HospitalInspections.org

Based on review of hospital documents, and interviews, it was determined that the facility failed to ensure the Governing Body had oversight of the institutional plan, which poses a high risk to the health and safety of patients, when the Governing Body who is legally responsible for the conduct of the hospital as an institution, failed to require that the institutional plan was reviewed, and updated annually.

Findings include:

Review of the Florence Hospital, LLC, Board of Manager's Meeting Minutes dated: 01/25/2017; 04/26/2017; 07/19/ 2017; 10/18/2017; and 01/17/2018 showed no evidence of the 2017 or 2018 institutional plan review.

CFO #3 confirmed during an interview conducted 04/17/2018 (0901-0930), that the institutional plans for fiscal years 2017 and 2018, (operating, and capital expenditure budgets) have not been reviewed annually by the Governing Body.

CEO #1 confirmed during an interview conducted 04/17/2018 (0945-1010), that the institutional plans for fiscal years 2017 or 2018, (operating, and capital expenditure budgets) have not been reviewed annually by the Governing Body.

Based on review of hospital documents, and interviews, it was determined that the facility failed to ensure the Governing Body had oversight of the institutional plan and/or ensured that a specific committee with required representation from the governing body, administrative staff and medical staff was established to prepare the institutional budget plan. This poses a high risk to the health and safety of patients, when the Governing Body who is legally responsible for the conduct of the hospital as an institution, has not provided direction of the institutional plan, and has not ensured a committee has been established to assist in preparing the institutional plan.

Findings include:

Review of the Florence Hospital, LLC, Board of Manager's Meeting Minutes dated: 01/25/2017; 04/26/2017; 07/19/ 2017; 10/18/2017; and 01/17/2018 showed no evidence of the 2017 or 2018 institutional plan preparation, review, or acknowledgement of a committee designated to participate in the preparation of the institutional plan.

CFO #3 confirmed during an interview conducted 04/17/2018 (0901-0930), that the institutional plans for fiscal years 2017 and 2018, (operating, and capital expenditure budgets) have not been prepared under the direction of the Governing Body. Additionally it was revealed, that the operating, and capital expenditure budgets were completed by CFO #3, and there was no committee established to assist in preparing the institutional plan.

CEO #1 confirmed during an interview conducted 04/17/2018 (0945-1010), that the institutional plans for fiscal years 2017 or 2018, (operating, and capital expenditure budgets) have not been prepared under the direction of the Governing Body. Additionally it was revealed, that the operating, and capital expenditure budgets were completed by CFO #3, and there was no committee established to assist in preparing the institutional plan. CEO #1 confirmed that the current 2018 operational, and capital expenditure budgets were not approved by the Governing Body.

Based on review of hospital documents, and interviews, it was determined that the facility failed to ensure the Governing Body had oversight of the contracted services furnished in the hospital. This deficient practice poses a high risk to the health and safety of patients, when the Governing Body has not verified that a contractor of services (providing services to the hospital) has complied with all applicable Center's for Medicare and Medicaid Services (conditions of participation, and standards).

Findings include:

Review of the Florence Hospital, LLC, Board of Manager's Meeting Minutes dated: 01/25/2017; 04/26/2017; 07/19/ 2017; 10/18/2017; and 01/17/2018 showed no evidence of the Governing Body approving contracts, specifically with those contractors furnishing services to the hospital.

Review of the facility document titled FHA Contracts Log provided to the department on 04/16/2018, listed one hundred and sixty-four (164) current contracts.

CEO #1 confirmed during an interview conducted 04/17/2018 (0945-1010), that all contracts are sent for legal review, and approved by the board if necessary. Additionally, it was revealed, that the legal review does not include review for Center's for Medicare and Medicaid Services (conditions of participation, and standards) for the contracted services.

Based on review of hospital policies and procedures, facility documents, observation and staff interviews, it was determined, the facility failed to create a procedure to clearly explain to patients how to submit a grievance to the hospital. Failure of the hospital to follow through with their established Grievance Process policies increases the likelihood of lack of understanding by patients or their representatives of what they must do to file a grievance thus resulting in poor patient satisfaction.

Findings include:

Review of hospital policy titled "Grievance Process, Policy Stat ID 3220551," last approved 01/2017, requires: "...at time of admission, the admitting staff provides the patient...with written information outlining how to submit a grievance...including phone numbers and addresses of regulatory agencies...time frames for review and resolution of grievance...."

Review of the document titled Patient Rights and Responsibilities and Patient Visitation Rights, dated 02/28/18, revealed: "...If any individual has concerns about patient care and safety that the hospital has not addressed, he or she is encouraged to contact the hospital's patient advocate...if concerns are not resolved through the hospital, you may also contact the DNV..." The acronym DNV is not spelled out or explained, and is therefore unclear.

