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Based on observation, interview and record review, the hospital failed to ensure the following:

1. The Pediatric and adult crash carts (Carts used during a life-threatening emergency) in the emergency room (ER) were checked daily to ensure the availability of emergency supplies.

2. The Operating Room (OR) pediatric crash cart (a wheeled container carrying medicine and equipment used in emergency resuscitations) was checked by the nursing staff to ensure the availability of emergency suppplies.

This failure had the potential to affect the health and safety of patients.

Findings:

1. During a tour of the ER on February 6, 2018 at 12:37 PM, 2 crash carts were observed in the ER. 1 was equipped for adult patients and the other was for adult patients.

During a review of the crash cart logs, there was a missing signature on the pediatric crash cart log and the adult crash cart log for February 5, 2018 indicating the carts were not checked on that day. There was a missing signature on the adult crash cart for January 28, 2017, indicating it was not checked on that day.

In an interview with Registered Nurse 4 (RN 3) on February 6, 2018 at 1:00 PM, she stated she was the Nurse who checked the crash carts in the ER. She stated she was on duty on February 5, 2018, and stated she got busy and did not check the crash carts on February 5, 2018. She confirmed the logs showed the carts were not checked on January 28, 2017 or February 5, 2018 and should have been checked.

2. A review of the facility's "Crash Cart Check," dated February 2018, indicated the following:

February 1, 2018- no signature indicating the crash cart was checked.

During an interview with the Operating Room Manager (ORM) on February 6, 2018 at 2:02 PM, he stated the pediatric crash cart (a wheeled container carrying medicine and equipment for use in emergency resuscitation) should be checked and signed by the nurse who verifies the crash cart contains the required items and is working properly. The ORM stated the nurse checked the pediatric crash cart but did not sign the log.

Based on observation, interview and record review, the hospital failed to ensure their preventive maintenance program was implemented for the following:

1. One (1) of four (4) electronic thermometers in the emergency room (ER).

2. One electronic thermometer in the Pre-Operative Unit (Preop- the time before surgery).

These failure had the potential for inaccurate patient temperatures taken to assess a patient's health status.

Findings:

During an observation tour of the ER on February 6, 2018 at 12:40 PM, there were 4 electronic thermometers mounted holders on the wall. Further observation showed there was no preventive maintenance sticker with a date the thermometer was checked to ensure proper and safe functioning of the thermometer.

In an interview with the Maintenance Manager (MM) on February 6, 2018 at 1:10 PM, he stated, he did not have a log for the individual equipment but he checked them when I check the area. He stated "I don't have proof that the thermometer was checked."


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2. During an observation of the Pre Anesthesia Care (Pre-op) Unit on February 6, 2018 at 1:54 PM, an observation was made of a thermometer with no Preventative Maintenance (PM-routine maintenance to help keep equipment up and running) sticker.

During an interview with the Maintenance Manager (MM) on February 7, 2018 at 2:19 PM, he stated preventative maintenance was not done for the Pre-op thermometer and it was overdue.

A review of the facility's policy and procedure titled, "Preventative Maintenance, undated, indicated, "Every six months, during the room PM, Each thermometer will be visually inspected for any physical damage. Each thermometer and probe will be cleaned with a 70 % isopropyl alcohol solution. A power-on self test will be performed."

The facility failed to ensure the Condition of Participation: CFR 485.627 Organizational Structure was met by failing to ensure:

1. Three (3) GI scopes were stored in accordance with infection control (IC) standards and in a manner to prevent cross contamination. (Refer to C-0278)

2. The GI scope accessories were stored with their perspective scopes. (Refer to C-0278)

3. There was documented evidence the Medivators (a reprocessor machine- used to high level disinfect (a method for cleaning and disinfecting reusable patient equipment) was routinely maintained according to manufacture instructions for use (IFU). The reprocessor was used to high level disinfect reusable scopes. (Refer to C-0278)

4. Terminal cleaning (a cleaning method used in healthcare environments to control the spread of infections) was performed in the Central Sterile Department (CSD-the area in the facility where the cleaning and sterilizization of surgical intruments was performed). (Refer to C-0278)

5. Temperatures and humidity were within range in the Central Sterile Department. (Refer to C-0278)

6. The CSD Technician (CSDT 1) was able to verbalize the process for out of range temperatures and humidity. (Refer to C-0278)

7. A processed (previously sterilized and ready for patient surgical procedures) minor tray did not contain a surgical intrument with brown staining. (Refer to C-0278)

8. A Registered Nurse (RN 3) properly donned the PPE gown when entering a contact isolation room. (Refer to C-0278)

9. Patient 2 received a timely dietary evaluation. (Refer to C-0294)

10. Operating Room (OR) and Emergency Department (ED) annual evaluations were completed for the Registered Nurse/Chief Operating Nurse (RN 1/CNO). (Refer to C-0294)

11. The OR pediatric crash cart (a wheeled container carrying medicine and equipment for use in emergency resuscitations) was checked by the nursing staff. (Refer to C-0202)

12. The Emergency Department (ED) adult and pediatric crash carts were checked by the nursing staff. (Refer to C-0202)

13. There was annual abuse training for five (5) of five (5) physicians. (Refer to C-0271)

14. Patient 20 had a discharge summary completed withiun 7 days of discharge. (Refer to C-0304)

15. There was an emergency pull cord in the Emergency Department patient restrooms. (Refer to C-0241)

16. One of four thermometers in the Emergency Department had evidence of Preventative Maintenace (PM- routine maintenance to help keep equipment up and running). (Refer to C-0222)

17. Preventative Maintenance was completed for one thermometer in the Pre-Operative Unit (Preop-the time before surgery). (Refer to C-0222)

18. There was documented evidence the Pharmacist (Pharm) completed a background check. (Refer to C-0241)

The cumulative effect of these systemic practices resulted in the failure of the facility to deliver care in compliance with the Condition of Participation: Organizational Structure.

Based on interview and record review, the Governing Body failed to ensure:

1. Three (3) GI scopes were stored in accordance with infection control (IC) standards and in a manner to prevent cross contamination.

2. The GI scope accessories were stored with their perspective scopes.

3. There was documented evidence the Medivators (a reprocessor machine- used to high level disinfect (a
method for cleaning and disinfecting reusable patient equipment) was routinely maintained according
to manufacture instructions for use (IFU). The reprocessor was used to high level disinfect reusable scopes.

4. Terminal cleaning (a cleaning method used in healthcare environments to control the spread of infections) was performed in the Central Sterile Department (CSD-the area in the facility where the cleaning and sterilizization of surgical intruments was performed).

5. Temperatures in the Central Sterile Department were within range.

6. The CSD Technician (CSDT 1) did not know the process for out of range temperatures.

7. A processed (previously sterilized and ready for patient surgical procedures) minor tray did not contain a surgical intrument with brown staining.

