HospitalInspections.org

Based on observation, interview and record review the Governing Body failed to effectively provide oversight in the conduct of the facility when:
- The facility failed to provide services by limiting capacity when licensed for 190 inpatient beds. (A-0057)
- The CEO failed to inform the Governing Body of financial details in regards to payment of vendors (persons or companies whose products supply the facility with goods or services) to maintain patient care. (A-0057)
- The facility failed to provide supplies for thirty four scheduled Electroconvulsive Therapy (ECT, an alternative treatment, also known as shock therapy, for individuals with major depression not helped by medication therapy or when medication therapy is contraindicated) treatments. (A-0057)
- The facility failed to manage the Governing Body including accountability for the effective oversight of compliance with the daily operations. (A-0057)
- The facility failed to specify in the Medical Staff Bylaws which staff were allowed to order restraints for patients. (A-47)
- The facility failed to follow Medical Staff Bylaws that gave only the Advisory Board/Governing Body the authority to grant medical staff privileges. (A-0046)
- The facility failed to ensure that four Emergency Department (ED) physicians (JJ, OO, QQ, and RR) of six reviewed were evaluated yearly on their clinical practice and practiced within their scope by reviewing the physician's Quality Assurance Performance Improvement (QAPI) program. (A-0049)
- The facility failed to provide an approved annual budget for 2019. (A-0076)
- The facility failed to ensure that patients that presented to the Emergency Department (ED) seeking care for an emergency medical condition and in-patient emergent care received stat (immediate results needed for the evaluation of an emergent medical condition) laboratory test results within twenty five minutes per the facility policy and failed to ensure the human decontamination sprayers (used to manage a contaminated patient that has been exposed to hazardous nuclear, biological or chemical materials, located outside of the ED entrance) were operational. (A-0091)
- Make necessary repairs and have regular pest control services; (A-0701)
- Control temperature and humidity in four Operating Room (OR) suites that hindered the infection prevention environment; (A-0726) and
- Maintain an adequate amount of patient supplies to ensure an acceptable level of safety and quality. (A-724)

Due to the widespread, severity and cumulative effect these failures had the potential to be harmful and presented multiple hazards to the safety and well-being of all patients, staff and visitors which resulted in the overall noncompliance with the CFR482.12 Condition of Participation: Governing Body and CFR482.41 Condition of Participation: Physical Environment. The facility census was 51.

Based on interview and record review, the facility failed to follow Medical Staff Bylaws that gave only the Advisory Board/Governing Body the authority to grant medical staff privileges. This deficient practice had the potential for all patients admitted to the facility to receive substandard care. The facility census was 51.

Findings included:

Review of the facility's document titled, "St. Alexius Hospital Medical Staff Bylaws," dated 2018, showed the following direction for staff appointment:
- The Advisory Board/Governing Body serves as the governing authority of the Hospital and any committee of the Board when such committee is exercising powers of the Advisory Board.
- After the Medical Staff recommendation, the application of the appointment is sent to the Advisory Board.
- The Advisory Board, after considering the recommendations of the Medical Executive Committee, shall in whole or in part adopt, reject, modify or defer any of the recommendations.
- The Chief Executive Officer gives written notice to the applicant of the Advisory Board's decision.

Review of the facility's document titled, "St. Alexius Hospital Rules and Regulations of the Advisory Board," 05/06/13, showed that the Advisory Board shall consider the Medical Staff recommendations in the exercise of the Advisory Board's authority to appoint members of the Medical Staff.

Review of the facility's medical staff records on 06/25/19, showed no documentation of staff appointment and Advisory Board review for five Emergency Department Physicians (JJ,OO, QQ, RR and SS) and Staff C, Chief Medical Officer, of six reviewed.

During an interview on 06/18/19 at 4:08 PM, Staff DD, Facility Owner, stated that he was working on the credentialing for the new Emergency Department (ED) physicians that were to staff in the ED beginning on 06/25/19.