Observation on tour, conducted 04/17/2018 (1045), the surveyor confirmed, that the facility has a policy and procedure related to the Grievance Process, and a document addressing Patient Rights and Responsibilities for patient concerns. However, it was observed that a registration personal did not follow the established policy for notifying patients how to file a grievance, and or complaint.

Registration Supervisor #41 confirmed during an interview conducted on 04/17/18 (1050-1100), that registration staff do not provide patients with any document that clearly explains the grievance procedure including: a phone number and address for the State agency, the patient's ability to file a compliant with the State agency regardless of whether s/he had first filed a grievance with the hospital, and time frames for resolution of grievances.

Based on review of hospital policies and procedures, documents, and staff interviews, it was determined the facility failed to notify Patient #19 of what steps were taken to investigate his/her grievance. Failure of the hospital to follow through with their established Grievance Process policy increases the high potential risk that the rights of a patient related to a grievance will not be adhered to and result in potential for low patient satisfaction and escalation of the grievance to a regulatory body.

Findings include:

Review of hospital policy titled "Grievance Process, Policy Stat ID 3220551," last approved 01/2017, revealed a failure by the facility to address the requirement that a patient must be notified of the steps taken to investigate their grievance.

Review of the hospital policy titled: "Grievance Process HW1052, Policy Stat ID 3220551," last approved 01/2017, requires: "...a failure by the facility to address the requirement that a patient must be notified of the steps taken to investigate their grievance...."

The facility's Grievance Process to investigate a grievance requires the following steps: "...The clinical liaison opens an investigation of the grievance and reviews the patient's medical record to obtain necessary information...interviews with the patient and /or patient's representative are also conducted...requests review by involved department managers or physicians and receives a summary within 5 days when possible...makes a recommendation and meets with the grievance committee members...sends a final letter of resolution to the patient...refers any quality of care issues to utilization review, quality management/performance improvement, or peer review functions as appropriate...."

Review of one (1) of one (1) letters sent to Patient #19 to resolve a grievance, the hospital failed to explain any of the steps taken on behalf of Patient #19 to investigate his/her grievance.

Director of Nursing (DON) #24 confirmed during an interview conducted on 04/18/18 (1145-1155), that the letter sent to Patient #19 did not explain how the hospital investigated Patient #19's grievance.

Based on review of hospital policy and procedure, documents, and patient medical records, it was determined, the facility staff failed to ensure a drug or medication used as a restriction to manage a patient's behavior was documented as a chemical restraint. Failure of the hospital to follow their established restraint policy poses a high risk to the health, and safety of patients, when the hospital medical staff fails to document the reason for a one time only medication order compared to a chemical restraint medication order.

Findings include:

Review of the hospital policy titled "Restraints Nurs2002, Policy Stat ID 4685584," last revised 03/2018, defines a chemical restraint as follows: "...the effect of a drug or medication or combination of drugs or medications is to reduce the patient's overall ability to effectively or appropriately interact with the world around the patient, then the drug or medication is NOT being used as a standard treatment or dosage for the patient's condition and is considered a chemical restraint...." Additionally, the policy requires: "...orders for behavioral restraint must specify the reason/rationale for restraint application...."

Review of the hospital document titled "Physician On Boarding Welcome Packet," last updated 05/2017, revealed a section titled "Restraint Training." Examples of orders which could be interpreted as a chemical restraint are described as: "...doses of a single medication above usual and customary amounts for our community's standard of practice....combinations of medications given at the same time (for the same purpose), or with too little time between doses to allow determination of efficacy...."

Review of the hospital document titled "Florence Hospital at Anthem, Medical Staff Rules and Regulations"; and "Medical Staff By-Laws", does not address requirements for restraints.

Review of the medication administration record for Patient #21 revealed the following:

Geodon 20 mg intramuscularly (IM) ordered by MD #19, administered once by RN #47 at 1618 on 01/28/18.
Ativan 2 mg IM ordered by MD #19, administered once by RN #47 at 1618 on 01/28/18.

Ativan 2 mg IM verbal order received by RN #44 for MD #17, administered once by RN #44 at 0014 on 01/29/18.
Geodon 10 mg IM verbal order received by RN #44 for MD #17, administered once by RN #44 at 0014 on 01/29/18.

Haldol 5 mg IM verbal order received by RN #44 for MD #19, administered once by RN #44 at 0510 on 01/29/18.

Geodon 5 mg IM verbal order received by RN #44 for MD #17, administered once by RN #44 at 0515 on 01/29/18.

Haldol 5 mg IM verbal order received by RN #44 for MD #17, administered once by RN #44 at 0530 on 01/29/18.

