HospitalInspections.org

Based on record review and interview, the hospital failed to ensure patients and staff were free from abuse and neglect and failed to ensure all incidents of abuse, neglect, and/or harassment were reported and analyzed, and the hospital was in compliance with applicable local, State, and Federal Laws and Regulations. This deficient practice was evidenced by the hospital's failure to report and investigate cases of possible abuse or neglect in 7 of 7 reviewed incidents.

Findings:

Pursuant to LA R.S. 40:2009.20 facilities/health care workers shall report abuse/neglect allegations within 24 hours of receiving knowledge of the allegation to either the local law enforcement agency or the Louisiana Department of Health (LDH). For the purposes of this process Health Standards, the Louisiana Department of Health (LDH) Legal Services Division, and the Office of the Attorney General have interpreted this to mean that the 24-hour time frame begins as soon as any employee or contract worker at the facility (including physicians) becomes aware that an incident of abuse/neglect has been alleged, witnessed, or is suspected, regardless of the source of information and regardless of the existence or lack of supporting evidence.

Review of hospital policy approved January 2021, titled "Abuse and/Or Neglect of Patients" revealed, in part: Policy Statement, in part: [The hospital] implements the Louisiana State mandated report law, which states that, any professional having contact with children, disabled persons, senior citizens or other identified vulnerable populations, are required to report ...when there is evidence of neglect, knowledge of an incident or an imminent risk of serious harm. D. Reporting Abuse And/Or Neglect of Patients, in part: 5. in part: Director of Nursing or Administrator will notify the appropriate authorities. These authorities may include in part: h. Department of Health and Hospitals.

Review of incident reports for April, May and June 2024 revealed, in part:

06/10/2024 at 8:00 p.m.: Patient #1 with unwitnessed fall after choking on a sandwich. Hit head hard and required Heimlich maneuver, patient sent to ER (Patient was on 1:1 observation).

06/06/2024 at 3:25 p.m.: MHT observed another MHT pulling Patient #R1 out of a chair in the hallway and shoving the patient in the back.

05/19/2024 at 8:15 a.m.: Patient #R2 came out of her room at 8:00 a.m. clutching her arm saying she had purposely ripped out the metal sutures to the laceration on her left arm. It was seeping blood, pressure put on her left arm until bleeding stooped. Patient was sent to ER.

05/11/2024 at 10:30 a.m.: Patient #R3 stated, "yeah I hit her, she ate my breakfast". Patient very hostile becomes easily agitated and aggressive.

05/11/2024 at 10:30 a.m.: Patient #R4 was hit on the back of the head from behind by Patient #R3, stated "All I did was eat a piece of her sausage". Patient #R4 sustained a lump to the back of the left side of her head.

05/06/24 at 11:00 a.m.: Patient #R5 gave his PRN Ativan that he took out of his mouth and gave it to another patient.

05/06/2024 at 12:30 p.m.: Patient #R6 gave his PRN Ativan to another patient (the same patient that was given Ativan by #R5).

04/09/2024 at 12:15 p.m.: Upon attempting rounds on Patient #R7, #R7 punched S5RN with his right hand and hit her right jaw.

Review of the ACTS database revealed the last self-report received from the provider was in December 2022.

In an interview on 06/12/2024 at 11:05 a.m, S13Admin reported he did not investigate, analyze or submit a self-report to the Louisiana Department of Health as per state rules and regulations for any of the above incidents involving negect, patient-to-patient abuse, patient-to-staff abuse, and staff-to-patient abuse.

Hospital was cited on 01/04/2024 for failure to self-report to the Louisiana Department of Health as per state rules and regulations

Based on record review and interview, the hospital failed to meet the Condition of Participation for Governing Body. The hospital's governing body failed to effectively carry out its responsibilities for the conduct of the hospital for the hospital's compliance not only with the specific standards of the governing body CoP, but also with the following CoPs. This deficient practice was evidenced by:
1) Failure of the governing body to assure that hospital services are provided in compliance with the Medicare Conditions of participation and according to acceptable standards of practice. (See Findings in A-0115, A-0263, A-0385, and A-0747);
2) Failure of the governing body to protect and promote each patient's rights. (See Findings in A-0115);
3) Failure of the governing body to implement, and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. Failure to ensure that the program reflects the complexity of the hospital's organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. Failure to maintain and demonstrate evidence of its QAPI program for review by CMS. (See Findings in A-0263);
4) Failure of the governing body to ensure the hospital has an organized nursing service. As a result of this noncompliance, on 06/10/2024 at 5:11 p.m., S13Admin was informed of the Immediate Jeopardy situation that existed. The hospital failed to have a director of nursing and an assistant director of nursing responsible for the operation of the nursing services, including determining the types and numbers of nursing personnel and staff necessary to provide nursing care to all areas of the hospital. (See findings in A-0385).
5) Failure of the governing body to ensure an active hospital-wide programs for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship. Failure to ensure programs that demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic resistant organisms. Failure to ensure infection prevention and control problems and antibiotic use issues identified in the programs are addressed in collaboration with a hospital-wide quality assessment and performance improvement (QAPI) program. This deficient practice resulted in an Immediate Jeopardy situation. As a result of this noncompliance, on 06/10/2024 at 3:00 p.m., S13Admin was informed of the Immediate Jeopardy situation that existed. The hospital failed to ensure patient safety by failing to adhere to nationally recognized guidelines when sanitizing patient glucometers and failing to perform glucometer control testing per hospital policy. (See Findings in A-0747).

Based on observation, record review, and interview, the hospital failed to meet the requirements of the Condition of Participation of Patient Rights. The hospital failed to protect and promote each patient's rights as evidenced by:
1) failure to ensure patients were observed per physician orders resulting in patient harm (See findings at A-0145);
2) failure to ensure glucometer controls were tested per hospital policy resulted in an Immediate Jeopardy Situation and S13Admin was notified on 06/10/2024 at 3:00 p.m. The hospital provided the following plan of removal for the Immediate Jeopardy situation at 4:40 p.m.:
A. Administrator will immediately implement the training of the three (3) RNs in-house at the time of the finding. S15HS will conduct one-to-one training of S5RN and S18RN before end of shift on 06/10/2024.
B. A step by step written training will be placed in the Communication Binders on each floor to be reviewed by subsequent shift RN's.
C. This written training will include a signature page that will be audited daily by the Administrator for compliance and understanding of the information in the training.
D. Each RN will demonstrate their understanding of the training to the Administrator or Director of Nursing until all full-time and PRN RNs are compliant.
E. The hospital's Policy and Procedures regarding Glucometers (Section 11.4.0) will be updated to include the latest standards in disinfection and control testing, including the specific hospital approved disinfection wipes.
F. The Administrator and/or the Director of Nursing will inspect the Glucometer Logs daily (Monday through Friday) to ensure compliance with disinfection and control testing. The results of this daily rounding will be reported monthly to the CEO and quarterly in the MEC meeting.
G. A currency with dates of completion for each full-time and PRN RN will be maintained, and compliance placed in the employees personnel file.
H. An online training course through will be assigned to all Clinical staff, RNs and MHTs.
I. Hospital's Policy and Procedures regarding Glucometers (Section 11.4.0) will be updated to include the latest standards in disinfection and control testing, including the specific hospital approved disinfection wipes.
J. The Administrator and/or the Director of Nursing will inspect the Glucometer Logs daily (Monday through Friday) to ensure compliance with disinfection and control testing.
K. Data will be collected on compliance of identified Infection Control standards and reported in Quality and Improvement measures.
L. The data will be reported to Administrator monthly, and the Medical Executive Committee and Governing Body quarterly.
M. Corrective Actions Completed: 06/17/2024-Including the online training of current clinical staff
On 06/11/2023 at 12:14 p.m., the Immediate Jeopardy Situation was lifted and the deficiencies remain at Condition levels. (See findings at A-0144);
3) failure to ensure appropriate staffing to meet the safety needs of the patients (See findings at A-0144);
4) failure to ensure staff personnel records contained documentation that demonstrated Patient Rights competencies had been successfully completed (See findings at A-0208);
5) failure to ensure the patient /patient representative's right to participate in the development and implementation of his or her plan of care was met (See findings at A-0130);
6) failure to inform patient/patient's representative of the patient's rights (See findings at A-0117); and
7) failure to obtain informed consent (See findings at A-0131).

