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Based on observation, interviews, and record review, the facility did not meet the Condition of Participation with regards to Nursing Services by failing to:
1. Ensure that one of 30 sampled patients (Patient 2), who was assessed to be at high-risk for fall (defined as any unintentional and unanticipated descent to the floor or any other lower surface) had a Nursing Care Plan developed that identifies risks as well as interventions to prevent fall.
(Refer to A-396)

2. Ensure that one of 30 sampled patients (Patient 6), had an individualized and updated seizure (sudden uncontrolled disturbance in the brain that causes changes in behavior, movements, feelings, and in levels of consciousness) care plan that identifies precautionary measures needed to be implemented to help prevent injury if a seizure occurs.
(Refer to A-396)

3. Ensure that staff implemented High Risk Prevention Interventions for two of 30 sampled patients (Patient 4 and 8). (Refer to A-398)

4. Ensure that staff implemented Seizure Precautions (safety measures taken before an individual experiences a seizure) for two of 30 sampled patients (Patient 6 and 21). (Refer to A-398)

5. Ensure that staff documented a clinical indication for an indwelling foley catheter (a tube inserted into the bladder to drain urine) for four of 30 sampled patients (22, 23, 25, and 27)
(Refer to A-398)

6. Ensure that staff properly administer medication via an enteral tube (to allow liquid food and medication to enter the stomach) for one of 30 sampled patients (Patient 19). (Refer to A-405)

The cumulative effect of these deficiencies resulted in the hospital's inability to ensure the Conditions of Participation for Nursing Services was met.

Based on interviews, and record reviews, the facility failed to develop, update, and implement an individualized Nursing Care Plan/Plan of Care (provides a framework for evaluating and providing patient care needs related to the nursing process) for two of 30 sampled patients (Patient 2 and Patient 6), to meet the patients' needs and treatment goals. The facility failures included the following:

1. Patient 2 who was assessed to be at high-risk for fall (defined as any unintentional and unanticipated descent to the floor or any other lower surface) had a Nursing Care Plan developed that identifies risks as well as interventions to prevent fall.

This deficient practice had the potential for harm as a result of not having an individualized care plan that includes information necessary to properly care for patient (Patient 2).

2. Patient 6 had an individualized and updated seizure (sudden uncontrolled disturbance in the brain that causes changes in behavior, movements, feelings, and in levels of consciousness) care plan that identifies precautionary measures needed to be implemented to help prevent injury if a seizure occurs.

This failure had the potential to result in harm to the patient's (Patient 6) safety by not identifying the patient's (Patient 6) needs and risks.

Findings:

1. A review of Patient 2's "History and Physical" (H&P), dated 1/5/2022, indicated that patient was admitted for chronic lower extremity venous stasis ulcers (wound on the lower leg or ankle caused by abnormal or damaged veins). The H&P also indicated that Patient 2 had become progressively weaker, had fallen a few times this week.

A review of Patient 2's "Morse Fall Scale" (a tool used for assessing a patient's likelihood of falling), dated 1/5/2022, at 3:45 p.m., indicated that Patient 2's fall risk score was 55 (Morse Fall Risk Scale: No Risk=0-24, Low Risk-25-44, High Risk=45 and higher) and the Patient 2 was considered a high fall risk. The Morse Fall Scale also indicated that required action was to "initiate fall precautions (interventions implemented to minimize or eliminate the risk of fall and maintain the safety of the patient)."

During an interview, on 1/6/2022, at 9:25 a.m., with the Director of Medical-Surgical Unit (DMS, a unit provides care to adults who are hospitalized with a wide variety of conditions), DMS stated that the expectation is for care plans to be updated, customized, and adjustments in interventions documented in every shift.

During a concurrent interview and record review, on 1/6/2022, at 10:56 a.m., with Registered Nurse 1 (RN 1), RN 1 stated that there was no care plan developed to address Patient 2's fall risk problem. RN 1 stated "nobody developed or initiated a care plan for Patient 2 regarding fall prevention."

A review of the facility's policy and procedure (P&P) titled, "Multidisciplinary Care Plan," dated 4/2016, indicated "the multidisciplinary care plan is initiated by the registered nurse within 24 hours of admission and updated every shift and as necessary ..."