Geodon 10 mg IM ordered by MD #19, administered once by RN #44 at 0642 on 01/29/18.
Versed 5 mg IM ordered by MD #19, administered once by RN #44 at 0642 on 01/29/18.

Geodon 20 mg IM verbal order received by RN #48 for MD #19, administered once by RN #48 at 1320 on 01/29/18.

Versed 5 mg IM ordered by MD #19, administered once by RN #48 at 1538 on 01/29/18.

Ativan 2 mg IM ordered by MD #19, administered once by RN #48 at 1707 on 01/29/18.

Haldol 10 mg IM verbal order received by RN #45 for MD #17, administered once by RN #45 at 2107 on 01/29/18.

Ativan 2 mg IM verbal order received by RN #44 for MD #17, administered once by RN #44 at 2123 on 01/29/18.

Zyprexa 10 mg by mouth (PO) ordered by MD #17, administered once by RN #45 at 2205 on 01/29/18.

Ativan 2 mg IM ordered by MD #2, administered once by RN #45 at 0619 on 01/30/18.

Zyprexa 10 mg PO ordered by MD #2, administered once by RN #45 at 0620 on 01/30/18.

Haldol 10 mg IM verbal order received by RN #45 for MD #17, administered once at 0623 on 01/30/18.

Valium 5 mg IM ordered by MD #2, administered once by RN #46 at 1123 on 01/30/18.
Geodon 5 mg IM ordered by MD #2, administered once by RN #46 at 1123 on 01/30/18.

Review of Patient #21's medical record titled: Progress Note confirmed the following documentation:
01/29/2018 (2300) documented by MD # 2: "...Restraints: Face to face patient evaluation completed...restraint type used: (blank)...Rationale for restraints: (blank)...."

Review of Patient #21's medical record titled: Progress Note confirmed the following documentation: 01/30/18 (0139) documented by MD #17: "...medications [sic] were given to make sure [she] does not elope or hurt herself...."

Twenty (20); one (1) time only medications were administered to Patient #21, and were not ordered or documented as a chemical restraint. The physician orders failed to include the reason why the medications identified above were ordered one time only for each dose given. There was no documentation of a restraint type (chemical restraint) being used as required per facility policy.

No verbal confirmation for the information provided above due to the fact these patient records were provided on the afternoon of the exit date, and were not reviewed in detail until return to the department.

Based on review of hospital policy and procedures, and patient medical records, it was determined that the facility failed to ensure staff follow their facility policy related to restraints and seclusion as evidenced by:

1. staff physically restrained an adolescent patient for greater than two (2) hours without renewal of the order. This deficient practice poses a very high risk to the health, and safety of the patient, when there is no face-to-face evaluation by the medical provider, and orders are not written in a timely manner to protect the patient.

2. staff placed an adolescent patient into seclusion without a physician order. This deficient practice poses a very high risk to the physical, and emotional well-being of the patient if they are secluded from other individuals without proper justification, and required monitoring.

Findings include:

1. Review of the policy titled "Restraints, Policy Stat ID 4685584," last revised 03/2018, requires: "... each written order for behavioral restraint or seclusion is limited to...two (2) hours for children and adolescents ages 9-17...."

Review of Patient #20's medical record revealed an order written on 04/06/18 (1738) by RN #49 for MD #17 to restrain Patient #20 with leather restraints. The Provider Order documentation for Restraint Reason the following was documented: "...Behavioral (order must be renewed within four (4) hours)..." On the Provider Order documentation under Restraint Rationale the following was documented: "...Aggressive, violent posing a danger to self/others...."

Review of the hospital document titled "Florence Hospital at Anthem, Medical Staff Rules and Regulations"; and "Medical Staff By-Laws", does not address requirements for restraints.

Restraint orders for adolescents may only be written for two (2) hours before a renewal is due. The order to apply restraints was not renewed after two (2) hours or four (4) hours. An order to discontinue restraints was written at 04/06/18 (2235) by RN #49 for MD #20.

Patient #20 was in leather restraints for four (4) hours and fifty-seven (57) minutes, of which two (2) hours and fifty-seven (57) minutes were without a doctor's order.

2. Review of the policy titled "Restraints, Policy Stat ID 4685584, last revised 03/2018," requires: "... each written order for behavioral restraint or seclusion is limited to...two (2) hours for children and adolescents ages 9-17...."

Review of medical record for Patient # 20 revealed that the patient was placed into seclusion on 04/06/18 (0945) -04/06/18 (2359), and again 04/07/18 (0000) without a physician order.

Review of the hospital document titled "Florence Hospital at Anthem, Medical Staff Rules and Regulations"; and "Medical Staff By-Laws", does not address requirements for restraints.

