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A. Based on document review and interview, it was determined that for 1 of 4 patients' (Pt #1) clinical records reviewed for nursing assessment, the Hospital failed to conduct a skin assessment, as required, to ensure a registered nurse supervised and evaluated the care of patients.

Findings include:

1. On 1/6/2022, Pt. #1's clinical record was reviewed. Pt. #1 was admitted to the Hospital on 11/24/2021 due to urinary tract infection. The clinical record included:

- E #5's (Wound Care Nurse) progress note dated 11/26/2021 included, "This wound (back/sacral area) is present on admission ... pain present only when performing wound care ... Skin assessment shows (stage 2) (Stages of ulceration: 1 skin redness, 2 skin damage, may have open sore, scrape or blister, 3 an area with crater-like appearance due to skin damage, and 4 area is severely damage and large wound is present), pressure injury to sacrum..."

- The nursing progress notes from 12/10/2021 through 12/14 2021 were reviewed. The nursing notes dated 12/10/2021 (night shift, 7:00 PM through 7:00 AM), 12/12/2021 (day shift, 7:00 AM through 7:00 PM), 12/12/2021 (night shift), and 12/13/2021 (day shift) lacked skin assessments regarding Pt. #1's pressure sore.

- The infectious disease physician's progress note dated 12/13/2021 indicated that Pt. #1 had cellulitis on her right lower extremity (skin infection). However, E #5's documentation on 12/14/2021 lacked an assessment of Pt. #1's right lower extremity cellulitis.

2.. On 1/7/2022, the Hospital's job description for staff registered nurse (undated) included, "The Staff Nurse is responsible for the direct provision of effective and comprehensive nursing care ... Direct Patient Care ... Initiates and follows through with ... continuing care. Performs assessments focusing on the physical, physiologic and cognitive status of the patient. Utilizes the nursing process in providing care to patients and families ... Nursing Process/Documentation ... Document all aspects of care as it relates to the patients' needs, problems..."

3. On 1/7/2022, the job description for the wound care nurse (dated 8/2019) was reviewed and required, "The Wound Care Staff Nurse is responsible for the direct provision of effective and comprehensive nursing care... Direct Patient Care... Performs assessment focusing on the physical... status of the patient... Provides evaluation and treatment of patients primarily with wounds... Provides accurate documentation of records..."

4. On 1/7/2022 at approximately 12:00 PM, the findings were discussed with the wound care nurse (E#5). E#5 stated that nurses should document a skin assessment every shift and her (E#5's) assessment of cellulitis for Pt.#1 was lacking.

B. Based on document review and interview, it was determined that for 1 (Pt. #1) of 4 clinical records reviewed regarding care plan, the Hospital failed to ensure that the registered nurse supervised the implementation of a care plan for each patient.

Findings include:

1. On 1/6/2022, the clinical record of Pt. #1 was reviewed. The clinical record indicated that Pt. #1's wound treatment plan required cleaning with normal saline and hydrocolloid dressing changes every 72 hours. The clinical record indicated that the treatment was completed on 12/10/2021. However, there was no documentation that the treatment was completed on 12/13/2021.

2. On 1/7/2022, the Hospital's job description for the wound care nurse (dated 8/2019) was reviewed and required, "The Wound Care Staff Nurse is responsible for the direct provision of effective and comprehensive nursing care... Direct Patient Care... Initiates and follows trough with... continuing care... Provides... treatment of patients primarily with wounds..."

3. On 1/7/2022, findings were discussed with E #5 (Wound Care Nurse). E #5 could not provide documentation that the recommended treatment for Pt. #1 was completed.

Based on document review and interview, it was determined that the Hospital failed to ensure an effective medical record service to maintain medical records and ensure efficient continuity of patient care. As a result, the Condition of Participation CFR 482.24, Medical Records, was not in compliance.

Findings include:

1. The Hospital failed to ensure patients' complete medical records were retained, accessible and secure. See deficiency at A-0438.

Based on document review and interview, it was determined that the Hospital failed to ensure patients' complete medical records were retained, accessible and secure. This potentially affected any patients that were seen at the Hospital prior to 12/10/2021.