During an interview on 06/25/19 at 9:00 AM, Staff II, Medical Staff Coordinator, stated that she found out about the transition of the ED Physicians on 06/24/19. She also stated that Staff C, Chief Medical Officer, stated that she didn't have to prepare the new appointment documentation.

Based on review of the facility's Medical Staff Rules and Regulations, Appendix A and interview, the facility failed to ensure that the Medical Staff Rules and Regulations utilized by medical staff included what staff was authorized and/or privileged to write orders for the use of restraint and seclusion for patients. This failure had the potential to place all patients placed in either restraint or seclusion at increased risk for their safety. The facility census was 51 that included 42 patients on the facility's Behavioral Health Unit (BHU).

Findings included:

Review of Appendix A of the State Operations Manual (SOM) under section §482.13 Condition of Participation: Patient's Rights, reference tag A-0168, gave directive for facilities to establish in the Medical Staff ByLaws what staff was authorized and/or privileged to order the use of restraint and seclusion for patients.

Review of the facility's document titled, "Medical Staff Rules and Regulations," dated 08/2018, showed that under section A-10 that included orders (including telephone/verbal orders and restraint and seclusion order) did not specify what staff was authorized and /or privileged to order restraint or seclusion for patients at the facility.

During an interview on 06/20/19 at 11:41 AM, Staff B, Registered Nurse, Chief Nursing Officer, stated and verified that the facility's current Medical Staff Rules and Regulations dated 08/2019 did not include what staff was authorized and/or privileged to order restraint and seclusion for patients.

Based on interview and record review, the governing body failed to ensure that four Emergency Department (ED) physicians (JJ, OO, QQ and RR) of six reviewed were evaluated yearly on their clinical practice and practiced within their scope by reviewing the physician's Quality Assurance Performance Improvement (QAPI) program. This had the potential to affect the health outcomes and quality of care for all patients presenting to the facility. The facility census was 51.

Findings included:

Review of the facility's document titled, "St. Alexius Hospital Medical Staff Bylaws," dated 2018, showed the following direction for the Peer Review Committee to evaluate, maintain, or monitor the quality and utilization of the health care professionals.

Review of the facility's document titled, "St. Alexius Rules and Regulations of the Advisory Board," dated 05/06/13, showed that the Advisory Board shall require Medical Staff reports of medical care evaluation, utilization review and other matters relating to quality of care rendered in the Hospital.

Review of the facility's medical staff records on 06/25/19, showed no documentation of Quality evaluation of clinical practice for four Emergency Department (ED) Physicians (JJ, OO, QQ and RR) of six reviewed.

During an interview on 06/25/19 at 9:00 AM, Staff II, Medical Staff Coordinator, stated that the last Quality review for the four ED Physicians (JJ, OO, QQ and RR) was in 2017.

During an interview on 06/20/19 at 3:00 PM, Staff D, CEO, stated that he was unaware that quality evaluation had not been performed on the physicians since 2017.

Based on interview and record review and review of the Social Security Act of 1935, the facility and Chief Executive Officer (CEO) failed to ensure:
- That the facility functioned as a hospital in providing services by limiting capacity when licensed for 190 inpatient beds.
- The CEO informed the Governing Body of financial details in regards to payment of vendors (persons or companies whose products supply the facility with goods or services) to maintain patient care.
- Management of the entire facility including accountability for the effective oversight of compliance with the daily operations.
- That the dietary department contained enough food and dietary supplies to adequately meet the nutritional needs of the various patients admitted to the facility.
These failures had the potential to affect all patients that presented to the facility, along with the potential for devastating effects of patient care due to lack of funds appropriately dispersed. The facility census was 51.

Findings included:

Review of the document titled, "Social Security Act," section 1861 (e) (1), showed the following definition: (e) The term "hospital" means an institution which - (1) Is primarily engaged in providing, by or under the supervision of physicians, to inpatients (A) diagnostic services and therapeutic services for medical diagnosis, treatment, and care of injured, disabled, or sick persons, or (B) rehabilitation services for the rehabilitation of injured, disabled, or sick persons and (4) meets such staffing requirements as the Secretary finds necessary for the institution to carry out an active program of treatment for individuals who were furnished services in the institution.