Review of the hospital documented titled "Sitter Flow Sheet", revealed that Patient #20 was in seclusion on the following dates and times:

04/06/18 (0945) - 04/06/18 (2359)
04/07/18 (0000) - 04/07/18 (1815)
04/07/18 (1915) - 04/07/18 (2359)
04/08/18 (0000) - 04/08/18 (1643)

Per Physician Orders, the following five (5) seclusion orders were entered into the medical record for Patient # 20 one (1) day after the actual seclusion events occurred:

04/07/18 (0305) seclude 04/06/18 from (1900-2300) - verbal order received by RN #49 from MD #20.

04/07/18 (0307) seclude from (2300-0300) - verbal order received by RN #49 from MD #20.

04/07/18 (0309) seclude 04/06/18 from (1200-1600) - verbal order received by RN #49 from MD #20.

04/07/18 (0311) seclude 04/06/18 from (1600-1700) - verbal order received by RN #49 from MD #20.

04/07/18 (0721) discontinue seclusion on 04/07/18 at (0600) - verbal order received by RN #42 from MD #17.

The documented reason for all the above orders were documented as follows:
Restraint Rationale: Aggressive, violent, posing a danger to self/others.
Restraint Type: Seclusion.
Restraint Reason: Behavioral. Order must be renewed within four (4) hours.

Additionally, two (2) of the above seclusion orders were written for four (4) hours, rather than the maximum allowed time of two (2) hours. Patient #20 was secluded for a total of nine (9) hours without a doctor's order.

No verbal confirmation for the information provided above due to the fact these patient records were provided on the afternoon of the exit date and were not reviewed in detail until return to the department.

Based on review of hospital policies and procedures and medical records, it was determined that the facility failed to ensure Patient #21 was not restrained or secluded when his/her condition, and/or symptoms no longer required restraint and/or seclusion. This deficient practice poses a high risk to the health, and safety of the patient due to the inherit risks of physically restraining and/or secluding a patient when it is not indicated.

Findings include:

Review of hospital policy titled "One to One Observation, Policy Stat ID 3221884," last revised 04/2015, revealed: "...one to one observation, suicide precautions, and sitter at bedside may be used interchangeably...if a patient's documented clinical, behavioral assessment changes, such that the patient no longer poses a danger to self or others, then the one to one observation may be discontinued...."

Review of the policy titled "Restraints Nurs2002, Policy Stat ID 4685584," last revised 03/2018, requires: "...all patients have the right to be free from restraints of any form...and only be imposed to ensure the immediate physical safety of the patient, staff member...and be discontinued at the earliest possible time...."

Review of hospital policy titled "Seclusion of a Patient, Policy Stat ID 3221941," last revised 04/2015, indicates: "... all efforts will be made to eliminate the need for patient seclusion as soon as possible in the patient's treatment course...."

Review of Patient #21's medical record included a document titled "Sitter Flow Sheet". This document confirmed the nursing staff's documentation of the patient's behavior while in seclusion, as "sleeping", "resting quietly", or "watching TV" as follows:

01/28/18 (1600) through 01/28/18 (2030)
01/28/18 (2130) through 01/28/18 (2330)
01/29/18 (0200) through 01/29/18 (0745)
01/29/18 (0845) through 01/29/18 (0945)
01/29/18 (1315) through 01/29/18 (2000)
01/29/18 (2100) through 01/30/18 (0700)

Review of Patient #21's medical record indicated s/he denied suicidal or homicidal ideation at admission. At no point during Patient #21's stay in the hospital did s/he make threats or gestures of suicide. Additionally, it was not documented that Patient #21 made verbal threats to harm staff or attempted to harm self.

No verbal confirmation for the information provided above due to the fact these patient records were provided on the afternoon of the exit date and were not reviewed in detail until return to the department.

Based on review hospital policies and procedures, hospital documents, and staff interviews, it was determined that the facility administrator failed to ensure that only trained staff implement restraint and/or seclusion. This deficient practice poses a risk to the health, and safety of patients as it increases the already high potential for a negative patient outcome.

Findings include:

Review of the policy titled "Restraints Nurs2002, Policy Stat ID 4685584," last revised 02/2018, revealed: " ...LIP, Physician, and staff who have received proper training will also have initial education upon hire and will have annual educational testing. Education will consist of review of current policy, any and all updated requirements, and an educational quiz...staff who have direct patient contact will receive training and will be able to demonstrate competency in the proper and safe application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion...."

Review of the document titled Course Online Results Archive Report provided on 04/18/18, revealed that for the class name "Use of Restraints", the completion rate for staff was 67 of 166 (40%).

Review of the undated document titled FHA (Florence Hospital at Anthem) 2017 Skills Fair revealed 65 of 166 (39%) employees attended the 2017 Skills Fair.

Review of the document titled "Medical Staff All Staff Meeting Minutes" for 6/30/17 (0730), revealed: " ...it is time to complete all learning harbor ...specifically restraint competency ..."