8. A Registered Nurse (RN 3) properly donned the PPE gown when entering a contact isolation room.

9. Patient 2 received a timely dietary evaluation.

10. Operating Room (OR) and Emergency Department (ED) annual evaluations were completed for the Registered Nurse/Chief Operating Nurse (RN 1/CNO).

11. The OR pediatric crash cart (a wheeled container carrying medicine and equipment for use in emergency resuscitations) was checked by the nursing staff.

12. The Emergency Department (ED) adult and pediatric crash carts were checked by the nursing staff.

13. There was annual abuse training for five (5) of five (5) physicians.

14. Patient 20 had a discharge summary completed withiun 7 days of discharge.

15. There was an emergency pull cord in the Emergency Department patient restrooms .

16. One of four thermometers in the Emergency Department had evidence of Preventative Maintenace (PM- routine maintenance to help keep equipment up and running).

17. One thermometer in the Pre-Operative Unit (Preop- the time before surgery) had preventative maintenance completed.

18. There was documented evidence the Pharmacist (Pharm) completed a background check.

These deficient findings had the potential to affect the health and safety of patients in a universe of 6 patients.

Findings:

1. During a tour of the Central Sterile Department (CSD) in the clean/packaging/work area, on February 6, 2018 at 2:31 PM, an observation was made of three (3) Gastrointestinal (GI-referring collectively to the stomach and the small and large intestine) scopes hanging vertically in a blue cabinet with glass doors.

During an interview with the Operating Room Manager (ORM) on February 6, 2018 at 2:55 PM, he stated he was not sure if the cabinet storing the three (3) GI scopes was a HEPA filtered cabinet. The ORM stated he was not sure if the cabinet storing the scopes was an air-drying scope storing cabinet.

During an interview with the Infection Control Preventionist (ICP), on February 8, 2018 at 3:19 PM, she stated that the hospital adopted and followed the Nationally Recognized Infection Control guidelines from:

a. AAMI-Association for the Advancement of Medical Instrumentation

b. AORN-Association of Perioperative Registered Nurses

c. CDC-Centers for Disease Control

d. SGNA-Standards of Infection Prevention in Reprocessing Flexible Gastrointestinal
Endoscopes

The ICP stated her expectation was for the staff to follow the Infection Control guidelines.

According to the "AORN Journal, May 2016, Vol. 103, No. 5, Back to Basics Flexible Endoscope Processing" stipulates, "Endoscopes should be stored in a manner which prevents them from contamination and protects them from damage ...If no drying cabinet is available, personnel should store the endoscopes in a closed cabinet with a High-Efficiency Particulate Arrestance (HEPA), filtered air that provides positive pressure and allows air circulation ...Flexible endoscopes should be stored with all valves opened and detached parts stored with the endoscope.

A review of the, "Olympus GI scope Instructions For Use," indicated, ..." Chapter 5 Storage and Disposal ...The storage cabinet must be clean, dry, well ventilated and maintained at ambient temperature."

2. During a tour of the Operating Room 2 (OR 2) on February 6, 2018 at 3:14 PM, an observation was made of scope accessories stored in the endoscopy (a procedure that involves inserting a long, flexible tube (endoscope) down the throat and into the esophagus) storage container. The endoscopy storage contained seven (7) water valve buttons, and three (3) suction valve buttons.

During a concurrent interview with the Operating Room Manager (ORM), he stated the scope accessories were stored separate from their perspective scopes. The ORM stated he was not aware the scope accessories were to be stored with their perspective scopes.

According to the "AORN Journal, May 2016, Vol. 103, No. 5, Back to Basics Flexible Endoscope Processing" stipulates, "Endoscopes should be stored in a manner which prevents them from contamination and protects them from damage ...If no drying cabinet is available, personnel should store the endoscopes in a closed cabinet with a High-Efficiency Particulate Arrestance (HEPA), filtered air that provides positive pressure and allows air circulation ...Flexible endoscopes should be stored with all valves opened and detached parts stored with the endoscope.


3. A review of the "Medivators processor (a machine used for cleaning and disinfecting reusable patient equipment) Product Re-order Guide," indicated, ..." Miscellaneous ...Lubricate O-rings at least once a week."

During an interview with the Operating Room Manager (ORM) on February 7, 2018 at 3:04 PM, he stated the O-rings are lubricated weekly but he does not document it.

During an interview with the Infection Control Preventionist (ICP), on February 8, 2018 at 3:19 PM, she stated that the hospital adopted and followed the Nationally Recognized Infection Control guidelines from:

a. AAMI-Association for the Advancement of Medical Instrumentation

b. AORN-Association of Perioperative Registered Nurses

c. CDC -Centers for Disease Control

d. SGNA-Standards of Infection Prevention in Reprocessing Flexible Gastrointestinal
Endoscopes

The ICP stated her expectation was for the staff to follow the Infection Control guidelines and manufacturer instructions for use.

4. During an interview with a Central Sterile Department Technician (CSDT 1) on February 7, 2018, she stated she only performs daily cleaning in the Central Sterile Department (CSD-the area in the facility where the cleaning and sterilization of surgical instruments was performed) and does not perform terminal cleaning (a cleaning method used in healthcare environments to control the spread of infections).

During an interview with the Lead Housekeeper (LH 1) on February 8, 2018 at 10:02 AM, she stated she was the assigned housekeeper to the CSD. The LH 1 stated she only completes terminal cleaning on Saturdays because the CSD is busy during the week [Monday through Friday].

During an interview with the Infection Control Preventionist (ICP), on February 8, 2018 at 3:19 PM, she stated, the facility has adopted and follows the nationally recognized Infection Control (IC) guidelines from AORN (Association of Perioperative Registered Nurses) and AAMI (Association for the Advancement of Medical Instrumentation). The ICP stated her expectation was for the staff to follow the Infection Control guidelines.

AORN, one of the nationally recognized infection control guidelines the hospital followed, defines terminal cleaning as "thorough environmental cleaning that is performed at the end of each day when the area is being used." Both AORN and AAMI (Association for the Advancement of Medical Instrumentation) ST79 recommend that sterile processing be terminally cleaned the same as the operating, delivery, and invasive procedure rooms. AAMI ST79 (Section 3.4) states that the best practice is to provide separate housekeeping facilities for the decontamination and clean areas to avoid transferring contaminates from "dirty to clean" areas.

AORN recommends that terminal cleaning and disinfection of the sterile processing areas "be performed daily when the areas are being used." Terminal cleaning should not be performed when personnel are actively de-contaminating instruments. Cleaning should progress from cleanest to dirtiest areas.

AORN recommends (Recommendation V) a schedule for cleaning the following:
"Clean and soiled storage areas, storage cabinets, sterile storage area, aerators on faucets should be cleaned and disinfected on a routine basis ..."

