a person was unable to breathe on their own), with an expiration date of 02/2023 (five months expired) and one Atropine (used to treat heart rhythm problems) with an expiration date of 09/2022 (10 months expired).

3. During an interview on 07/26/23 at 1:45 PM, Staff A, Director of Nursing (DON), stated staff was expected to remove expired medications monthly.


4. Although request, the hospital failed to provide a policy for expired medications.

Based on observation, interview and policy review, the hospital failed to ensure the dietary staff used safe sanitary food practices that included labeling food items with expiration dates and discarding expired foods to prevent usage. These failed practices had the potential to expose all patients, visitors and staff to cross-contamination and increased the potential to spread infection. The hospital census was one Acute Care patient and five Swing Bed patients for a total census of six.

Findings included:

1. Observation on 07/24/23 at 2:30 PM, in the kitchen, showed:
- In the walk-in freezer there was 10 baggies of unlabeled chili.
- In the desert freezer there was a bag of poppy seed muffins with an expiration date of 05/21/22 (one year and two months expired).
- In the current freezer there was one package of turkey and one package of ham unlabeled.
- In the cook's freezer there was a bag of chicken bacon with an expiration date of 02/03/22 (one year and five months expired).
- In the pass-through refrigerator there was one tartar sauce unlabeled.

2. During an interview on 07/24/23 at 3:00 PM, Staff O, Dietary Manager, stated staff should have checked the labels and expiration dates.

3. Review of the hospital's policy titled, "Rotation of Stock Policy", dated 03/23/18, showed the direction for staff to rotate all food items and identify the food item's use-by or expiration date and throw out food that has passed the manufacturer's use-by or expiration date.

Based on observation, interview and policy review, the facility failed to ensure that staff followed infection control policies and infection prevention standards when they failed to:
- Maintain cleanliness during a wound vacuum (wound vac) dressing change that included touching of inanimate (contaminated) objects and failing to perform hand hygiene before and after touching the inanimate objects for one patient (#1) of one observed.
- Discarded bio-hazardous waste (waste that potentially contains infectious material) into the appropriate containers.
- Maintain the cleanliness of six laryngoscope blades (equipment that allowed visualization of the vocal cords while a breathing tube was placed) out of six observed and stored in crash carts (a set of trays/drawers/shelves on wheels used for transporting and dispensing emergency medication/equipment for emergency life support) located in the emergency room.
- Maintain the inside of the Endoscope (an inspection instrument used in a procedure to examine the patient digestive system) cabinet in surgical services.
- Replace 12 ceiling tiles with exposed particle board (particle shedding) in the kitchen.
- Remove rust (reddish-brown oxidation of metal that can harbor bacteria) inside the dishwasher.
These failed practices had the potential to expose all patients, visitors and staff to cross contamination and increased the potential to spread infection. The facility census was one Acute Care patient and five Swing Bed patients for a total census of six.

Findings included:

1. Upon request, the hospital failed to provide a policy that provided staff direction for performing a wound vac dressing change.

Review of the hospital's policy titled, "Hand Hygiene," dated 05/05/21, showed the direction for staff to wash their hands between handling of patients, before applying and after removing gloves and when their hands were soiled (contaminated).

Review of the hospital's policy titled, "Standard Precautions," dated 05/05/21, showed the direction for staff to wash hands after touching contaminated items.

Review of the hospital's policy titled, "Medical Waste Management Plan Handling Requirements," dated 04/07/21, showed that all medical waste was to be contained separately from other waste.

Review of Patient #1's wound care orders that started on 07/18/23 showed that the wound vac was to be placed at 125 mm/hg (unit of pressure) continuous negative pressure to left hip wound and changed every three days. The orders had no other details about the care of the wound.

Observation on 07/24/23 at 2:07 PM, at Patient#1's bedside, Staff D, Licensed Practical Nurse (LPN), performed a wound vac dressing change that showed Staff D:
- Laid supplies on the patient's bed.
- Performed hand hygiene and gloved;
- Removed old dressing, removed gloves, performed hand hygiene and re-gloved.
- Cleansed the wound, touched the patient's bed sheets (contaminated), pushed gauze in the wound soaking up exudate (fluid that leaks out of blood vessels) and discarded into a regular trash can instead of a bio-hazard bag.
- Removed gloves, performed hand hygiene and re-gloved.
- Placed new dressing on, cut a hole in the middle, pushed sponge into center of wound and placed the outer dressing on.
- Removed the old wound vacuum canister (with exudate) and discarded into a regular trash can instead of a bio-hazard bag, then attached the new wound vacuum canister.

During an interview on 07/26/23 at 1:30 PM, Staff D, LPN, stated they had never had any direct education from Staff P, General Surgeon, they shouldn't have touched the contaminated sheets during the dressing change and they should have used the red hazard bags to discard the old dressing and canister.

During an interview on 07/26/23 at 1:45 PM, Staff A, Director of Nursing (DON), stated that:
- They haven't gone over wound vacs at the annual skills lab.
- The wound vac dressing change orders had no specifics that spoke to clean verses aseptic.
- Staff P, General Surgeon, had not performed any in-services on the wound vac care.
- Staff D should have brought the red bio-hazard bag to the bedside.