Review of the document titled "Medical Staff All Staff Meeting Minutes" for 11/01/17 (0730), revealed: " ...all learning harbor needs to be completed including Skills Fair competencies ..."

Review of the document titled "Florence Hospital at Anthem Physician On Boarding Welcome Packet," last updated 05/2017, revealed no information regarding seclusion and 1.5 pages of information regarding restraints. It was followed by an acknowledgement form confirming the physician/allied health professional read and understand the training.

DON #24 revealed during an interview conducted on 04/18/18 (1242-1250), that staff participates in a yearly Skills Fair, as well as education utilizing the on-line system called Learning Harbor. Additionally, DON #24 revealed that s/he facilitated the 2017 Skills Fair.

Medical Staff Coordinator #5 confirmed during an interview conducted on 04/18/18 (1310-1320), that MDs, DOs, and NPs do not receive hands on training in restraint or seclusion techniques upon appointment or annually. Additionally, Medical Staff Coordinator #5 was unable to access a list of providers that had completed restraint and seclusion training.

Based on review of hospital documents and staff interviews, it was determined that the facility failed to require education in the use of nonphysical intervention skills. This deficient practice poses a potential risk to the health, and safety of patients as it increases the likelihood of a seclusion or restraint event, and a negative patient outcome.

The findings include:

Review of a document titled: "Restraint Competency - RN/PCT/CNA" last revised 4/2015, includes the objective: "...may only use restraints when less restrictive interventions have been determined insufficient...the attempt documented by staff prior to initiation or [sic] restraints...alternative methods may include: reducing stimulation, diversionary techniques, communication, and limit setting...."

No evidence of further education, training, or demonstrated knowledge for clinical staff was provided to surveyors.

Director of Nursing (DON) #24 confirmed during an interview conducted on 04/18/18 (1242-1250), that Registered Nurses (RN), Patient Care Technicians (PCT), and Certified Nursing Assistants (CNA) are required to complete the Restraint Competency upon hire, and annually. Additionally, DON #24 reveled that staff (excluding MDs and Nurse Practitioners) are also required to attend an annual Skills Fair. DON #24 revealed that during the Skills Fair, staff practices using soft restraints by restraining one another to chairs. The Skills Fair does not include formal education on nonphysical intervention skills, or any other returned demonstration on the application of various types of restraints (leather), or practicing restraining to a bed.

RN #42 confirmed during an interview conducted on 04/19/18 (1505-1520), that staff is trained on the application of soft restraints at the annual Skills Fair by taking turns restraining each other to a chair. Additionally, RN #42 revealed that staff do not practice restraining each other with leather restraints, or restraining to a bed. RN #42 confirmed that staff is not formally educated on nonphysical intervention skills or nonviolent crisis intervention skills.

Based on review of hospital policies and procedures, and staff interviews, it was determined that facility administrator failed to ensure staff were trained on the safe application of all types of restraints, and seclusion used in the hospital. This deficient practice poses a significant risk to the health and safety of patients, as it increases the potential that restraints and/or seclusion will be applied incorrectly, thereby increasing the high potential for a negative patient outcome.

Findings include:

Review of hospital policy titled "Restraints Nurs002, Policy Stat ID 4685584," last revised 03/2018, requires: "...staff who have direct patient contact will receive training and will be able to demonstrate competency in the proper and safe application of restraints, implementation of seclusion...."

Director of Nursing (DON) #24 confirmed during an interview conducted on 04/18/18 (1242-1250), that Registered Nurses (RN), Patient Care Technicians (PCT), and Certified Nursing Assistants (CNA) are required to complete the Restraint Competency upon hire, and annually. DON #24 reveled that staff (excluding MDs and Nurse Practitioners) are also required to attend an annual Skills Fair. Additionally, DON #24 confirmed that during the Skills Fair, staff practices using soft restraints, by restraining each other to chairs. Staff do not practice the following: restraining with leather restraints, restraining to a bed, or discussing techniques to avoid seclusion.

Based on review of hospital policy and procedure, hospital documents, and staff interviews, it was determined that the facility failed to ensure the Governing Body required the Quality Assessment and Performance Improvement program to identify opportunities for improvement. This deficient practice poses a high risk to the health and safety of patients, when opportunities for improvement are not addressed, and that the same identified and/or deficient problems are not resolved in a timely manner.