Findings include:

1. On 1/6/2022, the clinical record for Pt.#1 for admission date 11/24/2021 was requested from the Hospital. The Hospital was not able to provide a complete medical record for Pt. #1. The clinical record of Pt. #1 prior to 12/10/2021 was not able to be retrieved by the Hospital for review.

2. On 1/6/2022, the Hospital provided an inter-office memorandum dated, 12/10/2021, and included, "To: All Staff. From: (name of Chief Executive Officer) ... This notice is for your information as staff ... (name of Hospital) became aware of a threat to our information technology systems ... follow downtime procedures ..."

3. On 1/11/2022, the Hospital's "Cyber Attack/System Failure Emergency Operations Plan" (revised 4/2020) was reviewed and required, " ... b. All patient information is backed up daily and the back-up tapes are stored off-site. In case of system failure, these tapes can be retrieved and used to restore the system so that patient information can be accessed."

4. On 1/11/2022, the Hospital's policy titled "Record Security & Retention Requirements Policy" (revised 9/21/2020) was reviewed and required, "Medical records are secured and retained in their original, legally reproduced form for a period of 10 years ... Offsite Storage: Due to limited physical space, (name of Hospital) keeps 3 years of physical paper portions of the medical records on campus in the file room of the Health Information Department ... All portions of the patients' medical records are retained in their original ... form in hard copy and computer memory banks ... The Hospital is able to promptly retrieve the complete medical record of every individual evaluated or treated ... within the last 10 years ..."

5. On 1/11/2022, the Hospital's policy titled, "Patient Record Content and Order Qualitative Checklist" (revised 7/2020) was reviewed and included, "A. Face Sheet... B. Emergency Room Report... C. History and Physical Examination... E. Consultations... K. Physician Progress Notes. L. Physician Orders."

6. On 1/11/2022 at 10:00 AM, an interview was conducted with the Manager of Health Information Management (E#8). E #8 stated, "We hold records for 10 years at our offsite storage facility. We have a hybrid system and a portion of records are kept on site in the filing room. The documents that are kept on site for up to 3 hears are consents or documents that require signature. Any portion of the medical record that is recorded in the electronic health record (EHR) prior to 12/10/2021, such as diagnostics or lab results, cannot be accessed due to the cyberattack our backup servers were also affected by the attack. As of now we have no idea when the system will be back up and running."

7. On 1/11/2022 at 11:36 AM, an interview was conducted with the Chief Information Officer (CIO). E#10 stated, "The status of the cyber-attack is that the Hospital is in the recovery phase working with a security firm to ascertain what occurred and are trying to recover all patient information. At this point we are not able to provide a complete medical record if requested. All information that was on the backup server was affected by the attack. We do not have for any patients admitted prior to 12/10/2021 a physical/hard copy of medical information."

Based on document review, observation, and interview, it was determined that the Hospital failed to ensure to implement infection surveillance, prevention and control practices to prevent and reduce the transmission of COVID-19 by not ensuring adherence to infection prevention and control guidelines for COVID-19. This is likely to cause serious harm or death to patient, visitor and staff in the Emergency Department (ED) and/or Hospital. As a result, the Condition of Participation, 42 CFR 482.42, Infection Prevention Control Antibiotic Stewardship, was not met.

Findings include:

1. The Hospital failed to follow infection prevention measures regarding isolation of COVID-19 positive patients. See A-749.

The immediate jeopardy (IJ) was identified on 1/07/2022, for the Hospital's failure to follow infection prevention measures regarding isolation of COVID-19 positive patients. The IJ was cited at 42 CFR 482.42, Infection Prevention Control Antibiotic Stewardship. The IJ was announced on 1/7/2022 at 10:15 AM, during an meeting with the Chief Nursing Executive, Quality Manager, President/Chief Executive Officer, and Assistant Administrator. The IJ was removed by the end of survey exit date of 1/11/2022. The Condition for Participation, 42 CFR 482.42, Infection Prevention Control Antibiotic Stewardship, remains out of compliance due to inability to determine sustained compliance as of survey exit date 1/11/2022.

Based on observation, document review, and interview, it was determined that the Hospital failed to follow infection prevention measures regarding isolation of COVID-19 positive patients. This failure is likely to cause cross contamination between all patients and staff in the ED (emergency department) and/or Hospital.