5. A review of the facility's Central Sterile Department (CSD) Decontamination (a workspace room used to process and clean soiled patient surgical equipment/instruments which could contain micro-organisms or hazardous materials, including gross substances, and infectious diseases) temperature and humidity log indicated the following:

January 1, 2018, Temperature 66, Humidity 16%

January 2, 2108, Temperature 64, Humidity 16%

January 3, 2018, Temperature 64, Humidity 16%

January 4, 2018, Temperature 63, Humidity 16%

January 5, 2018, Temperature 63, Humidity 16%

During an interview with the CSD Technician (CSDT 1) on February 6, 2018 at 2:50 PM, she confirmed the above temperature and humidity readings were out of range. The CDST 1 stated she did not know the process when the temperature and humidity readings are out of range.

During an interview with Maintenance Manager (MM) February 6, 2018, at 3:30 PM, he stated the temperature should be maintained within a range of 68 to 73 degrees Fahrenheit, and humidity should be be maintained within a range of 20% to 60%. The MM stated the process was to contact the Maintenance Department when the temperature and humidity readings are out of range.

6. Refer to finding # 5

7. During a tour of the Central Sterile Department (CSD) clean/packaging/work area on February 6, 2018 at 3:00 PM, an observation was made of a processed (previously sterilized and ready for patient surgical procedures) minor tray that contained a knife handle surgical instrument with brown staining.

During a concurrent interview with the Central Sterile Technician 1 (CSDT 1), she stated the surgical instrument should be removed and taken out of service.

During an interview with the Operating Room Manager on February 6, 2018 at 3:03 PM, he stated, "that looks like wear and tear." The ORM stated, "I guess they missed that one."

The facility's policy and procedure titled, "Inspection and Assembly of Instruments," dated, January 2012, indicated, " ...3. Visually inspect each instrument after decontamination for cleanliness, cracks, and worn or broken parts. Replace or have instruments repaired as necessary."

8. On February 6, 2018 at 4:10 PM, Registered Nurse 3 (RN 3) was observed sanitizing hands, putting on an isolation gown and gloves. RN 3 did not close the gown in the back, exposing her clothing. RN 3 then entered a contact isolation room. RN 3 was observed speaking to the patient and touching the bed rail and other items in the isolation room (the back of her clothing was still exposed), she then went into the patient's bathroom, then came out, and spoke to the patient again, took off PPE sanitized hands and left the room.

In an interview with RN 3 on February 6, 2018 at 4:20 PM, she stated, "I was just going in to give the patient an update. My usual practice would be to close the back of the gown."

A review of a hospital policy and procedure titled, "Precautions to Prevent Infection Transmission (Standard and Expanded)" With a revision date of February 2017, showed the following:

"Expanded Precautions (Airborne, Contact, Droplet)
These are special control measures done in addition to Standard precautions for patients with known or suspected contagious disease ...

Contact Precaution
...Wear gown if contact with patient or environment. Remove gloves, gown, and wash hands before leaving room. Avoid recontamination of hands or clothing."

9. A review of Patent 1's clinical record, the facesheet (demographics) indicated Patient 1 was admitted to the facility on February 1, 2018 for a placement of a Percutaneous Endoscopic Gastrostomy tube (PEG tube- a procedure in which a tube is passed into a patient's stomach through the abdominal wall to provide a means of feeding when oral intake is not adequate).

A review of Patient 1's, "History and Physical," dated February 2, 2018, indicated, "Assessment Generalized weakness, failure to thrive, severe dementia, dehydration, Urinary Tract Infection (UTI), Stage 3 (full thickness tissue loss) sacral (a wedge shape bone that is located at the base of the spine) decubitus ulcer (injury to the skin and underlying tissue resulting from prolonged pressure on the skin) ..."

A review of the Patient 1's, "Physical Assessment, " dated February 1, 2018, indicated the following:

Nutrition: Tube feeding, NPO (Nothing by Mouth)
Food/Fluid intake: NPO greater than 72 hours. Tube feeding.
Skin Condition: Stage 2-4 pressure ulcer; infected wounds.
What is the total score for nutritional screening: score 5-10 moderate risk. Refer to Dietitian.

During an interview with the Medical Surgical manager/Case manager (MSM) on February 7, 2018 at 9:19 AM, she reviewed the clinical record and was unable to find documentation of a dietary consult. The MSM stated a nutritional screening score greater than five (5) requires a dietary consult by the Registered Dietitian. The MSM stated it was her responsibility to notify the Registered Dietitian of new consults. The MSM stated, "I missed it."

The facility policy and procedure titled, "Assessment and Reassessment of Patients," dated July 2017, indicated, " ...C. Nutritional Services 1. Initial Assessment a. The purpose of the nutritional assessment is to evaluate the patient's nutritional status, develop a plan of nutritional care, and evaluate the efficacy of nutritional support. The need for a nutritional assessment is determined following a nutritional screening process completed by nursing during the initial patient assessment."

10. During a review of the Chief Nursing Officer/Registered Nurse (CNO/RN 1) employee file on February 8, 2018 at 9:10 AM, with the Human Resources manager (HRM), she reviewed the employee file and was unable to find documented evidence of current annual evaluations for the Emergency Department (ED) and the Operating Room (OR).

During a concurrent interview with the HRM, she stated the last ED annual evaluation was completed on June 10, 2013 and the last OR annual evaluation was completed on March 10, 2015.

During an interview with the CNO/RN 1 on February 8, 2018 at 9:28 AM, she stated she picks up GI (GI- referring collectively to the stomach and small and large intestines) OR shifts and covers one (1) shift per month in the ED. The CNO/ RN1 stated she has not completed ED or OR annual evaluations. The CNO/RN 1 stated she should have annual OR and ED evaluations completed.

The facility's policy and procedure titled, "(name of facility) Human Resources Performance Evaluations," dated February 2017, indicated, "To establish a method to periodically assess and document the job performance of employees and to ensure that they are competent to perform the require job duties and responsibilities ... B. Frequency of Evaluations: A written performance evaluation of competency assessment should be conducted to determine the initial competence of a new employee or an employee who has been promoted, demoted or transferring during the orientation period and on a periodic basis thereafter (usually annually)."

11. A review of the facility's "Crash Cart Check," dated February 2018, indicated the following:

February 1, 2018- no signature indiacting the crash cart was checked.

During an interview with the Operating Room Manager (ORM) on February 6, 2018 at 2:02 PM, he stated the pediatric crash cart (a wheeled container carrying medicine and equipment for use in emergency resuscitation) should be checked and signed by the nurse who verifies the crash cart contains the required items and is working properly. The ORM stated the nurse checked the pediatric crash cart but did not sign the log.

12. During a tour of the ER on February 6, 2018 at 12:37 PM, 2 crash carts were observed in the ER. 1 was equipped for adult patients and the other was for adult patients.

During a review of the crash cart logs, there was a missing signature on the pediatric crash cart log and the adult crash cart log for February 5, 2018 indicating the carts were not checked on that day. There was a missing signature on the adult crash cart for January 28, 2017, indicating it was not checked on that day.