Findings include:

Review of the hospital's policy and procedure titled: "Organizational Quality Assurance and Performance Improvement Plan, NQ 003, #4472774," last revised 01/2018 revealed "...The Governing Board, has the responsibility for monitoring patient care delivery and services...to achieve these goals, the plan strives to...assure that the improvement process is...evaluating the quality, and appropriateness of patient care...reporting of information to the Governing Body...necessary information is communicated among department/services when problems or opportunities to improve patient care and patient safety practices involve more than one department/service...the status of identified problems and action plans is tracked to assure sustained improvement and problem resolution...a detailed step by step plan of action is documented on how to achieve outcomes with responsibility assigned and timeliness established for completion...the Governing Body has a responsibility to evaluate the effectiveness of the performance improvement activities throughout the hospital...."

Review of the Florence Hospital @Anthem Performance Improvement Committee Meeting Minutes dated: 11/29/2017; 01/24/2018; and 03/21/ 2018; identified opportunities for improvement, to include specific indicators that were below benchmark (and/or threshold) including: History and Physical Turnaround Times within 24 Hours, Electronic Orders, Hospital Restraint Compliance, and department specific indicators. There was no documentation in the meeting minutes to include the following: opportunities that will lead to improvement, and a detailed step by step plan of correction with responsibility assigned, and timeliness for completion.

Review of the Florence Hospital, LLC, Board of Manager's Meeting Minutes dated: 01/25/2017; 04/26/2017; 07/19/ 2017; 10/18/2017; and 01/17/2018 showed no documented evidence of the Governing Body evaluating the effectiveness of the performance improvement activities throughout the hospital.

CNO #2 confirmed during an interview conducted 04/18/2018 (1155-1215), that opportunities for improvement are discussed at the Performance Improvement Committee Meeting, but not documented in the meeting minutes, making it difficult to track if the improvements are sustained.

Based on review of facility documents, and staff interviews, it was determined the facility failed to ensure that the director of food and dietetic services is qualified by experience or training. This deficient practice poses a high risk to the health, and safety of patients, when the director of dietary is not qualified to provide the required oversight of dietary services providing food to patients..

Findings include:

The facility document titled Job Description for the Manager of Plant Operations #9, revealed under the heading Supervisory Responsibilities: "...the Plant Manager will oversee all operations departments including Food Service...." Additionally, under the Job Description heading Minimum Qualifications requires "...a minimum of two (2) years of experience in a management position is required...."

Manager of Plant Operations #9 confirmed during an interview conducted on 04/17/18 (1300-1315), that s/he did not have previous experience in managing food services. Additionally, Manager of Plant Operations #9 revealed that s/he did not have a current Certified Food Protection Manager Certificate or Arizona Food Handler's card.

Based on review of hospital policies and procedures, observation on tour, and staff interviews, it was determined that the facility failed to require that medical supplies used for patient care were not expired. This deficient practice poses a potential risk for the health and safety of patients, when the hospital cannot ensure that the potential risk for infection, negative outcomes and/or false laboratory testing may result when using expired supplies.

Findings include:

Review of the hospital policy titled "Florence Hospital at Anthem, Infection Control Plan - 2018, ICP_1001, #4680883," last approved: 03/2018, requires: "...Infection Control Practitioner...participates in compliance monitoring activities as required by state, federal, and other governing agencies...assists with the facility decision making, and problem solving activities related to infection control...annual evaluation...the program is evaluated for effectiveness for the following...implementation of...prioritized goals...analysis of success and/or failure in meeting goals and/or targets to identify possible causes...."

Expired supplies is not addressed in the policy.

Observation on hospital tour with CNO #2, RN/DON #24, HIMS Supervisor #6, and RN/Clinical Coordinator #14, conducted 04/16/2018 (1348) through 04/17/2018 (1115), the surveyor identified one hundred twenty one (121) expired supplies from the following departments:

MOSU: A total of one hundred and one (101) expired supplies were found in the Code Carts (front, and back locations), and nursing station supply cabinets. Expired items included: Rapid Rhino 5.5cm, Sterile Tongue Depressors, Protect IV Catheters (various gauges and needle lengths), BD Microtainers PST Tubes Lithium Heparin, 0.9 Sodium Chloride Injectable's/10 ml, Ibuprofen 200 mg/120 tablet container, Cricket Bioseal Tracheostomy set, PDI Compound Tincture of Benzoin 10% swabstick, and Westmead CO2 Easy. The oldest outdate was dated 11/2013.

EMERGENCY DEPARTMENT: A total of four (4) expired supplies were found in the two (2) trauma rooms. Expired items included: Surgilube Sterile Lubricant (tubes), and 0.9% Sodium Chloride Injectable. The oldest outdate was dated 08/2016.

PACU: A total of sixteen (16) expired supplies were found in the cabinets, and drawers. Expired items included: foam dressing, Avance transparent film, gray-colored top vials, blue-colored top vials, pink-colored top vials, light green-colored top vials, and red-colored top tube. The oldest outdate was dated 10/2014.