Based on record review and interview, the hospital failed to ensure that each patient (or when appropriate, the patient's representative) was informed of their rights, in advance of furnishing or discontinuing patient care whenever possible. This deficient practice is evidenced by:
1) failure to have all of the required patient rights included in the patient rights policy and Patient Handbook;
2) failure to have evidence that 1 ( #1) of 4 ( #1-#4) patients (or their representatives) reviewed for patient rights were informed of their patient rights.
Findings:

Review of hospital policy titled "Patient Rights", last reviewed 01/2021, failed to reveal the following patient rights:
1. The patient has the right to have a family member or representative of his or her choice and his or her own physician notified promptly of his or her admission to the hospital.
2. The patient has the right to participate in the development and implementation of his or her plan of care.
3. The patient has the right to receive care in a safe setting.
4. The patient has the right to access their medical records, including current medical records, upon an oral or written request, in the form or format requested by the individual.

Review of hospital policy titled "Patient Handbook", last reviewed 01/2021, revealed, in part: A Patient and Family Handbook will be given to each patient upon admission to hospital. The acknowledgment of receipt of the Handbook is noted on the Conditions of Admission and Consents Form. Procedure, in part: The handbook shall include: h. Patient Rights.

Review of hospital document provided by S13Admin, titled "Patient and Family Handbook ", undated, failed to reveal the following patient rights:
1. The patient has the right to have a family member or representative of his or her choice and his or her own physician notified promptly of his or her admission to the hospital.
2. The patient has the right to participate in the development and implementation of his or her plan of care.
3. The patient has the right to receive care in a safe setting.
4. The patient has the right to be free from all forms of abuse or harassment.
5. The patient has the right to access their medical records, including current medical records, upon an oral or written request, in the form or format requested by the individual.

Review of Patient #1's medical record revealed admission date of 06/01/2024. Diagnoses included Mental Retardation, Autism and Schizophrenia. Continued review revealed a Physician's Emergency Certificate dated 05/31/2024. The certificate included the name and phone number of Patient #1's guardian. Further review revealed a document titled "Conditions of Admissions & Consents". The document failed to reveal evidence Patient #1 or his guardian was informed of Patient #1's rights.

In an interview on 06/12/2024 at 8:45 a.m., S13Admin reviewed the medical records for Patient #1 and acknowledged there was no documented evidence that the patient/representative was notified of the patient's rights prior to furnishing care.

Based on record review and interview, the hospital failed to ensure the patient/patient representative's right to participate in the development and implementation of his or her plan of care was met. This deficient practice was evidenced by failure to ensure 2 (#1 and #4) of 4 (#1-#4) patients/patient representatives reviewed participated in the development and implementation of his or her plan of care.
Findings:

Review of hospital policy titled "Patient Rights", last reviewed 01/2021, failed to reveal, in part: All patients have the right to participate in the development and implementation of his or her plan of care.

Review of hospital policy titled "Standards of Nursing Practice: Patient Care, Treatment & Services", last reviewed on 01/2021, revealed, in part: Procedure, in part: The plan is developed with the patient.

Review of Patient #1's medical record revealed admission date of 06/01/2024. Diagnoses included Mental Retardation, Autism and Schizophrenia. Continued review revealed a document titled "Treatment Plan" dated 06/10/2024 at 9:44 a.m. Further review failed to reveal Patient #1's/representative's signature indicating participation in the decision making process of his treatment plan. Additional review failed to reveal documentation that the family/caregiver was notified or given the opportunity to be included in the patient's plan of care.

In an interview on 06/12/2024 at 9:15 a.m., S13Admin confirmed the treatment plan failed to reveal Patient #1's/representative's signature indicating participation in the decision making process of his treatment plan and failed to reveal documentation verifying family/caregiver was notified or given the opportunity to be included in the patient's plan of care.

Review of Patient #4's medical record revealed admission date of 06/04/2024. Diagnoses included Major Depression, SI with plan to inject herself with insulin with intentions to harm herself after a sexual assault. Continued review revealed a document titled "Treatment Plan" dated 06/12/2024 at 9:41 a.m. Further review failed to reveal Patient #4's/representative's signature indicating participation in the decision making process of her treatment plan. Additional review failed to reveal documentation that the family/caregiver was notified or given the opportunity to be included in the patient's plan of care.

In an interview on 06/12/2024 at 11:10 a.m., S13Admin confirmed the treatment plan failed to reveal Patient #4's/representative's signature indicating participation in the decision making process of her treatment plan and failed to reveal documentation family/caregiver was notified or given the opportunity to be included in the patient's plan of care.

Based on record review and interview, the hospital failed to ensure proper documentation of informed consent. The deficient practice is evidenced by failure of the person obtaining the consent to sign the document in 1 (#1) of 4 (#1-#4) patient records reviewed.
Findings:

Review of hospital policy titled "Patient Rights", last reviewed 01/2021, revealed the following patient rights, in part: Procedure, in part: All patients have the right to a written, signed "Informed Consent" form obtained from all patients/representative...

Review of Patient #1's medical record revealed admission date of 06/01/2024. Diagnoses included Mental Retardation, Autism and Schizophrenia. Further review revealed a four page document which pertained to consent for the following: treatment, medical procedures, medications, nursing care, restraint and confinement, audio/video surveillance, to not use nor keep any drug not prescribed, transport release, personal valuables, patient rights, assignment of benefits, notice of advance directives, privacy practices, release of information, notification of emergency services when a physician is not present at the facility, and financial responsibility. The form was unsigned by the patient/representative. The form was not dated, and did not have the signature of the person obtaining the consent.

In interview on 06/12/2024 at 9:20 a.m., S13Admin verified the document was unsigned by the patient/representative, was not dated, and did not have the signature of the person obtaining the consent.

Based on observation, record review, and interview, the hospital failed to ensure care in a safe setting. The deficient practice is evidenced by:
1) failure to ensure staffing to meet the safety needs of the patients;
2) failure to test glucometer controls per hospital policy to meet the safety needs of the patients.
Findings:

1) Failure to ensure staffing to meet the safety needs of the patients.
Review of hospital policy titled "Staffing Plans and Delivery of Care", last reviewed 01/2021, revealed, in part: Policy: The Director of Nursing shall outline a staffing plan that shall be used to determine the personnel recommended for each shift as outlined in the units core coverage and as necessary to provide the scope of services ... Scheduling Limitations: The goal of staffing each nursing unit is to ensure patient safety in healthcare delivery ...Staffing Assessment: Staffing levels are assessed daily (by shift) and adjustments are made for staff assignments based on the needs of the patient. The charge nurse, Director of nursing or designee does this assessment prior to the beginning of each shift and staffing adjustments are made accordingly to accommodate patient needs ...

Review of Staffing Matrix as part of the "Staffing Plans and Delivery of Care" policy, revealed, each unit should be staffed with at least 1 RN and 2 MHTs for a census of 1-12 patients.

Observations on 06/11/2024 at 9:42 a.m. revealed 1 (S21MHT) mental health technician (MHT) and 1 registered nurse (RN) on Unit C caring for 8 (#1, R8-R14) patients. Further observations revealed Patient #1 was alone in his room and was not being observed. Continued observations revealed S21MHT was making rounds on patients R8-R14. S24RN was in room hh.

Review of Patient #1's medical record revealed physician orders dated 06/04/2024. The orders read "Place patient on 1:1". Further review revealed Patient #1 sustained an unwitnessed fall on the night of 06/10/2024 and was sent to the emergency room at 9:45 p.m. Patient #1 returned to Unit C on 06/11/2024 at 9:15 a.m.

In an interview on 06/11/2024 at 9:43 a.m., S24RN stated that S22MHT called in and S21MHT was the only MHT on Unit C. S24RN confirmed that there should be another MHT to assist S21MHT since Patient #1 is 1:1.

In an interview on 06/11/2024 at 10:30 a.m., S13Admin confirmed the Unit C was not staffed per hospital policy and patient safety needs.

2) Failure to test glucometer controls per hospital policy.
Review of hospital policy titled "Glucose Test Log", approved 01/2024, revealed, in part: Policy Statement: The night shift Registered Nurse is to perform control tests, every 24 hours and anytime there is a question about the blood glucose results and document control test results on the Glucose Test Log. Control tests confirm that the meter is functioning properly.

Review of June's Glucometer Log with S13Admin for Unit C on 06/10/2024 at 10:00 a.m. revealed the most recent controls test was completed on 06/08/2024 at 12:00 a.m.