2. A review of Patient 6's H&P, dated 12/29/2021, indicated that Patient 6 was admitted with chief complaint of seizures. The H&P also indicated that Patient 6 was on seizure medications but was not taking any medicine routinely. Patient 6 had history of seizure disorders.

A review of the Physician Orders, dated 12/29/2021, indicated "Seizure Precautions (safety measures taken before an individual experiences a seizure)."

During an interview, on 1/6/2022, at 9:25 a.m., with the DMS stated that the expectation is for care plans to be updated, customized, and adjustments in interventions documented in every shift.

During a concurrent interview and record review, on 1/6/2022, at 10:40 a.m., with RN 1, the Nursing Care Plan indicated that there was no change or update made on the seizure care plan to reflect the interventions necessary when the Patient 6 has a seizure. RN 1 stated "the nursing care plan should have been individualized based on Patient 6 assessed care needs." RN 1 further stated, "we should modify the care plan and add necessary information to it."

A review of the facility's policy and procedure (P&P) titled, "Multidisciplinary Care Plan," dated 4/2016, indicated "the multidisciplinary care plan is initiated by the registered nurse within 24 hours of admission and updated every shift and as necessary ..."

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

1.) Ensure that staff implemented High Risk Prevention Interventions for two of 30 sampled patients (Patient 4 and 8)

2.) Ensure that staff implemented Seizure Precautions (safety measures taken before an individual experiences a seizure) for two of 30 sampled patients (Patient 6 and 21)

3.) Ensure that staff documented a clinical indication for an indwelling foley cather (a tube inserted into the bladder to drain urine) for four of 30 sampled patients (Patient 22, 23, 25, and 27)

These failures had the potential to negatively affect the patient's safety and care.

Findings:

1a.) A review of Patient 4's "History and Physical" (H&P), dated 1/4/2022, indicated that Patient 4 was admitted for unhealing surgical wound associated with infection and surrounding cellulitis (a common and potentially serious bacterial skin infection), status post left patellar fracture (break of the kneecap), malnutrition, and dehydration. The H&P also indicated that Patient 4 was "disoriented and confused as well as with very poor memory."

A review of Patient 4's "Morse Fall Scale" (a tool used for assessing a patient's likelihood of falling), dated 1/6/22, indicated that Patient 4's fall risk score was 60 (Morse Fall Risk Scale: No Risk=0-24, Low Risk-25-44, High Risk=45 and higher) and the Patient 4 was considered a high fall risk.

During an interview on 1/6/2022, at 9:30 a.m., with the Director of Medical-Surgical Unit (DMS, provides care to adults who are hospitalized with a wide variety of conditions) stated that for high fall risk patients, the staff are expected to implement interventions such as "falling star sign in the patient's room and place yellow arm band (indicates that patient is a fall risk) on patient's wrist." DMS also stated, "staff must assess the level of fall risk for each patient."

During an observation on 1/6/2022, at 9:10 a.m., inside Patient 4's room, Patient 4 had no yellow armband. There was no posted "falling star sign (visual cue to indicate that patient is a fall risk)" inside the patient's room or headboard.

During a concurrent interview and record review, on 1/6/2022 at 10 a.m., with Registered Nurse (RN 2), Patient 4's Morse Fall Scale Documentation Notes indicated "initiation of fall precautions ...fall risk arm band ..." RN 2 stated, "the patient has no yellow arm band ...there is no falling star sign in the room." RN 2 further stated, "these fall interventions should have been implemented ...I will place the patient's yellow arm band later because I still have not passed my medications."

A review of Patient 4's Nursing Care Plan (provides a framework for evaluating and providing patient care needs related to the nursing process) regarding "Safety-Risk for Injury," dated 1/6/2022, indicated "fall precaution band on."

A review of the facility's policy and procedure (P&P), titled "Fall Reduction Program," dated 4/2018, indicated, "If patient is found to be at risk for falls, the fall prevention plan shall be instituted." The P&P also indicated "for high risk score=45 points or above ...requires falling star (visual cue) on the headboard and yellow armband ..."