CNO #2, RN/Clinical Coordinator #14, and HIMS Supervisor #6 confirmed during tours conducted 04/16/2018 (1348) through 04/17/2018 (1115), that the above identified supplies were expired. As the surveyor identified the expired supplies, the expired supplies were bagged. Additionally, it was confirmed by CNO #2, and RN/DON #24, that expired supplies are not to be used in the hospital, and should be discarded and/or removed from inventory no later than the expiration date. All 121 expired supplies were individually logged by the surveyor, and the expired supplies were given to CNO #2 at the time of the exit conference conducted 04/18/2018 (1607-1644).

Based on review of hospital policy and procedure, and staff interview, it was determined that the facility failed to ensure that a designated requestor, for organ, tissue, and eye procurement, was identified and trained by the Organ Procurement Organization (OPO). This deficient practice poses a high risk to the health and safety of patients, when the facility fails to ensure that a facility employee is trained as a designated requestor, allowing the employee to request the organ, and tissue donation to the legal decision maker of potential donors.

Findings include:

Review of the hospital's policy, and procedure titled "Organ/Tissue/Eye Donation - Nursing Staff Responsibilities, Nurs.2230, #3221737," last approved 01/2017 revealed: "...To outline procedures to facilitate organ, tissue, and eye donations that ensures compliance with federal, state regulatory agency...and enhance the collaborative relationship with Donor network of Arizona (DNAZ), OPO, and Tissue Recovery Agency...a designated trained requestor or DNAZ staff will make the request for organ, and tissue donation to the legal decision maker of potential donors...designated trained requestors are hospital staff that are trained, and certified by DNAZ to speak with the legal decision maker regarding donation...."

CNO #2 confirmed during an interview conducted 04/18/2018 (1155-1215), that the facility does not have a designated trained, and certified requestor.

Based on record review and staff interview, it was determined the facility failed to ensure within their Emergency Preparedness plan that they documented a community-based risk assessment utilizing an all-hazards approach. Failure to develop a community-based risk assessment involving the community, could leave the facilty with unplanned incidents during an emergency which could lead to harm.

Findings include:

The Plant Operations Manager and Chief Financial Officer reviewed the facility's Emergency Preparedness Plan with the surveyor on April 18-19, 2018. The facility was unable to locate any documentation of a community-based risk assessment utilizing an all-hazards approach within the current written plan. A facilty-based risk assessment was documented.

The Plant Operations Manager and Chief Financial Officer confirmed during an interview on April 19, 2018 the facility did not have documentation of a community-based risk assessment within the current written plan.

Based on review of the facility Emergency plan, record review and staff interview, it was determined, the facility failed to include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials. Failure to include a process for cooperation and collaboration could lead to harm to both patients and staff.

Findings include:

The Plant Operations Manager and Chief Financial Officer reviewed the facility's Emergency Plan with the surveyor on April 18-19, 2018. The Emergency Plan did not have documentation to show for cooperation and collaboration with local, regional, State, and Federal emergency preparedness officials. No documentation was reviewed of attempts for cooperation and collaboration.

The Plant Operations Manager and Chief Financial Officer acknowledged during the exit conference on April 19, 2018, the facility Emergency Plan did not indicate, with supportive documentation, a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials.

Based on review of the facility Emergency Preparedness plan, and staff interview, it was determined the facility failed to develop and implement policy and procedures for tracking of staff and sheltered patients during an emergency. Failure to adequately track residents and staff during an emergency could lead to harm to both residents and staff.

Findings include:

The Plant Operations Manager and Chief Financial Officer reviewed the facility's Emergency Plan with the surveyors on April 18-19, 2018. The emergency plan did not identify a process for the tracking of sheltered/evacuated patients and staff during during an emergency.

The Plant Operations Manager and Chief Financial Officer indicated they had processes's they could use, but did not have a process outlined in their Emergency plan.

The Plant Operations Manager and Chief Financial Officer confirmed during an exit conference on April 19,2018 the emergency plan did not identify a process for the tracking of sheltered/evacuated patients and staff during during an emergency.

Based on review of the facility Emergency Preparedness plan, and staff interview, it was determined the facility failed to develop and implement policy and procedures for a means to shelter in place for staff, patients, and volunteers who remain in the hospital during an emergency. Failure to have a plan in the event of sheltering during an emergency could lead to harm to both patients and staff.

Findings include:

The Plant Operations Manager and Chief Financial Officer reviewed the facility's Emergency Plan with the surveyors on April 18-19, 2018. The emergency plan did not identify a process for the sheltering of patients, staff, and volunteers during during an emergency.

The Plant Operations Manager and Chief Financial Officer confirmed during an exit conference on April 19, 2018 the emergency plan did not identify a process for the sheltering of patients, staff, and volunteers during during an emergency.