During an interview on 07/25/23 at 11:00 AM, Staff P, General Surgeon, stated that he had instructed and showed nurses when he saw them, although had never performed an in-service for them. He also stated that he did have concerns with staff performing wound vac care without having had his tutorial and if staff had contaminated the site he expected them to change gloves and perform hand hygiene.

2. Review of the hospital's document titled, "Protecting Disinfected Laryngoscope Blades in Storage," dated 01/11/16, stated that once the laryngoscope blades were cleaned, disinfected or sterilized, they should be packaged.

Observation 07/24/23 at 11:30 AM, in the Emergency Room, showed three laryngoscope blades in the pediatric crash cart, open to air with the date of sterilization on the outside of the package of 03/07/18 and three laryngoscope blades in the adult crash cart, open to air with the date of sterilization on the outside of the package of 03/07/18.

During an interview on 07/26/23 at 1:34 PM, Staff A, DON, stated that the laryngoscope blades should have been sealed.

3. Review of the hospital's policy titled, "Medivator Usage and Documentation," dated 06/21/10, showed the direction for staff to hang the disinfected scopes in the scope closet (cabinet).

Observation on 07/26/23 at 8:30 AM, in the Endoscopy suite, showed inside the endoscope cabinets (the place where sterilized endoscopes were stored) were exposed particle board (particle shedding) that had the potential to contaminate the endoscopes.

During an interview on 07/26/23 at 11:05, Staff J, Director of Surgical Services, stated they were unaware that the scopes were touching the particle board.

4. Observation on 07/24/23 at 2:00 PM, in the kitchen, showed 12 ceiling tiles missing that exposed the particle board (particle shedding) and rust inside of the dishwasher and the drain.

During an interview on 07/24/23 at 3:00 PM, Staff O, Dietary Manager, stated they had informed maintenance about the ceiling tiles and if they saw water sitting in the dishwasher between cycles they manually removed the plug.

Based on interview and record review the facility failed to ensure that all departments participated in a hospital wide quality assurance (QA) program. The facility census was one Acute Care patient and five Swing Bed patients for a total census of six.

Findings included:

1 During an interview on 07/26/23 at 10:15 AM, Staff G, Director of Medical Records, stated:
- The QA committee is composed of the department leaders;
- Each department has QA items they work on to improve services;
- The items are submitted for the meetings and placed in a book;
- During the meetings the items are not discussed as to progress; and
- The departments do have issues that need to be improved and are not addressed through a formal QA process.

2. Review of meeting minutes for the quality improvement meeting for 07/06/23 showed the directors discussed how they could make that portion of the meeting more meaningful. It was suggested that at each meeting a department would highlight their QA indicators and their successes or ways to improve upon a process. Next meeting they would start sharing some of their QA's.

3. Review of the facility's policy titled, "Hospital Wide Quality Improvement Program," dated 01/23, showed:
The evaluation of this information and use of the finding to improve patient care services or resolve problems is equally ongoing and an important part of the operation in each and every department, service and therefore the hospital as a whole.
The objectives are to communicate data, recommendations and followup to the appropriate levels within the hospital structure, administration, medical staff and Board of Directors as well as interdepartmentally.

Based on policy review, record review and interview the facility failed to develop a comprehensive activity Care Plan that provided specific individualized activity interest and interventions to stimulate the patient's physical and mental well-being for four of four current Swing Bed (Swing Bed - a Medicare program in which a patient can receive acute care services, then if needed Skilled Nursing Home Care) patients (#1, #3, #4 and #5) reviewed for a comprehensive quality of life activities Care Plan. This failed practice had the potential to affect all Swing Bed patients by failing to stimulate their minds, body and social interests. The facility census was one Acute Care patient and five Swing Bed patients for a total census of six.

Findings included:

1. Review of the facility's policy titled, "Care Planning," dated 04/06/22, showed staff directives:
- The care, treatment, and rehabilitation are planned to ensure that care is appropriate to the patient's needs and severity of disease, condition, psychosocial needs, impairment, or disability.
- Each patient's care is based on identified patient care needs and patient care standards and is consistent with the therapies of other disciplines.
- The Plan of Care shall be individualized, based on the diagnosis and patient assessment.

2. Review of Patients' Electronic Medical Health Records (EMHR) showed:
- Patient #1 was admitted to the facility's Swing Bed program on 07/18/23, for wound care of the left hip status post left hip fracture and therapy;
- Patient #3 was admitted to the facility's Swing Bed program on 07/21/23, for therapy related to right foot wound;
- Patient #4 was admitted to the facility's Swing Bed program on 07/19/23, for therapy status post fall; and
- Patient #5 was admitted to the facility's Swing Bed program on 07/17/23 for therapy and Intravenous (IV - needle placed into a vein for medication and fluid administration) therapy related to discitis (infection of the disc in the spinal column) and osteomyelitis (infection of bone and/or vertebrae).

Patient #1's, #3's, #4's and #5's EMHR showed staff failed to develop a comprehensive activity Care Plan for the patients during their admission in the facility's Swing Bed program.

3. During an interview on 07/24/23 at 2:55 PM, Staff C, Licensed Practical Nurse, acknowledged Patient #1's, #3's, #4's and #5's EMHR did not include a Care Plan for activities.

4. During an interview on 07/25/23 at 1:36 PM, Staff A, Registered Nurse, Director of Nursing, stated staff was expected to include activities in the Care Plan for patients admitted to the facility's Swing Bed program.