1b.) A review of Patient 8's H&P, dated 1/4/2022, indicated that Patient 8 was admitted for Failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition, and inactivity) and need for nursing home placement since family is no longer capable of taking care of Patient 8. The H&P also indicated that Patient 8 had history of CVA with left-sided hemiplegia (paralysis of limbs on the left side of body).

A review of Patient 8's "Morse Fall Scale" (a tool used for assessing a patient's likelihood of falling), dated 1/6/2022, indicated that Patient 8's Morse Fall Risk Score was 70 (Morse Fall Risk Scale: No Risk=0-24, Low Risk-25-44, High Risk=45 and higher) and the Patient 8 was considered a high fall risk.

During an interview, on 1/6/2022, at 9:30 a.m., with the Director of Medical-Surgical Unit (DMS, provides care to adults who are hospitalized with a wide variety of conditions) stated that for high fall risk patients, the staff are expected to implement interventions such as "falling star sign in the patient's room and place yellow arm band (indicates that patient is a fall risk) on patient's wrist." DMS also stated, "staff must assess the level of fall risk for each patient."

During an observation, on 1/6/2022, at 9:15 a.m., inside Patient 8's room, Patient 8 had no yellow arm band. There was no posted "falling star sign (visual cue to indicate that patient is a fall risk)" inside the patient's room or headboard.

During a concurrent interview and record review, on 1/6/2022, at 11 a.m., with RN 3, Patient 8's Morse Fall Scale Documentation Notes indicated "initiation of fall precautions ...fall risk arm band ..." RN 3 stated Patient 8 had no yellow arm band and there is no falling star sign in his room." RN 3 further stated, "we are supposed to place a yellow arm band for all our patients who are at risk for falling."

A review of Patient 8's Nursing Care Plan (provides a framework for evaluating and providing patient care needs related to the nursing process) titled "Fall Risk/Potential for Falls," dated 1/6/2022, indicated "post falling star or fall risk sign ...place yellow arm band on patient ..."

A review of the facility's P&P, titled "Fall Reduction Program," dated 4/2018, indicated "If patient is found to be at risk for falls, the fall prevention plan shall be instituted." The P&P also indicated "for high risk score=45 points or above ...requires falling star (visual cue) on the headboard and yellow armband ..."

2a.) A review of Patient 6's H&P, dated 12/29/2021, indicated that Patient 6 was admitted with chief complaint of seizures. The H&P also indicated that Patient 6 was on seizure medications but was not taking any medicine routinely. Patient 6 had history of seizure disorders.

A review of the Physician Orders, dated 12/29/2021, indicated Seizure Precautions.

During an observation, on 1/6/2022, at 9:52 a.m., inside Patient 6's room, the patient's side rails were not padded and there was no suction set-up available inside Patient 6's room.

During an interview, on 1/6/2022, at 10:40 a.m., with RN 1 stated, "when we have patients on seizure precaution, we should pad the side rails, right now, I don't see any pads on the side rails." RN 1 also stated, "we should also have a suction set-up available in the room ...it's not there either." RN 1 further stated, "the portable suction set-up have to be requested from central supply, but it looks like no one has done that."

A review of the facility's P&P, titled "Policy for Procedures," dated 7/2019, indicated "Nursing will follow the guidelines and protocols for all procedures as stated in the Lippincott Nursing Procedures Manual (addresses what the nurse needs to know and do to perform best-practice procedures at the bedside, and provides rationales and cautions to ensure patient safety and positive outcomes).

A review of the Lippincott Nursing Procedures Manual, undated indicated, "If the patient is at risk for seizures, pad the patient's side rails and have suction apparatus ...available at the patient's bedside. Make sure emergency equipment is readily available and in working condition."


2b.) A review of Patient 21's Physician Progress Notes, dated 1/5/2022, indicated Patient 21 had a seizure and ordered levetiracetam (medication to treat seizures).

During an observation, on 1/6/2022 at 9:51 a.m. inside Patient 21's room, the patient's bed side rails were not padded.

A review of the facility's form titled "Policy for Procedures," dated 7/2019, indicated "Nursing will follow the guidelines and protocols for all procedures as stated in the Lippincott Nursing Procedures Manual (addresses what the nurse needs to know and do to perform best-practice procedures at the bedside, and provides rationales and cautions to ensure patient safety and positive outcomes).