Review of the Centers for Medicare/Medicaid Services (CMS) exhibit 286 worksheet, dated 06/25/19, showed the facility was licensed to provide services for 190 inpatient beds.

Review of previous surveys showed a decrease in admissions as follows:
- 02/08/18 census was 101;
- 04/19/18 census was 78;
- 07/12/18 census was 68;
- 10/16/18 census was 54; and
- 07/02/19 current census was 51.

During an interview on 06/19/19 at 10:17 AM, Staff K, Clinical Leader for the Emergency Department (ED), stated that she was told by Staff B, Chief Nursing Officer (CNO), that he only wanted a limited number of patient admissions.

During an interview on 06/19/19 at 10:37 AM, Staff L, Psychiatric Intake Registered Nurse (RN), stated that the first direction given from Staff B, CNO, was that the facility was closing three west and capping the fourth floor unit and they couldn't take psychiatric patients. The second direction was if a patient comes in and they were suicidal to keep them, but if they were homicidal or aggressive, send them to another facility.

During an interview on 06/20/19 at 11:00 AM, Staff U, Clinical Liaison and Marketing for the facility, stated that for the last six months they have been downsizing due to the limited number of staff. She stated that this was told to her by the CNO.

During an interview on 06/18/19 at 10:00 AM, Staff B, CNO, stated that he was directed by Staff DD, Facility Owner, that he was not to utilize agency nurses in order to modify the census of the units. He also stated that census was low, but was a decided decrease to benefit the facility financially and two weeks ago he let the surrounding nursing homes know that they weren't going to take their patients.

During an interview on 06/18/19 at 3:00 PM, Staff D, Chief Executive Officer (CEO), stated that Staff DD, Facility Owner, intentions were to shrink the facility and run a "laboratory scheme" and that he needed to reduce the agency staff.

During an interview on 06/18/19 at 4:08 PM, Staff DD, Facility Owner, stated that he doesn't have a census goal and he was reducing agency nurses because it was too expensive.

During an interview on 06/18/19 at 1:55 PM, Staff CC, Manager of the ED, stated that Staff DD, Facility Owner, told him that he wanted the census to go down and to cut salaries.

During an interview on 06/27/19 at 1:00 PM, Staff C, Chief Medical Officer and Interim CEO as of 06/26/19, stated that they were trying not to renew any agency nurses and the plan was to decrease beds if they can't staff.

Review of the facility's document titled, "Medical Staff Bylaws," dated 2018, showed the definition of the CEO's duties was to perform as the legal representative responsible for the operational supervision of all of the affairs of the Hospital.

Review of the facility's document titled, "St. Alexius Rules and Regulations of the Advisory Board," dated 05/06/13, showed that the CEO responsibilities were:
- To make periodic financial reports to the Advisory Board;
- To serve as the Liaison among the Board of Directors, Advisory Board, administrative staff and the Medical Staff;
- Along with the Advisory Board, to develop short-term and long-term financial management plans to include capital and operating budgets; and
- To organize and manage services, departments and delegation of duties.

Review of the Advisory Board Meeting minutes for three months showed no detailed financial report given to the Advisory Board.

Review of the undated facility document titled, "Vendor," showed the following delinquent vendor accounts:
- MEDS (ED physician group) $546,567.50;
- Specialists in Anesthesia PC $209,384.40
- Blue Chip Exterminating $4,483.57, cut-off due to non-payment;
- Orkin Pest Control $775.00 account on hold due to non-payment;
- Shared medical Services $62,000 No further Magnetic Resonance Imaging (MRI, test that uses a magnetic field and radio waves to create images of the organs and tissues within the body) services due to non-payment;
- AYA Healthcare Incorporated $602,715.33 Contracted labor (travel/agency nursing) on verge of pulling out due to non-payment;
- Nurses PRN (travel agency nursing) $151,519.75;
- Cardinal health Pharmacy Distribution $437,503.53 cut off due to non-payment;
- Boston Scientific (surgical supply company) $72,411.94
- SYSCO Food Services $113,140.72 Needs $20,000 weekly to continue delivery of food;
- Ameren Electric $335,170.00; and
- Metropolitan St. Louis Sewer/Water $134,691.49.