In an interview with Registered Nurse 4 (RN 3) on February 6, 2018 at 1:00 PM, she stated she was the Nurse who checked the crash carts in the ER. She stated she was on duty on February 5, 2018, and stated she got busy and did not check the crash carts on February 5, 2018. She confirmed the logs showed the carts were not checked on January 28, 2017 or February 5, 2018 and should have been checked.

13. During a review of physician credential files on February 8, 2018, it was noted there was no documentation of abuse training for the physicians.

In an interview on February 8, 2018 at 8:30 AM, with the Medical Staff Coordinator/Health Information Management Director (MSC), she stated abuse training for the physicians was not required.

A review of a hospital policy and procedure titled "Abuse Adult (Abuse of Elders and Dependent Adults)," with a revision date of July 2017, showed the following:

"Responsibility:

Physicians, Licensed Healthcare Workers, Clinical Social Workers, Healthcare Administration ...

Employees Acknowledgement of Reporting Requirements-

(Name of Hospital) is required to provide forms on which persons hired for positions in health care acknowledge that they are aware of the elder and dependent abuse reporting requirements and will comply with them. The employer must retain these signed statements. These signed statements shall be retained as long as the employee remains employed.

Employer Obligation to Train Employees:

(Name of Hospital) shall provide all employees, at the time of orientation/reorientation a written copy of the elder and dependent adult abuse reporting requirements."

A review of a hospital policy and procedure titled, "Abuse/Neglect-Child," with a revision date of July 2017, showed the following:

"Responsibility:

Physicians, Licensed Healthcare Workers, Clinical Social Workers, Healthcare Administration ...

Employees Acknowledgement of Reporting Requirements:

(Name of Hospital) is required to provide forms on which persons hired for positions in health care acknowledge that they are aware of the child abuse and neglect reporting requirements and will comply with them. The employer must retain these signed statements. These signed statements shall be retained as long as the employee remains employed."

14. During a record review of Patient 20's medical record, it showed Patient 20 was admitted to the hospital on December 11, 2017 with diagnoses that included cholelithiasis (gall bladder stones) and cholecystitis (inflammation of the gall bladder) requiring surgery to remove the gall bladder. The patient was discharged from the hospital on December 15, 2017.

Further review of Patient 20's medical record showed there was no discharge summary written by the physician in the medical record.

In an interview with the Medical Staff Coordinator/Medical Records Director (MCS) on February 8, 2018 at 1:30 PM, she stated the patient's medical record should have one (a discharge summary).

During a review of the medical staff rules and regulations, approved by the board of directors on November 27, 2017, the following was noted:

"2.14 Completion of Medical Records
The patient's medical record shall be complete at the time of discharge, including progress notes and final diagnosis. The electronic or dictated discharge summary shall be completed within seven (7) days of discharge. When final laboratory or other essential reports are not received at the time of discharge, a notation shall be entered or dictated that this information is pending."

15. During the tour of the Emergency Department (ED) on February 6, 2018 at 1:37 PM, it was observed that two (2) ED restrooms did not have a pull cord or a manner to call or contact ED staff in an emergency.

During a concurrent interview with the Chief Nursing Officer (CNO), she stated there was no means for emergency room patients to summons for help in the ED waiting restrooms in a case of an emergency.

16. During an observation tour of the ER on February 6, 2018 at 12:40 PM, there were 4 electronic thermometers mounted holders on the wall. Further observation showed there was no preventive maintenance sticker with a date the thermometer was checked to ensure proper and safe functioning of the thermometer.

In an interview with the Maintenance Manager (MM) on February 6, 2018 at 1:10 PM, he stated, he did not have a log for the individual equipment but he checked them when I check the area. He stated "I don't have proof that the thermometer was checked."

17. During the tour of the Pre Anesthesia Care (Pre-op) Unit on February 6, 2018 at 1:54 PM, an observation was made of a thermometer with no Preventative Maintenance (PM-routine maintenance to help keep equipment up and running) sticker.

During an interview with the Maintenance Manager (MM) on February 7, 2018 at 2:19 PM, he stated preventative maintenance was not done for the Pre-op thermometer and it was overdue.

A review of the facility's policy and procedure titled, "Preventative Maintenance, undated, indicated, "Every six months, during the room PM, Each thermometer will be visually inspected for any physical damage. Each thermometer and probe will be cleaned with a 70 % isopropyl alcohol solution. A power-on self test will be performed."

18. During a review of the Pharmacist (Pharm) employee file on February 7, 2018 at 4:00 PM, with the Human Resources manager (HRM), she reviewed the employee file and was unable to find documented evidence of a background check.

During a concurrent interview with the HRM, she stated the Pharm background check was completed in 2013 but is not in the employee file. The HRM stated the background check should be in the employee file.

A review of the facility's policy and procedure, titled "(name of facility) Human Resources Background Checks," dated May 2013, indicated ... General Scope: I. Guidelines A. Careful selection of Candidates is essential to the Company's success. The company consistently strives to select and hire the most qualified candidates. All post-offer, pre-hire candidates shall undergo a thorough background check by an independent investigation company prior to beginning work. All background checks will be conducted in accordance with applicable Federal, State and local laws using criteria established herein.

The facility failed to ensure the Condition of Participation: CFR 485.635 Provision of Services was met by failing to ensure:

1. Three (3) GI scopes were stored in accordance with infection control (IC) standards and in a manner to prevent cross contamination. (Refer to C-0278)

2. The GI scope accessories were stored with their perspective scopes. (Refer to C-0278)

3. There was documented evidence the Medivators (a reprocessor machine- used to high level disinfect (a
method for cleaning and disinfecting reusable patient equipment) was routinely maintained according
to manufacture instructions for use (IFU). The reprocessor was used to high level disinfect reusable scopes. (Refer to C-0278)

4. Terminal cleaning (a cleaning method used in healthcare environments to control the spread of infections) was performed in the Central Sterile Department (CSD-the area in the facility where the cleaning and sterilizization of surgical intruments was performed). (Refer to C-0278)

5. Temperatures and humidity in the Central Sterile Department were within range. (Refer to C-0278)

6. The CSD Technician (CSDT 1) was able to verbalize the process for out of range temperatures and humidity. (Refer to C-0278)

9. A processed (previously sterilized and ready for patient surgical procedures) minor tray did not contain a surgical intrument with brown staining. (Refer to C-0278)

10. A Registered Nurse (RN 3) properly donned the PPE gown when entering a contact isolation room. (Refer to C-0278)

11. Patient 2 received a timely dietary evaluation. (Refer to C-0294)

12. Operating Room (OR) and Emergency Department (ED) annual evaluations were completed for the Registered Nurse/Chief Operating Nurse (RN 1/CNO). (Refer to C-0294)

13. The Malignant Hyperthermia (MH-a potentially life-threatening emergency caused by a reaction to anesthesia drugs used during surgery and must be treated immediately) emergency cart contained chilled normal saline (NS-a salt solution the same concentration as the body's fluid) for intravenous (IV-into the vein) injection. (Refer to C-0271)

14. The physicians on staff did not have abuse training as required by the hospital abuse policies and procedures. This failure had the potential for abuse to be unrecognized. (Refer to C-0271)

The cumulative effect of these systemic practices resulted in the failure of the facility to deliver care in compliance with the Condition of Participation: Provision of Services.