A review of the Lippincott Nursing Procedures Manual, undated indicated "If the patient is at risk for seizures, pad the patient's side rails...."

3.) During an observation, on 1/6/2022 at 9:55 a.m., on the 4th floor nursing unit, Patient 22, 23, 25, and 27 had an indwelling catheter.

A review of Patient 22, 23, 25, and 27's physician order for an indwelling catheter did not indicate a clinical reason for use.

A review of the facility's P&P, Catheter Associated Urinary Tracy Infection (CAUTI), dated 3/2018, indicated a physician's order with rationale is required for insertion of an indwelling catheter They must never be used for the convenience of patient-care personnel and should be discontinued when there is no indication for ongoing use to help prevent infections in the urinary tract.

Based on observation and record review, the facility failed to properly administer medication via an enteral tube (to allow liquid food and medication to enter the stomach) for one of 30 sampled patient (Patient 19).

This failure had the potential to affect the medication's absorption by the patient's body.

Findings:

A review of history and physical indicated Patient 19 was admitted to the facility on 1/4/2022 due to respiratory failure (when the lungs can't get enough oxygen into the blood) and sepsis (when the body has a strong inflammatory response to an infection.

During an observation, on 1/6/2022 at 8:57 a.m., in Patient 19's room, Registered Nurse (RN 4) dissolved acetaminophen (pain medication) 1300 milligrams , Potassium (mineral supplement) 20 milliequivalents, and famotidine (medication to prevent heartburn) 20 milligrams together in a single cup of water and administered it through Patient 19's enteral tube.

A review of the facility's policy and procedure titled, Administration of Medications - Enteral Feeding, dated 6/2017, indicated that body's absorption of medication when combined for enteral administration is not predictable. Therefore, mixing medication shall be avoided.

Based on observation, interview and record review, the facility failed maintain equipment to ensure an acceptable level of safety and quality. One of the facility's morgue refrigeration units was not maintained properly.

This deficient practice of an improperly maintained equipment could have negative effects to the health and safety of the facility staff and visitors.

Findings:

On 1/5/2022, at 10:14 a.m., a general observation of the facility's morgue room was conducted with the Chief Operating Officer, the Director of Quality and Risk Management, an engineering consultant, and an engineering staff. Upon entering the morgue, it was noticed that there were two morgue refrigeration units; 1) a two-drawer unit and 2) a four-drawer unit. Both refrigeration units had bodies in body bags, on each drawer. There was a total of six bodies in these refrigeration units.

On 1/5/2022 at 10:16 a.m., the two-drawer refrigeration unit had a temperature of 34.0 degrees Fahrenheit (F) and there was no foul odor when one of the doors was opened.

On 1/5/2022 at 10:18 a.m., the four-drawer refrigeration unit had a temperature of 54.5 degrees F and there was a foul odor noticed when one of the doors was opened.

On 1/5/2022 at 10:20 a.m., an interview was conducted with the engineering staff regarding the morgue refrigeration units. The engineering staff stated that he checks the refrigeration units and records their temperatures, everyday at 6:00 a.m. When asked who checks and records the temperatures on the weekends, he stated he did not know.

On 1/5/2022 at 11:30 a.m., an interview was conducted with the Director of Quality and Risk Management and the Engineering Consultant. Both were informed that the four-drawer refrigeration unit was out of temperature and the temperature logs were not completed, as indicated on the facility's morgue policy and procedure. The Engineering Consultant stated that a refrigeration service company was contacted and would send a repairman to fix that refrigeration unit today. The Engineering Consultant added that the four bodies (that were in the four-drawer refrigeration unit) were relocated in the temporary portable walk-in refrigerator. (This walk-in refrigerator was on-site at the rear, for any excess bodies, and had a temperature of 35.0 degrees F.)

A review of the temperature logs for the two morgue refrigeration units between 12/18/2021 to 1/5/2022, there were 10 days (which included every weekend) that no temperatures were recorded for both refrigeration units.

A review of the facility's morgue policy and procedure, dated 1/2019 indicated, "Engineering Department will daily check and record temperatures of the crypts. The temperature should be within 35-45 degrees F, with the ideal range for body storage being 40-45 degrees F. Engineering will ensure functionally of the autopsy table and all other fixtures and equipment."