These 12 vendors were a partial listing of a vendor list that totaled 117 vendors with delinquent accounts with a total amount owed of $5,689,319.80. The failure to keep vendor accounts current resulted in the withdrawal of services that were critical for continued day to day operations of the facility and had the potential for continued withdrawal of services from additional vendors and potential for negative outcomes to all patients admitted to the facility.

During an interview on 06/20/19 at 1:10 PM, Staff BB, Anesthesiologist, stated that the facility was behind in payments to their anesthesia group and that they continued service due to the loyalty they had for patients in that community. He also stated that he planned to give written notice of discontinuation and take it to the next level.

During an interview on 06/18/19 at 1:55 PM, Staff CC, Manager of the ED, stated that all of the hospital departments had no operating budgets.

During an interview on 06/20/19 at 2:15 PM, Staff X, Advisory Board member, stated that he was not aware of the vendors not being paid.

During an interview on 06/24/19 at 2:15 PM, Staff Y, Advisory Board member, stated that he did not trust Staff DD, Facility Owner, and he was not aware of the lack of payment to the vendors.

During an interview on 06/26/19 at 2:15 PM, Staff D, CEO, stated that he did not inform the Governing Body of the financial difficulties with the lack of payments to the vendors.

During interview on 06/19/19 at 9:00 AM, Staff D, CEO, stated that several vendors had stopped bringing supplies to the facility and other vendors had been utilized; however, there could come a time when the current vendors also stopped bringing supplies to the facility.

During an interview on 06/19/19 at 10:03 AM, Staff P, Food Service Director, stated that it had recently been a recurrent theme of vendors not delivering the food ordered until the bill was paid and current.

Observation on 06/19/19 at 10:22 AM of the dietary department showed that:
- The storage room for canned goods and non-perishable items had limited supply.
- The refrigerator storage room for meat, vegetables, milk, juice, produce and other food items that required refrigeration had limited supply of the various food items.
- The freezer storage room for items that required freezing had limited food supply.

During an interview on 06/19/19 at 10:30 AM, Staff P, Food Service Director, stated that with the facility's current census, the dietary department had approximately seven days it could supply meals to patients. Staff P stated that with the current supply of milk, juice and produce the dietary department could supply the current patient census for approximately three to four days. Staff P stated that the dietary department had ran out of milk sometime during the month of May 2019 due to lack of funds to pay the vendor. Staff P stated that it was a constant concern for the dietary department if they were going to have enough food to supply meals to meet patients' nutritional needs.




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32280

Based on interview and record review the facility failed to provide an approved annual budget. This failure created an unorganized environment for staff that effected patient care at the facility. The facility census was 51.

Findings included:
Review of the facility's document titled, "St. Alexius Rules and Regulations of the Advisory Board," dated 05/06/13, showed the direction for the Advisory Board and the Chief Executive Officer (CEO) to develop, review and approve an annual capital and operating budget in order for the facility to effectively serve the community.

Although requested, the facility failed to provide an annual capital and operating budget for the facility.

During an interview on 06/20/19 at 9:00 AM, Staff O, Controller, stated that they did not have an annual operating budget.

During an interview on 06/18/19 at 1:55 PM, Staff CC, Manager of the ED, stated that there was no operating budget for the departments at the facility.

During an interview on 06/18/19 at 4:08 PM, Staff DD, Facility Owner, stated that they were utilizing the former three year budget from the previous owner.