Based on observation, interview and record review, the hospital failed to ensure their policy and procedure were implemented as follows:

1. For Malignant Hyperthermia (MH-a potentially life-threatening emergency caused by a reaction to anesthesia drugs used during surgery and must be treated immediately) the Malignant Hyperthermia emergency cart did not contain chilled normal saline (NS-a salt solution the same concentration as the body's fluid) for intravenous (IV-into the vein) injection. This failure had the potential to affect the health and safety of patients undergoing surgery with general anesthesia.

2. The physicians on staff did not have abuse training as required by the hospital abuse policies and procedures. This failure had the potential for abuse to be unrecognized.

Findings:

1. During an observation tour of the operating room (OR) area on February 6, 2018 at 3:10 PM, it was observed there was no IV NS in the Malignant Hyperthermia emergency cart. A list of cart contents showed the IV NS was kept with the OR IV stock (not chilled).

In an interview with the hospital pharmacist regarding the Malignant Hyperthermia emergency cart and IV NS on February 7,2018 at 1:30 PM, he stated he was aware the IV NS should be chilled. He stated he could chill it down with ice if needed. (Chilled NS needs to be immediately available for the life-threatening emergency.)

During a review of a hospital policy and procedure titled, "Malignant Hyperthermia" with a review date of February 11, 2017, showed the following:

"II Acute Phase Treatment

a. Immediately discontinue all volatile anesthetics and succinylcholine (an injectable anesthetic) ...

b. Halt procedure ASAP (as soon as possible), if emergent, continue with non-triggering anesthetic technology.

c. Administer Dantrolene Sodium 25 mg/kg (milligrams per kilogram) initial bolus (IV dose) rapidly with increments up to 10 mg/kg
total. Continue to administer Dantrolene until signs of MH [e.g. tachycardia (rapid heart rate), rigidity (stiffened muscles), increased end tidal CO2 (exhaled carbon dioxide), and temperature elevation] are controlled ...

d. Administer bicarbonate (NaCO3) to correct metabolic acidosis as guided by blood gas analysis (test on arterial blood to show concentrations of oxygen and carbon dioxide dissolved in the blood) ...

e. Simultaneous with the above, actively cool the hyperthermic (high temperature) patient. Use IV cold saline (not Ringer's Lactate)...

2. During a review of physician credential files on February 8, 2018, it was noted there was no documentation of abuse training for the physicians.

In an interview on February 8, 2018 at 8:30 AM, with the Medical Staff Coordinator/Health Information Management Director (MSC), she stated abuse training for the physicians was not required.

A review of a hospital policy and procedure titled "Abuse Adult (Abuse of Elders and Dependent Adults)," with a revision date of July 2017, showed the following:

"Responsibility:

Physicians, Licensed Healthcare Workers, Clinical Social Workers, Healthcare Administration ...

Employees Acknowledgement of Reporting Requirements-

(Name of Hospital) is required to provide forms on which persons hired for positions in health care acknowledge that they are aware of the elder and dependent abuse reporting requirements and will comply with them. The employer must retain these signed statements. These signed statements shall be retained as long as the employee remains employed.

Employer Obligation to Train Employees:

(Name of Hospital) shall provide all employees, at the time of orientation/reorientation a written copy of the elder and dependent adult abuse reporting requirements."

A review of a hospital policy and procedure titled, "Abuse/Neglect-Child," with a revision date of July 2017, showed the following:

"Responsibility:

Physicians, Licensed Healthcare Workers, Clinical Social Workers, Healthcare Administration ...

Employees Acknowledgement of Reporting Requirements:

(Name of Hospital) is required to provide forms on which persons hired for positions in health care acknowledge that they are aware of the child abuse and neglect reporting requirements and will comply with them. The employer must retain these signed statements. These signed statements shall be retained as long as the employee remains employed."

Based on observation, interviews, and record reviews, the hospital failed to ensure they had a system in place for evaluating and implementing a hospital wide infection control prevention program and failed to ensure their hospital infection control program had a system in place for the surveillance, prevention, and control of infections in a universe of 6 patients, as evidence by:

1. Three (3) GI scopes were stored in accordance with infection control (IC) standards and in a manner to prevent cross contamination. (Refer to finding 1)

2. The GI scope accessories were not stored with their perspective scopes. (Refer to finding 1).

3. There was no documented evidence the Medivators (a reprocessor machine- used to high level disinfect (a method for cleaning and disinfecting reusable patient equipment) was routinely maintained according
to manufacture instructions for use (IFU). The reprocessor was used to high level disinfect reusable scopes.

4. Terminal cleaning (a cleaning method used in healthcare environments to control the spread of infections) was not being performed in the Central Sterile Department (CSD-the area in the facility where the cleaning and sterilizization of surgical intruments was performed).

5. Temperatures and humidity in the Central Sterile Department were out of range.

6. The CSD Technician (CSDT 1) did not know the process for out of range temperatures.

7. A processed (previously sterilized and ready for patient surgical procedures) minor tray contained a surgical intrument with brown staining.

8. A Registered Nurse (RN 3) did not properly don the PPE gown when entering a contact isolation room.

Findings:


1. During a tour of the Central Sterile Department (CSD) clean/packaging/work area, an observation was made of three (3) Gastrointestinal (GI-referring collectively to the stomach and the small and large intestine) scopes hanging vertically in a blue cabinet with glass doors.

During an interview with the Operating Room Manager (ORM) on February 6, 2018 at 2:55 PM, he stated he was not sure if the cabinet storing the three (3) GI scopes was a HEPA filtered cabinet. The ORM stated he was not sure if the cabinet storing the scopes was an air-drying scope storing cabinet.

During an interview with the Infection Control Preventionist (ICP), on February 8, 2018 at 3:19 PM, she stated that the hospital adopted and followed the Nationally Recognized Infection Control guidelines from:

a. AAMI-Association for the Advancement of Medical Instrumentation

b. AORN-Association of Perioperative Registered Nurses

c. CDC-Centers for Disease Control

d. SGNA-Standards of Infection Prevention in Reprocessing Flexible Gastrointestinal
Endoscopes

The ICP stated her expectation was for the staff to follow the Infection Control guidelines.

According to the "AORN Journal, May 2016, Vol. 103, No. 5, Back to Basics Flexible Endoscope Processing" stipulates, "Endoscopes should be stored in a manner which prevents them from contamination and protects them from damage ...If no drying cabinet is available, personnel should store the endoscopes in a closed cabinet with a High-Efficiency Particulate Arrestance (HEPA), filtered air that provides positive pressure and allows air circulation ...Flexible endoscopes should be stored with all valves opened and detached parts stored with the endoscope.