Review of patient census for Unit C revealed 1 patient (#3) with a diagnosis of Diabetes. Review of Patient #3's medical record revealed glucose checks were not performed.

In an interview on 06/10/2024 at 10:00 a.m., S13Admin verified the control testing on Unit C was not completed per hospital policy and could be a potential patient safety issue.

Review of June's Glucometer Log with S13Admin for Unit B on 06/10/2024 at 10:10 a.m. revealed the most recent controls test was completed on 06/06/2024 at 12:00 a.m.

Review of patient census for Unit B revealed Patient #4 with a diagnosis of Diabetes.

In an interview on 06/10/2024 at 10:12 a.m., Patient #4 reported she had her blood sugar checked earlier this morning and was given 6 units of insulin for a reading of 286. Patient #4 reported she felt her blood sugar was high.

Review of Patient #4's medical record on 06/10/2024 at 10:25 a.m., revealed patient blood glucose level per glucometer registered 268 mg/dl on 06/10/2024 at 8:00 a.m. Patient was given 6 units of insulin. The patient complained of drowsiness. The patient was rechecked at 10:15 a.m. and found to have a blood glucose level of 548 mg/dl. Patient #4 was administered another 2 units of insulin per physician orders.

In an interview on 06/10/2024 at 10:30 a.m., S13Admin verified the control testing on Unit B was not completed per hospital policy and could be a potential patient safety issue.

Based on record review and interview, the facility failed to ensure all patients were protected and free from neglect. The deficient practice is evidenced by failure to provide the ordered level of observations in 1 (#1) of 4 (#1-#4) patients reviewed, potentially resulting in patient harm.
Findings:

Review of hospital policy titled "Shift Assignments", last reviewed 01/2022, revealed, in part: Purpose: To ensure a safe, therapeutic milieu and delivery of quality patient care by designating specific duties to appropriate staff members ...2., in part: ...Mental Health Technicians will: Perform 1:1 observation level of patients if ordered.

Review of hospital policy titled "Patient Observation Record", last reviewed 01/2021, revealed, in part: The MHT is to note the Level of Observation ordered for each patient: 4. 1:1

Observations on 06/10/2024 at 9:55 a.m. on Unit C in room hh revealed a white board with Patient #1 noted to be on observation level 1:1.

Observations on 06/10/2024 at 10:50 a.m. on Unit C revealed Patient #1 wandering the unit alone and proceeding into room ff. Further observations revealed S20MHT in hallway gg.

Review of Patient #1's observation sheet revealed level of observation "close observation without unit restriction". The observation sheet failed to reveal Patient #1 was on observation level 1:1.

Review of Patient #1's medical record revealed physician orders dated 06/04/2024. The orders read, "Place patient on 1:1".

In an interview on 06/10/2024 at 10:51 a.m., S20MHT stated that he was assigned to Patient #1 and was not aware that Patient #1 was on 1:1 observations.

In an interview on 06/10/2024 at 10:51 a.m., S13Admin and S18RN confirmed patient #1 was on 1:1 and should be observed on a 1:1 level per hospital policy.

On 06/11/2024 at 10:30 a.m., a review of incident report dated 06/10/2024 at 8:00 p.m. revealed Patient #1 had an unwitnessed fall. The incident report stated the patient started choking, hit head hard. Heimlich maneuver performed by S25MHT, patient coughed out food. Patient became stable but continued to touch and grab the back of his head. Orders to send out for neurological exam due to complaints of head injury.

Review of nursing note dated 06/10/2024 at 9:34 p.m. revealed at 8:00 p.m. patient had an unwitnessed fall in the hallway. He landed supine and assuming hit back of head. He appeared to be choking was sat up immediately and Heimlich maneuver was performed. He coughed up several pieces of sandwich. Then sat upright in chair and became stable. Verbal orders to send to emergency room for neurological testing.

Review of Hospital Transfer Sheet dated 06/10/2024 revealed Patient #1 had an unwitnessed fall; landed supine; hit head hard; maneuver performed; coughed out food items, patient stable but continued to touch / grab back of head.

Review of Patient #1 observation sheet dated 06/10/2024 revealed level of observation noted 1:1. Further noted that Patient #1 was in a hallway pacing from 5:00 p.m.-8:00 p.m. At 8:15 p.m. and 8:30 p.m., it was noted that Patient #1 was in his room resting quietly.

On 06/12/2024 at 9:14 a.m. with S13Admin, reviewed hospital video of Unit C, dated 06/10/2024 from 7:43 p.m.-9:44 p.m.. The video revealed the following:

7:43 p.m.-8:30 p.m.: observation failed to reveal evidence that Patient #1 was observed on a 1:1 basis as per orders and observation sheets. The video revealed Patient #1 was in and out of room q and room ff. Both rooms not within line-of-sight of nurse's station. Patient #1 was seen pacing the hallways between going in and out of rooms q and ff.

7:52 p.m.: Patient #1 left room q, went to room hh where S26MHT gave him a sandwich. Patient #1 went back to room q.
7:53 p.m.: S26MHT was seen going into room q to give Patient #1 a cup of what appeared to be water and then leaving and going back to room hh.
7:53 p.m.-7:56 p.m.: Patient finished eating his sandwich and then walked into room ff and obtained a cookie and then went back into room q where he ate the cookie.
7:57 p.m.-8:05 p.m.: S25MHT and S26MHT entered into room q and stripped the bed as Patient #1 left and walked alone to his own room u.
8:14 p.m.: S25MHT proceeded into elevator and left Unit C after looking in Patient #1's room u.
8:15 p.m.-8:21 p.m.: Patient #1 left his room, paced back and forth between hallway gg and his room and then went back into his room.
8:23 p.m.: S25MHT returned to Unit C and went into room hh.
8:25 p.m-8:26 p.m: Patient #1 left his room and spoke to S26MHT in the hallway by room hh.
8:26-8:28 p.m.: Patient #1 entered room ff alone except for another patient who was watching tv with his back to Patient #1. Patient #1 noticed another patient's sandwich sitting on the table in the dayroom and preceded to sit down and eat it.
8:29 p.m.: While eating the sandwich Patient #1 began to show signs of distress. He threw his sandwich down, stumbled out of the dayroom, and fell in hallway ii where he was alone.
8:29 p.m.: S25MHT, S26MHT and S23RN were all in room hh.
8:29 p.m.: S25MHT walked out of room hh, looked to the right and noticed Patient #1 on the floor in hallway ii. S26MHT and S23RN came out of room hh and assisted S25MHT in helping Patient #1 into a standing position where S25MHT proceeded to give Patient #1 the Heimlich maneuver. The video shows food-like object projecting out of Patient #1's mouth.
8:30 p.m. Patient #1 assisted to a chair in hallway gg where he proceeded to fall on the floor again. He was lifted up by S25MHT and S26MHT.
8:31 p.m.-9:19 p.m.: S25MHT and S26MHT stayed with Patient #1 in chair in hallway gg while S23RN intermittently checked on him.
9:20 p.m.-9:44 p.m.: S25MHT and S26MHT walked patient to room u. S26MHT stayed with him until EMS arrived at 9:44 p.m.

In an interview on 06/12/2024 at 10:35 a.m., S13Admin verified that nursing staff failed to provide the level of observation that was ordered by the physician and documented on the observation sheet, potentially causing patient neglect and harm.

Based on record review and interview, the hospital failed to ensure staff personnel records contained documentation that demonstrated Patient Rights competencies had been successfully completed during orientation upon hire for 1 (S4RN) of 6 (S1RN-S6RN) hospital registered nurses reviewed for Patient Rights training.
Findings:

Review of hospital policy titled "Nursing Staff Orientation", last reviewed 01/2021, revealed, in part: Procedure, in part: Each new employee reviews and is oriented to the following core areas: Online courses, in part: Patient Rights.

Review of S4RN's personnel record revealed hire date of 01/31/2024. Further review failed to reveal Patient Rights training and competency was successfully completed during orientation upon hire.

In an interview on 06/12/2024 at 12:30 p.m., S17HR confirmed that S4RN was not oriented to hospital Patient Rights policies upon hire.