Findings include:

1. On 1/6/2022 between approximately 10:45 AM through 11:15 AM, an observational tour of the Emergency Room was conducted. The following were observed:

- There were 3 occupied negative pressure rooms, 3 occupied rooms with doors, and there were 9 occupied patient beds staggered along the hallways surrounding the nurse's station, which included Pt. #9. The beds in the hallway were not separated by curtains or doors. Pt. #9 was brought to the ED on 1/2/2022 due to atrial flutter (irregular heartbeat) and COVID-19. Pt. #9's COVID-19 result dated 1/2/2022 was positive. Pt. #9 was in the hallway along with other patients (not in an individual room).

- There were 5 patients (Pt. #2, Pt. #3, Pt. #4, Pt.#5, and #6) in an area that was separated with clear plastic curtain from the ED hallways and nursing station. There was no solid wall between each bed. The beds were separated by a curtain, however, there were gaps above and below the curtains between the ceiling and the floor. Inside this area were three patients (Pt. #2, Pt. #4, and Pt. #6) who were positive for COVID-19, and two patients (Pt. #3 and Pt. #5) who were COVID-19 negative:

Pt. #2 was brought to ED on 12/31/2021 due abdominal pain. Pt.#2's COVID-19 result dated 1/1/2022 was positive.

Pt. #4 was brought to the ED on 1/4/2022 due to chronic obstructive pulmonary disease. Pt. #4's COVID -19 result dated, 1/4/2022 was positive.

Pt. #6 was brought to ED on 1/3/2022 due to diabetic ketoacidosis. Pt.#6's COVID-19 result dated 1/3/2022 was positive. Pt. #6 required oral suctioning and had endotracheal intubation (artificial airway insertion) while two other COVID-19 negative patients (Pt. #3 and Pt. # 5) were in the room.

Pt. #3 was brought to the ED on 1/4/2022 due to mental status changes and sepsis (blood infection). Pt #3's COVID-19 result dated 1/5/2022 was negative.

Pt. #5 was brought to the ED on 1/3/2022 due to chest pain and abdominal pain. Pt. #5's COVID-19 result dated 1/3/2022 was negative.

2. On 1/6/2022 at approximately 12:15 PM, the Hospital's policy titled, "Infection Control" (revised 4/2020) was reviewed and included, "Policy: 1. The Hospital Infection Control Program for isolation procedures will be adhered to by all ED staff ...2. All patients who present to triage with a potentially communicable disease will have appropriate isolation precautions instituted immediately ..."

3. On 1/6/2022 at approximately 12:20 PM, the Hospital's "COVID-19 Infection Control Plan" (updated 10/2021) was reviewed and required, " ...II. Background: COVID-19 is a respiratory illness ... Spread in the healthcare setting can occur through person-to-person transmission. III, CDC Guidance ... To respond rapidly (to) changing circumstances ... Primary Goal: Reduce morbidity and mortality, minimize disease transmission, Protect healthcare personnel ... VI Precautions at the Emergency Department ... Place patient with known or suspected COVID-19 in AIIR (Airborne Infection Isolation Room) if available; otherwise, in a single room with the door closed ..."

4. On 1/6/2022 at approximately 10:45 AM, an interview was conducted with an RN (E#4). E#4 stated that there were 3 patients that were positive for COVID-19 and two patients that were negative for COVID-19 in the same room in the ED. E #4 stated that there was no other room to use to separate the patients.

5. On 1/6/2022 at approximately 11:35 AM, an interview with the Chief Nursing Executive (CNE-E#2). E#2 stated that it is not appropriate to co-mingle COVID-19 positive and negative patients, however, this is the current situation in the ED.

6. On 1/6/2022 at 2:55 PM, an interview was conducted with the Director of Infection Prevention (MD#1). MD#1 stated that it is not appropriate to room COVID-19 positive patients with patients that are negative for COVID-19. If a patient is positive ideally they should be placed in a negative pressure room or placed in a regular room with isolation precautions. Patients under investigation should also be placed under isolation precautions. When patients with positive and negative results are roomed together, there is a high risk for infection. MD #1 stated that there is also a high risk of transmission of COVID-19 when aerosol generating procedures are done such as oral suctioning and mechanical intubation.