Based on observation, interviews, and record review, the facility did not meet the Condition of Participation with regards to Infection Prevention and Control by failing to:

1. Store corrugated boxes (composed of three different sheets of container board, in which two sheets on the outside are flat liners and the sheet in the middle has rippled shape) used for storage off the floor. (Refer to A-749)

2. Follow routine tuberculosis (an infectious disease that affects the lungs) screening for RN 2. (Refer to A-749)

3. Provide infection prevention and deceased body handling training for facility's security personnel. (Refer to A-775)

The cumulative effect of these deficiencies resulted in the hospital's inability to ensure the Conditions of Participation for Infection Prevention and Control was met.

Based on observation, interview, and record review, the facility failed to follow their policy and procedures on preventing transmission of diseases by:

1. Leaving corrugated boxes (composed of three different sheets of container board, in which two sheets on the outside are flat liners and the sheet in the middle has rippled shape) used for storage directly on the floor.

2. Not following up on routine tuberculosis (an infectious disease that affects the lungs) screening for Registered Nurse (RN 2).

These failures had the potential to spread infectious diseases.

Findings:

1.) During a tour, on 1/5/2022, at 10:23 a.m., of the facilities inside morgue located in the facility's basement, corrugated boxes with shipping labels were observed stacked in the basement hallway directly on the floor and not elevated on pallets (flat transport structures that allows handling and storage deficiencies). Several empty corrugated boxes of various sizes were also observed stacked near the hallway entrance to the inside morgue.

During an interview, on 1/5/2022, at 10:25 a.m., with the Facilities Department Coordinator (FDC), stated, "yes, they are on the floor, but we are in the process of moving the boxes to proper storage."

During an interview, on 1/5/2022, at 10:26 a.m., with the facility's Director of Performance Improvement (DPI), stated "there should be no boxes on the floor due to infection control protocols ...we will make sure to move the boxes."

A review of the Joint Commission (an organization that seeks to continuously improve healthcare for the public) Perspectives, dated 04/2019, indicated "shipping containers, especially those made of corrugated material, serve as generators of and reservoirs of dust. Corrugated cardboard boxes are susceptible to moisture, water, vermin, and bacteria during warehouse or storeroom storage, as well as transportation environments. Boxes and containers may have been exposed to unknown and potentially high microbial contamination."

A review of the facility's policy and procedure (P&P), titled "Corrugated Cardboard Containers, Prohibited Storage for Hospital Departments," dated 6/2018, indicated "Corrugated cardboard boxes may pose a habitable substrate for insect and pest propagation as well as well as safety and fire hazards if not properly stored and removed from egress corridors." The P&P also indicated "it is the policy to prohibit the use of corrugated boxes for storage in any service or area where potentials for damage to the integrity of the container exist, either through moisture, deterioration or disruption."

2.) During a review of RN 2's employee health file, RN 2 was initially screened for tuberculosis during the facility's new hire process with a chest x-ray dated 6/3/2016. The subsequent and latest chest x-ray results for RN 2's routine tuberculosis screening indicated it was done on 5/11/2021.

A review of the facility's policy and procedure, Employee Tuberculosis Surveillance Program, dated 9/2016, indicated that employees who are screened for tuberculosis by chest x-ray, should be done every four years.

During an interview, on 1/7/2021 at 9:50 a.m., with Licensed Vocational Nurse (LVN 1), stated that RN's 2 last chest x-ray was overdue, since screening for tuberculosis with a chest x-ray needs to be done every four years.

Based on interview and record review, the facility failed to provide infection prevention and deceased body handling training for facility's security personnel. This failure had the potential to result in the spread of infecctious diseases.

On January 6, 20222 at 4:45 p.m., the survey team called an immediate jeopardy (IJ) situation in the presence of the Chief Nursing Officer (CNO) and Corporate Chief Operating Officer (COO), and Facility Chief Cooperating Officer (Facility COO).

The facility failed to provide infection control training to the security personnel for the following:
1. handling of deceased bodies
2. use of Personal Protective Equipment (PPE)

The CNO and the COOs were informed of the immediate jeopardy situation regarding the failure to provide infection control training which had the potential to contribute to the spread of communicable diseases or infection from body fluids.