Based on record reviews and interview, the hospital failed to meet the requirements of the Condition of Participation for Quality Assessment and Performance Improvement (QAPI) as evidenced by failing to implement, and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. This deficient practice is evidenced by:
1) the hospital failed to ensure the Quality Assessment Performance Improvement (QAPI) Program specified the method and frequency of data collection for indicators as evidenced by failure to have documented evidence of current data on quality indicators (see findings in A-0273);
2) the hospital's Quality Assurance and Performance Improvement (QAPI) program failed to identify opportunities for improvement, implement effective action, measure success and track performance related to not having quality improvement activities (see findings in A-0283);
3) the hospital failed to track and analyze all events involving abuse and neglect. The deficient practice is evidenced by failure to investigate several patient-to-patient, patient-to-staff, and staff-to-patient incidents. (see findings in A-0286);
4) the hospital's governing body, medical staff and administrative officials failed to be responsible and accountable for ensuring that an ongoing program for quality improvement and patient safety is implemented, and maintained as evidenced by failing to have a current written, approved and implemented Quality Assurance/Performance Improvement (QAPI) plan and program (see findings in A-0309) and
5) the governing body failed to provide adequate resources for measuring, assessing, improving, and sustaining the hospital's performance by having insufficient staff designated to conduct the Quality Assurance/Performance Improvement (QAPI) functions of the hospital. (see findings in A-0315).

Based on record review and interview, the hospital failed to ensure the Quality Assessment Performance Improvement (QAPI) Program specified the method and frequency of data collection for indicators as evidenced by failure to have documented evidence of current data on quality indicators.
Findings:

In an interview on 06/10/2024 at 9:20 a.m., S13Admin stated that he was one year behind in aggregating Quality Assurance and Performance Improvement (QAPI ) data. He has not been able to collect or update Quality Assurance and Performance Improvement (QAPI) data and minutes for the last year.

Based on record review and interview, the hospital failed to identify opportunities for improvement. This deficient practice was evidenced by failing to investigate and collect the data necessary to identify opportunities for improvement and changes that will lead to improvement.
Findings:

In an interview on 06/12/2024 at 12:10 p.m., S13Admin again verified that the hospital did not have Quality Assurance and Performance Improvement (QAPI ) data. He agreed that without the necessary data, the hospital is unable to identify opportunities for improvement and changes that will lead to improvement. S13Admin confirmed the QAPI program had no updated quality indicators and there were no corrective action plans because they have not identified problems.

Based on record review and interview, the hospital failed to ensure the hospital wide QAPI program's performance improvement program implemented preventive actions. This deficient practice is evidenced by the lack of an implemented preventive action plan following an increase in patient safety incidents and injuries.
Findings:

Review of incident reports for April, May and June 2024 revealed, in part:

06/10/2024 at 8:00 p.m.: Patient #1 with unwitnessed fall after choking on a sandwich. Hit head hard and required Heimlich maneuver, patient sent to ER (Patient was on 1:1 observation).

06/06/2024 at 3:25 p.m.: MHT observed another MHT pulling Patient #R1 out of a chair in the hallway and shoving the patient in the back.

05/19/2024 at 8:15 a.m.: Patient #R2 came out of her room at 8:00 a.m. clutching her arm saying she had purposely ripped out the metal sutures to the laceration on her left arm. It was seeping blood, pressure put on her left arm until bleeding stooped. Patient was sent to ER.

05/11/2024 at 10:30 a.m.: Patient #R3 stated, "yeah I hit her, she ate my breakfast". Patient very hostile becomes easily agitated and aggressive.

05/11/2024 at 10:30 a.m.: Patient #R4 was hit on the back of the head from behind by Patient #R3, stated "All I did was eat a piece of her sausage". Patient #R4 sustained a lump to the back of the left side of her head.

05/06/24 at 11:00 a.m.: Patient #R5 gave his PRN Ativan that he took out of his mouth and gave it to another patient.

05/06/2024 at 12:30 p.m.: Patient #R6 gave his PRN Ativan to another patient (the same patient that was given Ativan by #R5).

04/09/2024 at 12:15 p.m.: Upon attempting rounds on Patient #R7, #R7 punched S5RN with his right hand and hit her right jaw.

In an interview on 06/12/2024 at 12:10 p.m., S13Admin stated that he had not been able to collect or update Quality Assurance and Performance Improvement (QAPI) data and minutes for the last year. S13Admin reported the hospital did not have documented actions taken to prevent incidents and patient injuries on the Performance Improvement meeting minutes because the hospital has not had QAPI meetings to discuss preventive action plans and the hospital has not investigated and collected data on the incidents discussed above.

Based on record review and interview, the hospital's Governing Body failed to ensure the QAPI program reflected the complexity of the hospital's services as evidenced by failing to include all hospital services in the QAPI program. This deficient practice was evident by failing to include the following contracted services: linen service, elevator service, fire systems, generator, fuel for generator, plumbing, pest control, electrician, biohazard waste, security, telephone service, and equipment, managed IT.
Findings:

Review of list of contracted services provided by S13Admin revealed the following services: linen service, elevator service, fire system, generator, fuel for generator, plumbing, pest control, electrician, biohazard waste, security, managed IT, telephone service, and equipment.

In an interview on 06/10/2024 at 9:20 a.m., S13Admin verified the hospital is at least one year behind on collecting any QAPI data including contracted services.

In an interview on 06/10/2024 at 11:30 a.m., S13Admin reported the hospital has no QAPI program at this time.

Based on record review and interview, the hospital's governing body, medical staff and administrative officials failed to be responsible and accountable for ensuring that an ongoing program for quality improvement and patient safety is defined, implemented, and maintained as evidenced by failing to have a current written, approved and implemented Quality Assurance/Performance Improvement (QAPI) plan and program.
Findings:

Review of hospital document provided by S13Admin, titled "Amended and Re-Statement of the By-Laws of [Hospital]", signed and dated by Governing Body's only member on 06/01/2021, revealed, in part: pages 2,4,6, and 8 are missing. Section 1 Page 9, revealed, in part: The Hospital will document appropriate remedial action to address deficiencies found to the quality assurance program. The Hospital will document the outcome of the remedial action.
Policies and Procedures, Section 1, in part: The following policies/procedures/plans must be created and approved by the Board of Managers: Quality Assurance Plan.

Review of Governing Body meeting minutes from January 2024 - June 2024 provided by S13Admin, failed to indicate an ongoing program for quality improvement and patient safety because no indicators were discussed.

Review of most recent Medical Executive Meeting minutes dated 01/15/2024, provided by S13Admin, failed to indicate an ongoing program for quality improvement and patient safety because no indicators were discussed.

Based on record review and interview, the Hospital's Governing Body failed to ensure adequate resources were allocated for measuring, assessing, improving, and sustaining the hospital's performance improvement functions as evidenced by insufficient staff designated to conduct the Quality Assessment Performance Improvement (QAPI) program functions of the hospital.
Findings:

Review of the hospital's organizational chart provided by S13Admin, failed to reveal a position for Quality Assurance or Infection Control Coordinator.

Review of the list of hospital department heads provided by S13Admin, failed to reveal a position for Quality Assurance or Infection Control Coordinator.

In an interview on 06/10/2024 at 9:05 a.m., S13Admin verified that the hospital does not have a dedicated position for Quality Assurance Coordinator. He has not done any QAPI data collection for this year because he has not had time to do so. S13Admin confirmed the hospital has not had an infection control coordinator since the last Director of Nursing (DON) resigned over 4 months ago. S13Admin stated that the interim DON is not the Infection Control Coordinator, and further reported she is on a cruise since 06/07/2024. S13Admin stated that the hospital does not have an Assistant Director of Nursing and he is not sure if they need one.