A review of the, "Olympus GI scope Instructions For Use," indicated, ..." Chapter 5 Storage and Disposal ...The storage cabinet must be clean, dry, well ventilated and maintained at ambient temperature."

2. During a tour of the Operating Room 2 (OR 2), an observation was made of scope accessories stored in the endoscopy (a procedure that involves inserting a long, flexible tube (endoscope) down the throat and into the esophagus) storage container. The endoscopy storage contained seven (7) water valve buttons, and three (3) suction valve buttons.

During an interview with the Operating Room Manager (ORM) on February 6, 2018 at 2:55 PM, he stated the scope accessories were stored separate from their perspective scopes. The ORM stated he was not aware the scope accessories were to be stored with their perspective scopes.

According to the "AORN Journal, May 2016, Vol. 103, No. 5, Back to Basics Flexible Endoscope Processing" stipulates, "Endoscopes should be stored in a manner which prevents them from contamination and protects them from damage ...If no drying cabinet is available, personnel should store the endoscopes in a closed cabinet with a High-Efficiency Particulate Arrestance (HEPA), filtered air that provides positive pressure and allows air circulation ...Flexible endoscopes should be stored with all valves opened and detached parts stored with the endoscope.

3. A review of the "Medivators processor (a machine used for cleaning and disinfecting reusable patient equipment) Product Re-order Guide," indicated, ..." Miscellaneous ...Lubricate O-rings at least once a week."

During an interview with the Operating Room Manager (ORM) on February 7, 2018 at 3:04 PM, he stated the O-rings are lubricated weekly but he does not document it.

During an interview with the Infection Control Preventionist (ICP), on February 8, 2018 at 3:19 PM, she stated that the hospital adopted and followed the Nationally Recognized Infection Control guidelines from:

a. AAMI -Association for the Advancement of Medical Instrumentation

b. AORN-Association of Perioperative Registered Nurses

c. CDC-Centers for Disease Control

d. SGNA-Standards of Infection Prevention in Reprocessing Flexible Gastrointestinal
Endoscopes

The ICP stated her expectation was for the staff to follow the Infection Control guidelines and manufacturer instructions for use.

4. During an interview with a Central Sterile Department Technician (CSDT 1) on February 7, 2018, she stated she only performs daily cleaning in the Central Sterile Department (CSD-the area in the facility where the cleaning and sterilization of surgical instruments was performed) and does not perform terminal cleaning (a cleaning method used in healthcare environments to control the spread of infections).

During an interview with the Lead Housekeeper (LH 1) on February 8, 2018 at 10:02 AM, she stated she was the assigned housekeeper to the CSD. The LH 1 stated she only completes terminal cleaning on Saturdays because the CSD is busy during the week [Monday through Friday].

During an interview with the Infection Control Preventionist (ICP), on February 8, 2018 at 3:19 PM, she stated, the facility has adopted and follows the nationally recognized Infection Control (IC) guidelines from AORN (Association of Perioperative Registered Nurses) and AAMI (Association for the Advancement of Medical Instrumentation). The ICP stated her expectation was for the staff to follow the Infection Control guidelines.

AORN, one of the nationally recognized infection control guidelines the hospital followed, defines terminal cleaning as "thorough environmental cleaning that is performed at the end of each day when the area is being used." Both AORN and AAMI (Association for the Advancement of Medical Instrumentation) ST79 recommend that sterile processing be terminally cleaned the same as the operating, delivery, and invasive procedure rooms. AAMI ST79 (Section 3.4) states that the best practice is to provide separate housekeeping facilities for the decontamination and clean areas to avoid transferring contaminates from "dirty to clean" areas.

AORN recommends that terminal cleaning and disinfection of the sterile processing areas "be performed daily when the areas are being used." Terminal cleaning should not be performed when personnel are actively de-contaminating instruments. Cleaning should progress from cleanest to dirtiest areas.

AORN recommends (Recommendation V) a schedule for cleaning the following:
"Clean and soiled storage areas, storage cabinets, sterile storage area, aerators on faucets should be cleaned and disinfected on a routine basis ..."

5. A review of the facility's Central Sterile Department (CSD) Decontamination (a workspace room used to process and clean soiled patient surgical equipment/instruments which could contain micro-organisms or hazardous materials, including gross substances, and infectious diseases) temperature and humidity log indicated the following:

January 1, 2018, Temperature 66, Humidity 16%

January 2, 2108, Temperature 64, Humidity 16%

January 3, 2018, Temperature 64, Humidity 16%

January 4, 2018, Temperature 63, Humidity 16%

January 5, 2018, Temperature 63, Humidity 16%

During an interview with the CSD Technician (CSDT 1) on February 6, 2018 at 2:50 PM, she confirmed the above temperature and humidity readings were out of range. The CDST 1 stated she did not know the process when the temperature and humidity readings are out of range.

During an interview with Maintenance Manager (MM) February 6, 2018, at 3:30 PM, he stated the temperature should be maintained within a range of 68 to 73 degrees Fahrenheit, and humidity should be be maintained within a range of 20% to 60%. The MM stated the process was to contact the Maintenance Department when the temperature and humidity readings are out of range.

6. Refer to finding # 5

7. During a tour of the Central Sterile Department (CSD) clean/packaging/work area, an observation was made of a processed (previously sterilized and ready for patient surgical procedures) minor tray that contained a knife handle surgical instrument with brown staining.

During an interview with the Central Sterile Technician (CSDT) on February 6, 2018 at 3:00 PM, she stated the surgical instrument should be removed and taken out of service.

During an interview with the Operating Room Manager on February 6, 2018 at 3:03 PM, he stated, "that looks like wear and tear." The ORM stated, "I guess they missed that one."

The facility's policy and procedure titled, "Inspection and Assembly of Instruments," dated, January 2012, indicated, " ...3. Visually inspect each instrument after decontamination for cleanliness, cracks, and worn or broken parts. Replace or have instruments repaired as necessary."




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8. On February 6, 2018 at 4:10 PM, Registered Nurse 3 (RN 3) was observed sanitizing hands, putting on an isolation gown and gloves. RN 3 did not close the gown in the back, exposing her clothing. RN 3 then entered a contact isolation room. RN 3 was observed speaking to the patient and touching the bed rail and other items in the isolation room (the back of her clothing was still exposed), she then went into the patient's bathroom, then came out, and spoke to the patient again, took off PPE sanitized hands and left the room.

In an interview with RN 3 on February 6, 2018 at 4:20 PM, she stated, "I was just going in to give the patient an update. My usual practice would be to close the back of the gown."

A review of a hospital policy and procedure titled, "Precautions to Prevent Infection Transmission (Standard and Expanded)" With a revision date of February 2017, showed the following:

"Expanded Precautions (Airborne, Contact, Droplet)
These are special control measures done in addition to Standard precautions for patients with known or suspected contagious disease ...

Contact Precaution
...Wear gown if contact with patient or environment. Remove gloves, gown, and wash hands before leaving room. Avoid recontamination of hands or clothing."