7. On 1/6/2022 at 3:05 PM an interview was conducted with the Quality Director of Quality/Covering for Infection Control (E#1). E#1 stated that patients that are positive for COVID-19 should be in an individual room with isolation precautions and not roomed with negative patients. It is not appropriate to hold any COVID-19 positive patients in the emergency department hallway because of risk for cross-contamination.

A. Based on observation, document review, and interview, it was determined that for 5 of 15 patients (Pt. #2-Pt.#6) classified as "Hold Beds" (waiting for bed on the unit) in the ED (Emergency Department), the Hospital failed to ensure that the policies and procedures governing the care provided in the ED were followed regarding infection control practices for COVID-19.

Findings include:

1. On 1/11/2022 at approximately 12:15 PM, the Hospital's policy titled, "Infection Control" (revised 4/2020) was reviewed and included, "Policy: 1. The Hospital Infection Control Program for isolation procedures will be adhered to by all ED staff ...2. All patients who present to triage with a potentially communicable disease will have appropriate isolation precautions instituted immediately ..."

2. On 1/6/2022, the Hospital's ED Hold List for 1/6/2022 was reviewed. The list included Pt. #2, Pt. #3, Pt. #4, Pt. #5, and Pt. #6 that were waiting for inpatient beds.

3. On 1/6/2022, the clinical records for Pt. #2, Pt. #3, Pt. #4, Pt. #5, and Pt. #6 were reviewed. The clinical records indicated that Pt. #2, Pt. #4, and Pt. #6, were COVID-19 positive patients while Pt. #3 and Pt. #5 were COVID-19 negative.

4. On 1/6/2022, the ED room list indicated that Pt. #2, Pt. #3, Pt. #4, Pt. #5, and Pt. #6 were co-mingled in the same room. The Hospital did not follow isolation procedures for COVID-19 patients while in the ED.

5. On 1/6/2022 at approximately 10:45 AM, and on 1/7/2022 at approximately 1:45 PM, interviews were conducted with the ED Manager (E #3). E#3 confirmed that the patients (Pt. #2, Pt. #4, and Pt. #6) were COVID-19 positive and that the documentation did not include that these patients were on isolation precautions as required per policy.

B. Based on document review and interview, it was determined that for 3 (Pt. #2, Pt. #5 and Pt. #6) of 15 patients classified as "Hold Beds" (waiting for bed on the unit) in the ED (Emergency Department), the Hospital failed to ensure the policies and procedures governing the care provide in the emergency department were followed by failing to ensure blood glucose monitoring was performed per physician's orders.

Findings include:

1. On 1/6/2022, the clinical record for Pt. #2 was reviewed. Pt. #2's clinical record included a physician's order for blood sugar check AC (before meals) and HS (at bedtime) dated 1/4/2022. The blood sugars were not check as ordered on the following dates: 1/2/2022 through 1/5/2022, and 1/6/2022.

2. On 1/6/2022, the clinical record for Pt. #5 was reviewed. Pt. #5's clinical record included a physician's order for accu-check (blood sugar checks) QID (four times a day) dated 1/3/2022. The blood sugars were not checked as ordered on the following dates: 1/3/2022 through 1/6/2022.

3. On 1/6/2022, the clinical record for Pt. #6 was reviewed. Pt. #6's clinical record included a physician's order for accu-check qhrs (every hour) dated 1/4/2022. The blood sugars were not checked as ordered on the following dates: 1/4/2022 through 1/6/2022.

4. On 1/11/2022, the Hospital's job description for ED registered nurse (dated 9/2014) was reviewed and included, " ... Mission/Values ...2. It is the responsibility of each individual employee to provide quality service in all endeavors by supporting organization changes designed to improve quality ... Responsibilities ... 3. Coordinates patient care with the Emergency Department Physician ..."

5. On 1/6/2022 at approximately 10:45 AM, and on 1/7/2022 at approximately 1:45 PM, interviews were conducted with the ED Manager (E #3). The above findings were discussed with E#3. E#3 stated that when staff performs any task such as accu-checks, it is documented on the flow sheets. E #3 stated that if it is not documented on the flow sheet, it is considered that order was not carried out.