Based on observation, record review, and interview the hospital failed to meet the Conditions of Participation (CoP) of Nursing Services. The deficient practice is evidenced by:
1) failure of the nursing service to be under the direction of a registered nurse resulted in an Immediate Jeopardy situation called on 06/10/2024. S13Admin was informed of the Immediate Jeopardy situation that existed at 5:11 p.m.. The hospital failed to have a director of nursing and an assistant director of nursing responsible for the operation of the nursing services, including determining the types and numbers of nursing personnel and staff necessary to provide nursing care to all areas of the hospital. On 06/11/2024 at 2:16 p.m., the hospital provided a plan of removal for the Immediate Jeopardy situation. This plan included:
A. Administrator will present minutes of the Governing Body to the surveyor June 11,2024.
B. CEO who is the Governing Body will be updated on the DON orientation progress regularly.
C. Administrator will orient S14DON to administrative duties.
D. Commencing today, June 11, 2024 and June 12, 2024, S14DON will orient in the milieu with House Supervisor S15HS in regard to nursing duties.
E. Commencing Tuesday, June 18, 2024 orientation to the duties of Director of Nursing will be provided by S16DON.
F. Following the Director of Nursing initial orientation, the key position form will be submitted to the Health Standards Section.
G. Administrator will meet with S14DON on a daily basis, followed by weekly meetings and as needed attention and assistance.
H. Corrective Actions to be Completed: 06/19/2024
On 06/11/2023 at 3:51 p.m., the Immediate Jeopardy Situation was lifted and the deficiencies remain at Condition levels. (See Findings in A-0386);
2) failure to ensure the nurse assigns the nursing care of each patient to other nursing personnel in accordance with the patient's needs and the specialized qualifications and competence of the nursing staff available (see findings in A-397).
3) failure to implement physician orders and evaluate clinical activities (See findings in A-0398);
4) failure to ensure observation checks are being performed by RN on all patients (See findings in A-0395);
5) failure to implement a plan of care consistent with the plan for medical care of the practitioner responsible for the care of the patient (See findings in A-0396)

Based on record review and interview, the hospital failed to ensure the operation of the nursing service would include the quality of the patient care provided by the nursing service. This deficiency is evidenced by:
1) failure of the nursing service to be under the direction of a registered nurse responsible for the operation of the nursing services, including determining the types and numbers of nursing personnel and staff necessary to provide nursing care to all areas of the hospital;
2) failure to adhere to nursing policies and procedures requiring the patient or the patient's representative to be notified of a transfer.
Findings:

1) Failure of the nursing service to be under the direction of a registered nurse responsible for the operation of the nursing services, including determining the types and numbers of nursing personnel and staff necessary to provide nursing care to all areas of the hospital.
Review of hospital document titled "Competency-based Job Description, Director of Nursing", revealed, in part: III. Summary: This position is responsible for being the senior level provider of leadership to nursing services and coordinates the delivery of nursing serves, treatment and care ...this position is responsible for nursing services that include training, staffing, education and development, communications and documentation in order to maintain quality patient care ...V. Essential Duties and Responsibilities, in part: 1. Serves as the leader of nursing services at the hospital. 3. Support the staffing coordinator with staffing needs that meet standards. 6. Maintains quality care standards that admissions and transfers are appropriate considering the patients level of acuity, the hospitals capacity and staff, and and whether the patient has proper consent. 13. Assures, measures, assesses and improves patient outcomes by properly education and directing clinical staff. 15. Provides access and guidance to all staff in relation to nursing policy and procedures. 16. Serves as final authority for all nursing staff. 19. Assures that the highest quality of nursing care is given. 21. Assures that all patients are treated with respect and that all patient rights and regulations governing them are followed. 22. Serves as the hospital's Infection Control Officer. The Infection Control Officer will be qualified by education and experience and competent in infection control practices. The Infection Control Officer will be required to complete 10 CEU's in infection control related topics.

Review of hospital policy titled "Staffing Plans and Delivery of Care", last reviewed 01/2021, revealed, in part: Policy: The Director of Nursing shall outline a staffing plan that shall be used to determine the personnel recommended for each shift as outlined in the units core coverage and as necessary to provide the scope of services ... Scheduling Limitations: The goal of staffing each nursing unit is to ensure patient safety in healthcare delivery ...Staffing Assessment: Staffing levels are assessed daily (by shift) and adjustments are made for staff assignments based on the needs of the patient. The charge nurse, Director of nursing or designee does this assessment prior to the beginning of each shift and staffing adjustments are made accordingly to accommodate patient needs....

Review of the hospital's organizational chart provided by S13Admin, revealed S16DON as Director of Nursing.

Review of the hospital's organizational chart provided by S13Admin, failed to reveal an Assistant Director of Nursing.

Review of the list of hospital department heads provided by S13Admin, revealed S16DON as Director of Nursing.

Review of the list of hospital department heads provided by S13Admin, failed to reveal an Assistant Director of Nursing.

Review of the hospital's organizational chart provided by S13Admin, failed to reveal a position for Infection Control Coordinator.

Review of the list of hospital department heads provided by S13Admin, failed to reveal a position for Infection Control Coordinator.

In an interview on 06/12/2024 at 12:38, S17HR confirmed that 2 nurses (S4RN and S6RN) were unable to have Performance Evaluations due to the previous DON resigning 4 months ago (See findings in A-0398).

In an interview on 06/11/2024 at 10:30 a.m., S13Admin confirmed the Unit C was not staffed per hospital policy and patient safety needs (See findings in A-0144).

In an interview on 06/10/2024 at 9:48 a.m., S13Admin confirmed the MHTs were assigning their own patients (See findings in A-397).

In an interview on 06/10/2024 at 10:20 a.m., S13Admin confirmed that the registered nurses are not signing observation sheets, which indicates the nurses are not rounding and observing the patients (See findings in A-395).

In an interview on 06/10/2024 at 9:54 a.m., S13Admin confirmed the registered nurses are not using the correct disinfecting solution when cleaning the glucometers (See findings in A-0043 and A-0749).

In an interview on 06/10/2024 at 10:00 a.m., S13Admin confirmed the registered nurses are not testing the controls for the glucometer per hospital policy (See findings in A-0043 and A-0144).

In an interview on 06/11/2024 at 1:18 p.m., S24RN verified that nurses are not implementing physician orders. (See findings in A-0398).

In an interview on 06/10/2024 at 9:05 a.m., S13Admin stated that the previous Director of Nursing (DON) resigned approximately 4 months prior. The interim DON, S16DON, was on a cruise since 06/07/2024. The previous Assistant Director of Nursing (ADON) resigned last week. S13Admin reported that the hospital is waiting on the receipt of a criminal background check before the new DON, S14DON, will start. S13Admin verified the hospital currently has no qualified person to cover the DON responsibilities while S16DON is out.

2) Failure to adhere to nursing policies and procedures requiring the patient or the patient's representative to be notified of a transfer or discharge.
Review of hospital policy titled "Medical Emergency Transfer to Another Facility", last reviewed 01/2021, revealed, in part: Procedure: After emergency procedures have been initiated and the physician has given transfer orders, the Registered Nurse must: 2. Notify patient's family/significant other of patient's transfer. 3. Complete the Emergency Transfer Sheet with the following contents, in part: Receiving Hospital and phone number, Family/Caregiver's name and phone number and time contacted.

Review of Patient #1's medical record revealed admission date of 06/01/2024. Diagnoses included Mental Retardation, Autism and Schizophrenia. Continued review revealed a Physician's Emergency Certificate dated 05/31/2024. The certificate included the name and phone number of Patient #1's guardian.

Review of Patient #1's nursing note dated 06/10/2024 at 9:34 p.m. revealed at 8:00 p.m. Patient #1 had an unwitnessed fall in the hallway. He landed supine and assuming hit back of head. He appeared to be choking was sat up immediately and Heimlich maneuver was performed. He coughed up several pieces of sandwich. Then sat upright in chair and became stable. Verbal orders to send to emergency room for neurological testing. Continued review failed to reveal the nurse contacted Patient #1's guardian as per hospital Emergency Transfer policy.

Review of Patient #1's transfer sheet dated 06/10/2024 failed to reveal the name of the receiving hospital or phone number. Further review failed to reveal the Family/Caregiver's name and phone number and time contacted.

In an interview on 06/12/2024 at 8:45 a.m., S13Admin confirmed there was no evidence the guardian of Patient #1 was notified of the emergency transfer.

Based on record review and interview, the hospital failed to ensure the registered nurse supervised the care of each patient. The deficient practice is evidenced by failure of the nurse to review and sign the observation sheet for 46 out of 46 observation sheets reviewed.
Findings:

Review of the hospital policy "Patient Observation Record," last reviewed, 01/2021, revealed in part, Procedure, in part: The RN is responsible for MHT assignments re: Patient Observation Records. 1. A review of this record is performed every 2 hours. 2. A rounding of all patients is to be performed every 2 hours and documented on the Patient Observation Record.

Review of the Patient Observation Record for Patient #1 revealed the registered nurse failed to review and sign the following records every 2 hours within the timeframes below:
06/06/2024 between 4:00 p.m. - 11:00 p.m.