Based on interview, and record review, the facility failed to ensure the following:

1. Patient 2 received a timely dietary evaluation.

2. Operating Room (OR) and Emergency Department (ED) annual evaluations were completed for the Registered Nurse/Chief Operating Nurse (RN 1/CNO).

These failures had the potential to negatively affect patient care.

Findings:

1. A review of Patent 1's clinical record, the facesheet (demographics) indicated Patient 1 was admitted to the facility on February 1, 2018 for a placement of a Percutaneous Endoscopic Gastrostomy tube (PEG tube- a procedure in which a tube is passed into a patient's stomach through the abdominal wall to provide a means of feeding when oral intake is not adequate).

A review of Patient 1's, "History and Physical," dated February 2, 2018, indicated, "Assessment Generalized weakness, failure to thrive, severe dementia, dehydration, Urinary Tract Infection (UTI), Stage 3 (full thickness tissue loss) sacral (a wedge shape bone that is located at the base of the spine) decubitus ulcer (injury to the skin and underlying tissue resulting from prolonged pressure on the skin) ..."

A review of the Patient 1's, "Physical Assessment, " dated February 1, 2018, indicated the following:

Nutrition: Tube feeding, NPO (Nothing by Mouth)
Food/Fluid intake: NPO greater than 72 hours. Tube feeding.
Skin Condition: Stage 2-4 pressure ulcer; infected wounds.
What is the total score for nutritional screening: score 5-10 moderate risk. Refer to Dietitian.

During an interview with the Medical Surgical manager/Case manager (MSM) on February 7, 2018 at 9:19 AM, she reviewed the clinical record and was unable to find documentation of a dietary consult. The MSM stated a nutritional screening score greater than five (5) requires a dietary consult by the Registered Dietitian. The MSM stated it was her responsibility to notify the Registered Dietitian of new consults. The MSM stated, "I missed it."

The facility policy and procedure titled, "Assessment and Reassessment of Patients," dated July 2017, indicated, " ...C. Nutritional Services 1. Initial Assessment a. The purpose of the nutritional assessment is to evaluate the patient's nutritional status, develop a plan of nutritional care, and evaluate the efficacy of nutritional support. The need for a nutritional assessment is determined following a nutritional screening process completed by nursing during the initial patient assessment."

2. During a review of the Chief Nursing Officer/Registered Nurse (CNO/RN 1) employee file on February 8, 2018 at 9:10 AM, with the Human Resources manager (HRM), she reviewed the employee file and was unable to find documented evidence of current annual evaluations for the Emergency Department (ED) and the Operating Room (OR).

During a concurrent interview with the HRM, she stated the last ED annual evaluation was completed on June 10, 2013 and the last OR annual evaluation was completed on March 10, 2015.

During an interview with the CNO/RN 1 on February 8, 2018 at 9:28 AM, she stated she picks up the GI (GI- referring collectively to the stomach and small and large intestines) OR procedures and covers one (1) shift per month in the ED. The CNO/ RN1 stated she has not completed ED or OR annual evaluations. The CNO/RN 1 stated she should have annual OR and ED evaluations completed.

The facility's policy and procedure titled, "(name of facility) Human Resources Performance Evaluations," dated February 2017, indicated, "To establish a method to periodically assess and document the job performance of employees and to ensure that they are competent to perform the require job duties and responsibilities ... B. Frequency of Evaluations: A written performance evaluation of competency assessment should be conducted to determine the initial competence of a new employee or an employee who has been promoted, demoted or transferring during the orientation period and on a periodic basis thereafter (usually annually)."

Based on observation, interview and record review the hospital failed to ensure medications were administered to 1 of 20 sampled patients (Patient 11) in accordance with physician orders. This failure had the potential to adversely affect Patient 11's health.

Findings:

During a medication pass observation on February 7, 2018 at 8:40 AM, Registered Nurse 2 (RN 2) gave Patient 11 the following medications:

Rocephin (antibiotic) 1 Gm (gram) IVPB (intravenous piggyback-administered slowly into a vein)

Potassium chloride (an electrolyte) 10 meq (millequivalents) po (by mouth)

levothyroxine (thyroid replacement medicine) 50 mcg. (microgram) po

Magnesium Oxide (an electrolyte)) 400 mg (milligrams) po

metoprolol tartrate (medication to lower blood pressure) 25 mg po

amiodarone (medication to control fast irregular heartbeats) 200 mg. po

During a review of the physician orders dated February 5, 2018, the following physician orders were noted in addition to the medication listed above:

NF (non-formulary-not on the hospital's list of medications that they carry) Eliquis (a blood thinner) 5 mg po daily

NF Midodrine HCl (a medication to raise blood pressure for persons who have low blood pressure when standing up) 5 mg po TID (three times a day)

In an interview with RN 2 on February 7, 2018 at 9:15 AM, she stated she called the doctor today (after surveyor questioned why meds were not given) and got an order to discontinue the Midodrine and called Patient 11's family to bring in the Eliquis, she stated the family agreed to bring it in today. She was unable to explain why the medications were not clarified with the physician directly after they were ordered.

In an interview with the Chief Nursing Officer (CNO) February 8, 2018 at 9:40 AM, regarding non-formulary medications and nursing responsibility, she stated the nurse is supposed to call the doctor and inform him the ordered medication is non-formulary and see if he can order a similar medication. She acknowledged RN 2 made a medication error.

In an interview with the hospital pharmacist on February 8, 2018 at 10:00 AM, he stated the nurses would see the orders and they would ask me if the medication is available. He stated he does look at the orders and he missed the orders for Midodrine and Eliquis.

During a review of a hospital policy titled, "Non-Formulary Drugs (Prescribing-Ordering-Procuring)" with a review date of February 2017, showed the following:

"REVIEW BY A PHARMACIST
A pharmacist shall review all requests for non-formulary drugs ...

ORDERS FOR NON-FORMULARY DRUGS
If a prescriber orders drugs that are not listed in the formulary, the pharmacy shall review formulary alternatives with the prescriber. If an alternative drug is not acceptable, the pharmacy shall obtain the non-formulary drug from another hospital, community pharmacy, or other approved source."

Based on interview and record review, the hospital failed to ensure for 1 of 20 sampled patients (Patient 20), that a discharge summary that contained a brief summary of hospitalization, the location the patient went when discharged and instructions to the patient. This failure had the potential to affect the health and safety of Patient 20.

Findings:

During a record review of Patient 20's medical record, it showed Patient 20 was admitted to the hospital on December 11, 2017 with diagnoses that included cholelithiasis (gall bladder stones) and cholecystitis (inflammation of the gall bladder) requiring surgery to remove the gall bladder. The patient was discharged from the hospital on December 15, 2017.

Further review of Patient 20's medical record showed there was no discharge summary written by the physician in the medical record.

In an interview with the Medical Staff Coordinator/Medical Records Director (MCS) on February 8, 2018 at 1:30 PM, she stated the patient's medical record should have one (a discharge summary).