On January 10, 2022 at 4:01 p.m., the immediate jeopardy situation was lifted after verifying an acceptable plan of action. The plan of action indicated a process of handling and storage of bodies, training staff, contingency plans for equipment/morgue freezer breakdowns, and unexpected surges.

1. Policies on handling and storage of decedents were created and updated that explicitly dictates how decedents should be handled and maintained, including direction to never stack decedents or put decedents on the ground.
2. Educational in-services on appropriate PPE use and the process of donning and doffing was implemented for security personnel and environmental services staff.
3. Implemented new process for daily checking of internal temperature for both internal and external morgue.
4. Process developed and in place for managing freezer breakdowns or when the maximum capacity is reached

Findings:

During an interview on 1/5/22, at 10:28 a.m., with the security lead (SL 1), SL 1 stated that he never received training on how to properly handle deceased bodies. SL 1 also said "regarding the use of PPEs, it was self-taught...No one provided us training on how to use the PPEs."

During an interview on 1/6/22, at 2:05 p.m., with the security lead (SL 2), SL 2 stated that on 12/27/21, because there was fluid leaking out of the door of the outside freezer trailer, she (SL 2) was instructed to have her security team move the deceased bodies from the outside freezer trailer on to the ground, outside of the freezer trailer. SL 2 also said it was raining when the bodies were taken out of the freezer trailer and left on the ground. SL 2 said that prior to moving the deceased bodies, she (SL 2) saw fluids coming out of the outside freezer trailer door on to the pavement.

During an interview on 1/6/22, at 2:07 p.m., with the security lead (SL 2), SL 2 said that when she opened the freezer trailer door, she saw 12 bodies on the floor with a couple of bodies stacked on top of each other. SL 2 also stated that some of the body bags were ripped and fluids were leaking out. SL 2 said that she (SL 2) and her security team were not provided training on how to properly handle deceased bodies as well as how to use PPEs.

During an interview on 1/6/22, at 2:22 p.m., with security personnel (SP 1), SP 1 said that on 12/27/21, he had to move the bodies with SL 2. SP 1 stated "I had no gown on ...I only had N95 mask and gloves." SP 1 further added that while transferring the deceased bodies, the fluids leaked on his uniform, and he had to go home and take a shower and change. SP 1 said that he did not receive training regarding handling of deceased bodies including proper use of PPEs. SP 1 said that he observed bodies were on the ground and stacked on top of each other inside the outside freezer trailer. SP 1 also said that some of the body bags were already ripped with fluids leaking out of it.

During an interview on 1/6/22, at 3:12 p.m., with security personnel (SP 2), SP 2 stated that he worked on 12/27/21 and he was instructed along with SP 1 to move the bodies from the outside freezer trailer to the outside ground so that the freezer can be cleaned and disinfected. SP 2 also said that he did not receive training regarding handling of deceased bodies and how to properly use PPEs. SP 2 stated that fluids leaked on his uniform while moving the bodies.

During an interview on 1/6/22, at 1:40 p.m., with the Corporate System Director for Infection Prevention (Corporate IP), Corporate IP stated that security personnel should be trained on infection prevention by the facility's IP as well as provided with PPE.

During an interview on 1/6/22, at 2:41 p.m., with the Director of Performance Improvement
(DPI), DPI stated that the security personnel did not receive infection prevention training in the past until after the incident on 12/27/21. DPI also said that training was only started by the facility's Nurse Educator on 1/6/22 and will continue until all security personnel received training.

A review of the Security Professional Service Agreement, dated 11/1/20, indicated "proof of annual in-service education in fire, safety, infection control, and customer service relations."

A review of the facility's policy and procedure (P&P) titled, "Infection Prevention Plan for 2021," dated 1/21/21, indicated "the goals of the Infection Prevention and Control Program include: Limit unprotected exposure to pathogens: Examples include hand hygiene, use of PPE ..."

A review of the facility's policy and procedure (P&P) titled, "Morgue-Delineation of Responsibilities," dated 1/2019, does not indicate how security personnel should handle and store deceased bodies.