In interview on 06/12/2024 at 9:05 a.m., S13Admin verified nurses did not supervise Patient #1's care according to the hospital's policy.

Review of the Patient Observation record for Patient #2 revealed the registered nurse failed to review and sign the following records every 2 hours within the timeframes below:
05/04/2024 between 11:00 p.m. - 4:00 a.m.
N.D. between 11:00 p.m. - 4:00 a.m.
04/24/2024 between 2:00 a.m. - 8:00 a.m.
04/25/2024 between 4:00 a.m. - 8:00 a.m.
04/26/2024 between 2:00 p.m. - 8:00 p.m.

In interview on 06/12/2024 at 10:38 a.m., S13Admin verified nurses did not supervise Patient #2's care according to the hospital's policy.

Review of the Patient Observation record for Patient #4 revealed the registered nurse failed to review and sign the following records every 2 hours within the timeframes below:
06/08/2024, 06/09/2024 and 06/10/2024 between 2:00 a.m. - 6:00 a.m.; 8:00 a.m. - 2:00 p.m.; 8:00 p.m. - 6:00 a.m.; 8:00 p.m. - 8:00 a.m.; and 8:00 p.m.-12:00 a.m.

In interview on 06/11/2024 at 11:55 a.m., S13Admin verified nurses did not supervise Patient #4's care according to the hospital's policy.

Review of the Patient Observation records on 06/10/2024 at 10:38 a.m., for Unit A, dated 06/10/2024, revealed the registered nurse failed to review and sign the following records every 2 hours within the timeframes below:
Patients R15 - R25 between 6:00 a.m. - 10:38 a.m.

In interview on 06/10/2024 at 10:38 a.m., S13Admin verified nurses did not document supervised care according to the hospital's policy in 11 (R15 - R25) out of 11 (R15 - R25) patient observations sheets reviewed.

Review of the Patient Observation records on 06/10/2024 at 10:16 a.m., for Unit B, dated 06/10/2024, revealed the registered nurse failed to review and sign the following records every 2 hours within the timeframes below:
Patients R26 - R29 between 12:00 a.m. - 8:00 a.m.
Patients #4 and R30 - R34 between 11:00 p.m. - 10:16 a.m.

In interview on 06/10/2024 at 10:16 a.m., S13Admin verified nurses did not document supervised care according to the hospital's policy in 10 (#4, and R26 - R34) out of 10 (#4, and R26 - R34) patient observations sheets reviewed.

Review of the Patient Observation records on 06/10/2024 at 9:50 a.m., for Unit C, dated 06/10/2024, revealed the registered nurse failed to review and sign the following records every 2 hours within the timeframes below:
Patients #1, #3 and R8 - R13 between 6:00 a.m. - 9:50 a.m.

In interview on 06/10/2024 at 9:50 a.m., S13Admin verified nurses did not document supervised care according to the hospital's policy in 8 (#1, #3 and R8 - R13) out of 8 (#1, #3 and R8 - R13) patient observations sheets reviewed.

Review of the Patient Observation records on 06/11/2024 at 9:42 a.m., for Unit C, dated 06/11/2024, revealed the registered nurse failed to review and sign the following records every 2 hours within the timeframes below:
Patients #1, #3 and R8 - R13 between 6:00 a.m. - 9:42 a.m.

In interview on 06/11/2024 at 9:42 a.m., S27SS verified nurses did not document supervised care according to the hospital's policy in 8 (#1, #3 and R8 - R13) out of 8 (#1, #3 and R8 - R13) patient observations sheets reviewed.

Based on record review and interview, the nursing staff failed to update the plan of care after a significant event. The deficient practice is evidenced by failure to update the nursing plan of care for Patient #1 after having an unwitnessed fall involving a head injury and Heimlich maneuver and sent to emergency room.
Findings:

Review of hospital policy titled "Standards of Nursing Practice", last reviewed 01/2021, revealed, in part: Procedure, in part: Treatment plan goals and expected outcomes are derived from an analysis of the physical and mental health status data. The treatment plan for nursing care must include individualized nursing actions to achieve the established outcomes. The plan is developed with the patient. The treatment plan for nursing care is systematic, ongoing, and must be updated regarding whether or not the patient is making progress toward established goals.

Review of Patient #1's medical record revealed an incident report. Further review revealed Patient #1 had an unwitnessed fall involving a head injury and Heimlich maneuver on the night of 06/10/2024 at 8:00 p.m. and was transferred to the emergency room for neurological workup at 9:45 p.m. The patient returned to Unit C on 06/11/2024 at 9:15 a.m.

Review of Patient #1's Treatment Plan dated 06/11/2024 at 10:05 a.m., revealed Hypothyroidism was addressed. Further review failed to reveal the treatment plan was updated to address the unwitnessed fall involving a head injury, heimlich maneuver or transfer to emergency room.

In interview on 06/12/2024 at 9:15 a.m., S13Admin verified the plan of care was not updated to address the unwitnessed fall involving a head injury, Heimlich maneuver or transfer to emergency room.

Based on observation and interview the hospital failed to ensure a registered nurse assigned the nursing care of each patient to other nursing personnel in accordance with Hospital policy and the patient's needs. This deficiency is evidenced by failing to ensure a Registered Nurse completed all patient care assignments at the beginning of each shift.
Findings:

Review of hospital policy titled "Shift Assignments", last reviewed 01/2022, revealed, in part: Purpose: To ensure a safe, therapeutic milieu and delivery of quality patient care by designating specific duties to appropriate staff members ...Procedure, in part: 1. Charge Nurse: The charge nurse will determine the nursing care assignments for that shift based on patient acuity and capabilities of available staff.

In an interview on 06/10/2024 at 9:48 a.m., when asked to produce Unit C assignment sheets, S18RN stated that she did not prepare an assignment sheet because the Mental Health Technicians assign themselves the patients they will care for on each shift.

In an interview on 06/10/2024 at 9:48 a.m., S13Admin verified the Mental Health Technicians assign to themselves the patients they will care for on each shift.

In an interview on 06/10/2024 at 10:07 a.m., when asked to produce Unit B assignment sheets, S5RN stated that she did not have an assignment sheet because the Mental Health Technicians pick their patients and make their assignments.

In an interview on 06/10/2024 at 10:07 a.m., S13Admin verified the Mental Health Technicians assign their own patients and stated "we have been doing that for years".

In an interview on 06/10/2024 at 10:35 a.m. when asked to produce Unit A assignment sheets, S15HS stated that she did not have an assignment sheet because the Mental Health Technicians make their own patient assignments.

In an interview on 06/10/2024 at 10:35 a.m., S13Admin verified the Mental Health Technicians assign to themselves the patients they will care for on each shift.

Based on record review and interview, the hospital failed to have a Director of Nursing ensure adequate supervision and evaluation of the nursing personnel and nursing staff adherence to policies and procedure. This deficient practice was evidenced by:
1) failure of the nurses to implement physician orders per hospital policy;
2) failure of the hospital to have documentation of Performance Evaluations for 3 (S4RN, S5RN, and S10MHT) of 12 (S1RN - S6RN and S7MHT - S12MHT) nursing staff personnel records reviewed.
Findings:

1) Failure of the nurses to implement physician orders.
Review of hospital policy titled "Receiving and Recording Verbal Orders", last reviewed, 01/2021, revealed, in part: Procedure, in part: The Charge RN is responsible for implementing the orders and indication as such on the physician's order by bracketing off the entire order and signing his/her name.

Review of Patient #1's medical record revealed an order written on 06/04/2024 reading "Place Patient on 1:1".

Review of Patient #1's Observation record failed to reveal patient was placed on observation level 1:1 from 06/04/2024-06/10/2024 as per physician order.

In an interview on 06/10/2024 at 10:51 a.m., S13Admin and S18RN confirmed patient #1 was on 1:1 observation per physician order but the order was not implemented.

Review of Patient #3's medical record on 06/11/2024 at 1:18 p.m., revealed admission date of 06/06/2024. Diagnoses include Depression with SI and Diabetes on Metformin 500 mg once in the morning.

Review of Patient #3's Treatment Plan dated 06/06/2024 at 4:30 p.m. revealed Diabetes included in the problem list. Continued review revealed the following intervention: Nurse will monitor and record blood glucose levels regularly and report values outside normal parameters specified by physician. This will occur daily per shift and will last as needed.