Based on review of the facility Emergency Plan, and staff interview, it was determined the facility failed to develop and implement policy and procedures for the use of volunteers in an emergency. Failure to address the use of volunteers in an emergency could adversely impact patient care during an emergency.

Findings include:

The Plant Operations Manager and Chief Financial Officer reviewed the facility's Emergency Plan with the surveyors on April 18-19, 2018. The plan did not include policies and procedures to address the use of volunteers in an emergency.

The Plant Operations Manager and Chief Financial Officer confirmed on April 19, 2018, the facility Emergency Plan did not include policies and procedures to address the use of volunteers in an emergency.

Based on review of the facility Emergency Plan (EP), record review and interview with the staff, it was determined the facility failed to develop and implement emergency preparedness policies and procedures to describe its role in providing care at alternate care sites during an emergency. Failure to develop emergency policies and procedures at alternative care sites may cause harm to the patients during an emergency.

Findings include:

The Plant Operations Manager and Chief Financial Officer reviewed the facility's Emergency Plan with the surveyor on April 18-19, 2018. The plan did not include policies and procedures describing the facility's role in providing care and treatment at alternate care sites under an 1135 waiver.

Plant Operations Manager and Chief Financial Officer confirmed during the exit conference on April 19, 2018, their EP plan did not include policies and procedures describing the facility's role in providing care and treatment at alternate care sites under an 1135 waiver.

Based on review of the facility Emergency Preparedness Plan, and staff interview, it was determined the facility failed to perform a Community-Based full scale exercise. Failure to provide facility based training and testing tailored to the Emergency Plan may lead to untrained staff in an emergency situation and may result in harm to the patients during an emergency.

Finding include:

The Plant Operations Manager and Chief Financial Officer reviewed the facility's Emergency Plan (EP) on April 18-19, 2018. The plan did not have a documented Community-Based full scale exercise for staff based on the Emergency Plan.

The Plant Operations Manager and Chief Financial Officer confirmed during an interview on April 19, 2018, the EP plan did not include annual facility based training and testing for staff based on the Emergency Plan.

Based on record review and staff interview, it was determined the facility failed to ensure within their Emergency Preparedness plan that they incorporated documentation to include the emergency and standby power systems. Failure to implement emergency and standby power systems plan during an emergency which could lead to harm.

Findings include:

The Plant Operations Manager and Chief Financial Officer reviewed the facility's Emergency Preparedness Plan with the surveyor on April 18-19, 2018. The facility was unable to locate any documentation on the emergency and standby power systems.

The Plant Operations Manager and Chief Financial Officer confirmed during an interview on April 19, 2018 the facility did not have documentation on the emergency and standby power systems.

Based on review of hospital policies, and procedures, documents, and staff interviews, it was determined that the facility failed to ensure the Chief Executive Officer (CEO), Medical Staff, and Chief Nursing Officer (CNO) be responsible for the implementation of successful corrective action plans in affected problem areas identified through the infection control program. This deficient practice poses a high risk to the health and safety of patients, when infection control opportunities for improvement are identified, but corrective action plans are not documented, to ensure sustained compliance.

Findings include:

Review of the hospital's policy and procedure titled "Organizational Quality Assurance and Performance Improvement Plan, NQ 003, #4472774," last revised 01/2018 requires: "....The purpose of the organizational Quality
Assessment and Performance Improvement Plan...is to ensure that...a consistent endeavor to deliver safe, effective optimal patient care and services...the approach to to improving performance involves...establishing the plans, processes, and mechanisms to prevent the comprise of the quality, and performance improvement activities...the primary goals are to continually, and systematically...assess, and improve performance...improve healthcare outcomes...."

Review of the hospital's policy titled "Florence Hospital at Anthem, Infection Control Plan - 2018, ICP_1001, #4680883," last approved: 03/2018, requires: "...Infection Control Practitioner...participates in compliance monitoring activities as required by state, federal, and other governing agencies...assists with the facility decision making, and problem solving activities related to infection control...analysis of success and/or failure in meeting goals and/or targets to identify possible causes...." Expired supplies is not addressed in the policy.

A review of the Florence Hospital @Anthem Performance Improvement Committee Meeting Minutes dated: 11/29/2017, 01/24/2018, and 03/21/2018; identified opportunities for improvement specific to Infection Control. There was no documentation in the meeting minutes to include the implementation of successful corrective action plans for those infection control affected problem areas.

CNO #2 confirmed during an interview conducted 04/18/2018 (1155-1215), that opportunities for improvement are discussed at the Performance Improvement Committee Meeting, but not documented in the meeting minutes. Additionally, it was revealed that the Infection Preventionist/Employee Health Registered Nurse, was on a leave of absence, and that the facility is actively recruiting for an Infection Preventionist. Currently RN #29 is serving as an interim Infection Preventionist.