During a review of the medical staff rules and regulations, approved by the board of directors on November 27, 2017, the following was noted:

"2.14 Completion of Medical Records
The patient's medical record shall be complete at the time of discharge, including progress notes and final diagnosis. The electronic or dictated discharge summary shall be completed within seven (7) days of discharge. When final laboratory or other essential reports are not received at the time of discharge, a notation shall be entered or dictated that this information is pending."

The facility failed to ensure the Condition of Participation: CFR 485.641 Periodic Evaluation and QA review was met by failing to ensure:

1. Three (3) GI scopes were stored in accordance with infection control (IC) standards and in a manner to prevent cross contamination. (Refer to C-0278)

2. The GI scope accessories were stored with their perspective scopes. (Refer to C-0278)

3. There was documented evidence the Medivators (a reprocessor machine- used to high level disinfect (a method for cleaning and disinfecting reusable patient equipment) was routinely maintained according to manufacture instructions for use (IFU). The reprocessor was used to high level disinfect reusable scopes. (Refer to C-0278)

4. Terminal cleaning (a cleaning method used in healthcare environments to control the spread of infections) was performed in the Central Sterile Department (CSD-the area in the facility where the cleaning and sterilizization of surgical intruments was performed). (Refer to C-0278)

5. Temperatures and humidity were within range in the Central Sterile Department. (Refer to C-0278)

6. The CSD Technician (CSDT 1) was able to verbalize the process for out of range temperatures and humidity. (Refer to C-0278)

7. A processed (previously sterilized and ready for patient surgical procedures) minor tray did not contain a surgical intrument with brown staining. (Refer to C-0278)

8. A Registered Nurse (RN 3) properly donned the PPE gown when entering a contact isolation room. (Refer to C-0278)

9. Patient 2 received a timely dietary evaluation. (Refer to C-0294)

10. Operating Room (OR) and Emergency Department (ED) annual evaluations were completed for the Registered Nurse/Chief Operating Nurse (RN 1/CNO). (Refer to C-0294)

11. The OR pediatric crash cart (a wheeled container carrying medicine and equipment for use in emergency resuscitations) was checked by the nursing staff. (Refer to C-0294)

12. The Emergency Department (ED) adult and pediatric crash carts were checked by the nursing staff. (Refer to C-0202)

13. There was annual abuse training for five (5) of five (5) physicians. (Refer to C-0271)

14. Patient 20 had a discharge summary completed withiun 7 days of discharge. (Refer to C-0241)

17. There was an emergency pull cord in the Emergency Department patient restrooms. (Refer to C-0241)

18. One of four thermometers in the Emergency Department had evidence of Preventative Maintenace (PM- routine maintenance to help keep equipment up and running). (Refer to C-0241)

19. Preventative Maintenance was completed for one thermometer in the Pre-Operative Unit (Preop- the time before surgery). (Refer to C-0241)

20. There was documented evidence the Pharmacist (Pharm) completed a background check. (Refer to C-0241)

21. The Malignant Hyperthermia (MH-a potentially life-threatening emergency caused by a reaction to anesthesia drugs used during surgery and must be treated immediately) emergency cart did contained chilled normal saline (NS-a salt solution the same concentration as the body's fluid) for intravenous (IV-into the vein) injection. (Refer to C-0271)

22. The Quality Assurance Committee identified the 20 deficient practices identified by the survey team. (Refer to C-0336)

The cumulative effect of these systemic practices resulted in the failure of the facility to deliver care in compliance with the Condition of Participation: Periodic Evaluation and QA Review.

Based on interview and record review, the hospital failed to ensure their quality assurance program was effective to identify deficient practices throughout the hospital as follows:

1. Three (3) GI scopes were not stored in accordance with infection control (IC) standards and in a manner to prevent cross contamination. (Refer to C-0278)

2. The GI scope accessories were not stored with their perspective scopes. (Refer to C-0278)

3. There was no documented evidence the Medivators (a reprocessor machine- used to high level disinfect (a method for cleaning and disinfecting reusable patient equipment) was routinely maintained according to manufacture instructions for use (IFU). The reprocessor was used to high level disinfect reusable scopes. (Refer to C-0278)

4. Terminal cleaning (a cleaning method used in healthcare environments to control the spread of infections) was not performed in the Central Sterile Department (CSD-the area in the facility where the cleaning and sterilizization of surgical intruments was performed). (Refer to C-0278)

5. Temperatures and humidity were not within range in the Central Sterile Department. (Refer to C-0278)

6. The CSD Technician (CSDT 1) was not able to verbalize the process for out of range temperatures and humidity. (Refer to C-0278)

7. A processed (previously sterilized and ready for patient surgical procedures) minor tray contained a surgical intrument with brown staining. (Refer to C-0278)

8. A Registered Nurse (RN 3) did not properly don the PPE gown when entering a contact isolation room. (Refer to C-0278)

9. Patient 2 did not receive a timely dietary evaluation. (Refer to C-0294)

10. Operating Room (OR) and Emergency Department (ED) annual evaluations were not completed for the Registered Nurse/Chief Operating Nurse (RN 1/CNO). (Refer to C-0294)

11. The OR pediatric crash cart (a wheeled container carrying medicine and equipment for use in emergency resuscitations) was not checked by the nursing staff. (Refer to C-0294)

12. The Emergency Department (ED) adult and pediatric crash carts were not checked by the nursing staff. (Refer to C-0202)

13. There was no annual abuse training for five (5) of five (5) physicians. (Refer to C-0271)

14. Patient 20 did not have a discharge summary completed withiun 7 days of discharge. (Refer to C-0241)

17. There was no emergency pull cord in the Emergency Department patient restrooms. (Refer to C-0241)

18. One of four thermometers in the Emergency Department did not have evidence of Preventative Maintenace (PM- routine maintenance to help keep equipment up and running). (Refer to C-0241)

19. Preventative Maintenance was not completed for one thermometer in the Pre-Operative Unit (Preop- the time before surgery). (Refer to C-0241)

20. There was no documented evidence the Pharmacist (Pharm) had a completed a background check. (Refer to C-0241)

21. The Malignant Hyperthermia (MH-a potentially life-threatening emergency caused by a reaction to anesthesia drugs used during surgery and must be treated immediately) emergency cart did not contain chilled normal saline (NS-a salt solution the same concentration as the body's fluid) for intravenous (IV-into the vein) injection. (Refer to C-0271)

The failure of the Quality Assurance Committee to identify the deficient practices had the potential to affect the health and safety of all patients admitted to the hospital.

Findings:

During a review of the quarterly Quality Asssurance Committee meeting minutes, there was no documented evidence the committee identified the 20 deficient practices noted above.

In an interview on February 8, 2018 at 3:10 PM, with Quality Assurance committee members, the Chief Nursing Officer stated that the committee did not identify the issues identified by the surveyors. She stated the expectation is for staff to follow infectiion control standards, policy and procedures, manufacturer's recommendations and facility processes.