Review of Patient #3's History and Physical dated 06/06/2024 at 7:13 a.m., revealed a Diagnosis of Diabetes with plan of care for Metformin and Insulin sliding scale coverage per protocol.

Review of Patient #3's physician orders revealed a verbal order for Accuchecks twice a day with sliding scale protocol dated 06/06/2024 at 10:12 a.m. and signed by nurse.

Review of Patient #3's medical record dated 06/06/2024-06/11/2024 failed to reveal a record of blood glucose levels or a record of insulin administration per sliding scale protocol.

In an interview on 06/11/2024 at 1:18 p.m., S24RN confirmed that the Accuchecks and sliding scale protocol were ordered but the orders were not implemented.

2) Failure of the hospital to have documentation of Performance Evaluations for 3 (S4RN, S5RN, and S10MHT) of 12 (S1RN - S6RN and S7MHT - S12MHT) nursing staff personnel records reviewed.
Review of hospital policy titled "Staff Development/Continuing Education", last reviewed on 01/2021, revealed, in part: Policy Statement: It is the policy of [Hospital] to establish minimum training requirements and to provide ongoing education specific to areas of responsibility to promote skill development, maintain skills, increase knowledge, provide job enrichment, support desired competencies and comply with regulatory requirements. Procedure, in part: DON or designee, in part: Assesses nursing areas of staff's need for education by outcomes of ... staff evaluations.

A review of S4RN's personnel record with S17HR revealed a hire date of 01/31/2024. Further review failed to reveal a completed Performance Evaluation on file.

In an interview on 06/12/2024 at 12:33 p.m., S17HR verified that S4RN did not have a completed Performance Evaluation on file. S17HR reported the first evaluation should be completed within the first 90 days of hire. S17HR stated that the Performance Evaluations have not been completed since the last DON resigned approximately 4 months ago.

A review of S5RN's personnel record with S17HR revealed a hire date of 02/16/2024. Further review failed to reveal a completed Performance Evaluation on file.

In an interview on 06/12/2024 at 12:33 p.m., S17HR verified that S5RN did not have a completed Performance Evaluation on file.

A review of S10MHT's personnel record with S17HR revealed a hire date of 11/21/2023. Further review failed to reveal a completed Performance Evaluation on file.

In an interview on 06/12/2024 at 12:33 p.m., S17HR verified that S10MHT did not have a completed Performance Evaluation on file.

Based on observation, record review and interviews, the hospital failed to ensure the condition of the physical plant and overall hospital environment were maintained in such a manner that the safety and well-being of patients were assured. This deficient practice was evidenced by failing to maintain the physical plant in good repair.
Findings:

Review of hospital policy titled "Environmental Services Policy & Procedure, Environmental Safety", last reviewed 01/2023, revealed, in part: Policy Statement. It is the policy to operate and maintain a safe environment, which minimizes risk and promotes safety.

Review of hospital policy titled "Environmental Services Policy & Procedure, Maintenance Rounding", last reviewed 01/2023, revealed, in part: Purpose: to ensure thoroughness and consistency in providing a safe and functional environment, the Environmental Services department will conduct environmental tours to maintain compliance. Procedure, in part: Maintenance Rounding checklist ...of the following items, in part: Shower/bath cleanliness and functionality; Patient bed cleanliness and functionality.

Observations during a tour of Unit C 06/10/2024 from 9:25 a.m. to 10:00 a.m. revealed the following:
9:25 a.m.- Observations of Room o revealed trash with a pair of strappy sandals noted under mattress of bed by door.
9:29 a.m.- Observations of Room p revealed trash under mattress near door.
9:33 a.m.- Observations of Room r revealed trash under mattress by door.
9:36 a.m.- Observations of wall to the left of Room hh revealed a hole in wall approximately 4 inches in diameter.
9:37 a.m.- Observations of Room q revealed trash under mattress.
9:39 a.m.- Observation of Room u revealed mal-functioning overhead lights.
9:40 a.m.- Observations of Room aa revealed non-functioning shower head, no water.
9:41 a.m.- Observations of shower curtain in Room z partially hanging off the shower curtain rod in disarray and missing hooks..
9:44 a.m.- Observations of Room ff with windowsill noted to be cracked and broken cement falling to the floor.

In an interview on 06/10/2024 at 10:00 a.m., S13Admin and S19EVS verified the above-mentioned findings In Unit C during the hospital tour.

Observations during a tour of Unit B on 06/10/2024 from 10:04 a.m. to 10:20 a.m. revealed the following:
10:20 a.m.- Observations of Room k revealed the over-head lights malfunctioning.
10:21 a.m.-Observation of Room m revealed broken latch on door.

In an interview on 06/10/2024 at 10:25 a.m., S13Admin and S19EVS verified the above-mentioned findings In Unit B during the hospital tour.

Observations during a tour of Unit A on 06/10/2024 from 10:29 a.m. to 10:38 a.m. revealed the following:
10:29 a.m.- Observations of Room e revealed overhead light malfunctioning.
10:30 a.m.- Observations of Room g with trash noted under mattress by door.

In an interview on 06/10/2024 at 10:40 a.m., S13Admin and S19EVS verified the above-mentioned findings In Unit B during the hospital tour.

In an interview on 06/10/2024 at 1:00 p.m., S13Admin confirmed there is no maintanenance log. There is an online system for staff to report maintenance issues, but no one utilizes the system.

In an interview on 06/10/2024 at 3:00 p.m. S19EVS reported he did not have a log of maintenance rounding but presented a sheet titled "[Hospital] Rounding dated 06/10/2024. The documented revealed the following:

Unit C
Room u lights not working, baseboard missing next to toilet.
Room t clean restroom floor, missing paper towel dispenser, room door drags, baseboard repair in closet.
Room r strip and wax floor.
Room s strip and wax floor, chipped wood on closet door, baseboard repair behind desk.
Room o baseboard missing under window, strip and wax floor.
Room p strip and wax floor.
Room aa shower faucet has no water coming out.
Room z shower curtain missing hooks.
Room ff floor repair needed by wall chairs sit against.
Hallway gg hand rail off wall, finish wall repair between Rooms r and s.
Unit B
Room n restroom wall and baseboard repair, paint room door.
Room m door broke at latch, latch is missing.
Room l floor tile broke next to toilet.
Room k lights not working.
Room h missing baseboard under window.
Room i missing baseboard behind door.
Room jj broken counter top in med room, strip and wax med room floor.
Room kk wall repair around window frame.
Room x wall repair above toilet.
Hallway ll replace baseboard left of Room k.
Unit A
Room g soap dispenser not working.
Room f soap dispenser not working.
Room d missing door stopper, light switch not working.
Room a reattach blind behind plexiglass.
Room b clean entrance floor around threshold.
Room x shower faucet has a trickle, paint wall next to toilet, strip and wax floor
Hallway nn schedule with Company B to repair west stairwell lock
Unit D
Room oo strip and wax floor, update lights to led bulbs.
Hallway pp replace missing baseboard, strip and wax floor.
Area qq tighten net against wall.
Room rr replace internet wire to security desk.
Common
1. Paint west stairwell.
2. Install generator timer.
3. Install Brand ss switch on driveway lights.

Based on observations, record reviews, and interviews, the hospital failed to meet the requirements of the Condition of Participation of Infection Control by failure to have active hospital-wide programs for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship. This was evidenced by:
1) failure to adhere to nationally recognized guidelines when sanitizing patient glucometers which led to an Immediate Jeopardy Situation. As a result of this noncompliance, on 06/10/2024 at 3:00 p.m., S13Admin was informed of the Immediate Jeopardy situation that existed. The hospital failed to ensure patient safety by failing to adhere to nationally recognized guidelines when sanitizing patient glucometers and failing to perform glucometer control testing per hospital policy. The hospital was utilizing a mulitpatient glucometer on 1 (#R1) patient receiving insulin injections per sliding scale. Staff were not cleaning the glucometer per the nationally recognized guidelines recommendations by using alcohol wipes to sanitize the glucometer. Staff were not performing control testing per hospital policy. On 06/10/2024 at 4:40 p.m., the hospital provided a plan of removal for the Immediate Jeopardy situation. This plan included:
A. Administrator will immediately implement the training of the three (3) RNs in-house at the time of the finding. S15HS will conduct one-to-one training of S5RN and S18RN before end of shift on 06/10/2024.
B. A step by step written training will be placed in the Communication Binders on each floor to be reviewed by subsequent shift RN's.
C. This written training will include a signature page that will be audited daily by the Administrator for compliance and understanding of the information in the training.
D. Each RN will demonstrate their understanding of the training to the Administrator or Director of Nursing until all full-time and PRN RNs are compliant.
E. The hospital's Policy and Procedures regarding Glucometers (Section 11.4.0) will be updated to include the latest standards in disinfection and control testing, including the specific hospital approved disinfection wipes.
F. The Administrator and/or the Director of Nursing will inspect the Glucometer Logs daily (Monday through Friday) to ensure compliance with disinfection and control testing. The results of this daily rounding will be reported monthly to the CEO and quarterly in the MEC meeting.
G. A currency with dates of completion for each full-time and PRN RN will be maintained, and compliance placed in the employees personnel file.
H. An online training course through will be assigned to all Clinical staff, RNs and MHTs.
I. Hospital's Policy and Procedures regarding Glucometers (Section 11.4.0) will be updated to include the latest standards in disinfection and control testing, including the specific hospital approved disinfection wipes.
J. The Administrator and/or the Director of Nursing will inspect the Glucometer Logs daily (Monday through Friday) to ensure compliance with disinfection and control testing.
K. Data will be collected on compliance of identified Infection Control standards and reported in Quality and Improvement measures.
L. The data will be reported to Administrator monthly, and the Medical Executive Committee and Governing Body quarterly.
M. Corrective Actions Completed: 06/17/2024-Including the online training of current clinical staff
On 06/11/2023 at 12:14 p.m., the Immediate Jeopardy Situation was lifted and the deficiencies remain at Condition levels. (See Findings in A-0748, A-0749, and A-0750).
2) failure to demonstrate an individual (or individuals), who is qualified through education, training, experience, or certification in infection prevention and control, is appointed by the governing body as the infection preventionist(s)/infection control professional(s) responsible for the infection prevention and control program and that the appointment is based on the recommendations of medical staff leadership and nursing leadership (See findings in A-0748);
3) failure to implement an infection prevention and control program that includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities (See Findings Tag A0750).

Based on record review and interview the hospital failed to demonstrate an individual (or individuals), who is qualified through education, training, experience, or certification in infection prevention and control, is appointed by the governing body as the infection preventionist(s)/infection control professional(s) responsible for the infection prevention and control program and that the appointment is based on the recommendations of medical staff leadership and nursing leadership.
Findings:

Review of hospital document titled "Competency-based Job Description, Director of Nursing", revealed, in part: V. Essential Duties and Responsibilities, in part: 22. Serves as the hospital's Infection Control Officer. The Infection Control Officer will be qualified by education and experience and competent in infection control practices. The Infection Control Officer will be required to complete 10 CEU's in infection control related topics.

Review of the hospital's organizational chart provided by S13Admin, failed to reveal a position for Infection Control Coordinator.

Review of the list of hospital department heads provided by S13Admin, failed to reveal a position for Infection Control Coordinator.

A review of Governing Body minutes failed to reveal evidence that the governing body appointed an Infection Control Professional to be responsible for the infection prevention and control program within the timeframe of 01/2024 to 06/2024.

In an interview on 06/10/2024 at 9:05 a.m., S13Admin verified the hospital has not had an Infection Control Coordinator since March of 2024 when S28RDON resigned.

This hospital was cited for same deficiency in 2011.

Based on observations, record review and interview the hospital failed to employ methods for preventing and controlling the transmission of infections. This deficient practice was evidenced by failure to adhere to nationally recognized guidelines when sanitizing patient glucometers, which led to an Immediate Jeopardy Situation. (See findings in A-0747)
Findings:

Review of hospital policy titled "Cleaning and Disinfecting Medical Equipment", last reviewed, 01/2024, revealed, in part: Policy Statement: ...shared patient care equipment is clean before use and that all used or contaminated equipment is appropriately cleaned before reuse. Purpose: To decrease the incidence of nosocomial infections by maintaining clean equipment ...

Review of hospital policy titled "Glucometer", last reviewed 01/2024, revealed, in part: Care of the Meter ..., in part: Clean the meter monthly; using the hospital approved disinfecting solution.

Review of hospital policy titled "Glucometer", revised 06/2024 as part of the Immediate Jeopardy Removal Plan, revealed, in part: Care of the Meter ..., in part: Clean the meter between each patient use; using the hospital approved purple top sanitizer.

In an interview on 06/10/2024 at 9:54 a.m., S18RN reported she uses alcohol wipes to clean the glucometer between patient uses. S13Admin confirmed.

In an interview on 06/10/2024 at 10:11 a.m., S5RN stated she located the appropriate wipes for cleaning the multi- use glucometer and cleaned it per manufacturer's guidelines. S13Admin confirmed.

In an interview on 06/10/2024 at 10:33 a.m., S15HS reported she cleans the glucometer with alcohol wipe between patients. S13Admin confirmed.

Based on observation, record review, and interview, the hospital failed to ensure the infection prevention program included surveillance of the facility to identify and mitigate identified sources with potential for transmission of infection. The deficient practice is evidenced by:
1) failure to provide hand sanitizer for staff use;
2) failure to provide and maintain equipment to prevent the spread of infection;
3) failure to ensure the hospital maintained a sanitary environment to prevent infections.
Findings:

1) Failure to provide hand sanitizer for staff use.
On 06/10/2024 at 9:32 a.m., observations of Unit C failed to reveal hand sanitizer in the locked Room hh available for staff use.

In an interview on 06/10/2024, R18RN and S13Admin confirmed that hand sanitizer was not available for staff use in room hh on Unit C. S13Admin stated they did not have hand sanitizer because the patients were ingesting the hand sanitizer. S13Admin agreed that the hand sanitizer should be available to the nurses in the locked nurses' station.

2) Failure to provide and maintain equipment to prevent the spread of infection.
Review of hospital policy titled "Environmental Services Policy & Procedure, Maintenance Rounding", last reviewed 01/2023, revealed, in part: Purpose: to ensure thoroughness and consistency in providing a safe and functional environment, the Environmental Services department will conduct environmental tours to maintain compliance. Procedure, in part: Maintenance Rounding checklist ...of the following items, in part: Shower/bath cleanliness and functionality; Patient bed cleanliness and functionality.

Observations during a tour of Unit C 06/10/2024 from 9:25 a.m. to 10:00 a.m. revealed the following:
9:39 a.m.-Observations of Room t revealed missing paper towel holder.
9:40 a.m.- Observations of Room aa revealed non-functioning shower head. When the faucet lever was turned to the on position, water did not run from the faucet.

In an interview on 06/10/2024 at 10:00 a.m., S13Admin verified the above-mentioned findings on Unit C during the hospital tour.

Observations during a tour of Unit A on 06/10/2024 from 10:29 a.m. to 10:38 a.m. revealed the following:
10:30 a.m.- Observations of Room g with malfunctioning soap dispenser.
10:31 a.m.- Observations of Room f with malfunctioning soap dispenser.

In an interview on 06/10/2024 at 3:00 p.m., S19EVS confirmed the malfunctioning soap dispensers.

3) Failure to ensure the hospital maintained a sanitary environment to prevent infections.
Observations during a tour of Unit C 06/10/2024 from 9:25 a.m. to 10:00 a.m. revealed the following:
9:25 a.m.-Observations of Room o revealed torn mattress noted to bed by window.

In an interview on 06/10/2024 at 10:00 a.m., S13Admin verified the above-mentioned findings on Unit C during the hospital tour.

Observations during a tour of Unit B on 06/10/2024 from 10:05 a.m. to 10:20 a.m. revealed the following:
10:05 a.m.- Observations of Room l revealed torn mattress by door.
10:20 a.m.- Observations of Room k revealed a mold-like substance noted to the middle portion on the under part of the mattress located in the bed by the door.

In an interview on 06/10/2024 at 10:00 a.m., S13Admin verified the above-mentioned findings In Unit B during the hospital tour.

Observations during a tour of Unit A on 06/10/2024 from 10:29 a.m. to 10:38 a.m. revealed the following:
10:29 a.m.- Observations of Room e revealed a mold-like substance noted to the middle portion on the under part of the mattress located in the bed by the door.

In an interview on 06/10/2024 at 10:40 a.m., S13Admin verified the above-mentioned findings In Unit A during the hospital tour.