During an interview on 06/26/19 at 2:15 PM, Staff D, Interim CEO as of 06/26/19, stated that they had no current annual budget.

Based on interview and record review the facility failed to ensure that patients that presented to the Emergency Department (ED) seeking care for an emergency medical condition and in-patient emergent care received stat (immediate results needed for the evaluation of an emergent medical condition) laboratory test results within twenty five minutes per the facility policy and failed to ensure the human decontamination sprayers (used to manage a contaminated patient that has been exposed to hazardous nuclear, biological or chemical materials, located outside of the ED entrance) were operational.
The severity and effect of these failures affected all patients that presented to the facility for emergency treatment. The facility census was 51.

Findings included:

Review of the facility's policy titled, "Laboratory Turn Around Times," dated 05/2016, showed:
- All STATS/Critical tests should be reported within twenty five minutes from the time received in the laboratory.
- Laboratory was to provide accurate precise, and timely results for physicians in order to provide quality patient care.
- STATS/Critical results was a result that was so abnormal and required rapid communication for the safe care of the patient.

Review of Patient #26's medical record showed that the patient presented to the ED on 06/14/19 at 1:20 PM with shortness of breath, weakness, severely anemic, lung cancer and foot ulcers. Staff RR, ED Physician, ordered Stat labs for Brain Natriuretic Peptide (BNP, a critical laboratory test for built up pressure in the heart chambers that can result in heart failure) and a D-Dimer (a critical laboratory test used to determine the presence of a blood clot) on 06/14/19 at 2:35 PM and received results for the BNP at 06/16/19 at 10:31 AM and received the results of the D-Dimer on 06/17/19 at 12:04 PM.

Review of Patient #27's medical record showed that the patient presented to the ED on 06/15/19 at 11:38 PM with leg pain, increased lower extremity pitting edema (observable swelling due to fluid accumulation) shortness of breath and lower abdominal pain. Staff QQ, ED Physician, ordered a BNP Stat on 06/16/19 at 1:05 AM and received results on 06/18/19 at 8:47 AM.

Review of Patient #24's medical record showed that the patient was an in-patient in the Intensive Care Unit (ICU) on 06/18/19 at 1:27 AM with respiratory distress and chronic obstructive pulmonary disease (COPD, a lung disorder that persistently obstructs airflow). Staff UU, ED Physician, ordered a Stat BNP on 06/18/19 at 2:00 AM and received results on 06/19/19 at 7:58 AM.

Review of Patient #28's medical record showed that the patient presented to the ED on
06/17/19 at 2:21 PM with shortness of breath and leg pain. Staff OO, ED Physician, ordered Stat labs for a BNP and a D-Dimer on 06/17/19 at 4:05 PM and received results on the BNP on 06/19/19 at 7:35 AM and the results of the D-Dimer on 06/19/19 at 10:18 AM.

Review of Patient #8's medical record showed that the patient was an in-patient on the fifth floor with respiratory distress on 06/13/19 at 10:00 AM. Staff QQ, ED Physician, ordered a Stat D-Dimer on 06/13/19 at 10:25 AM and received results on 06/15/19 at 7:35 AM.

These patients all presented with an emergent condition and the physicians ordered Stat labs with delayed results up to 48 hours. This delay placed all patients at risk for harm or death.

During an interview on 06/19/19 at 10:17 AM, Staff K, ED Clinical Leader, stated that the Lab told us that they were unable to perform BNPs and D-Dimers in-house and that they had to send them out due to lack of supplies. They have had several patients that would have benefited from having these results sooner.

During an interview on 06/19/19 at 11:45 AM, Staff N, Laboratory Manager, stated that due to lack of payment to the vendor she retrieves supplies from, she has not been able to produce the emergent lab tests in -house. She stated that she has to send them to an outside laboratory that causes the delay in receiving the results. She also stated that she has spoken with administration many times regarding this egregious delay in care.

During an interview on 06/27/19 at 3:00 PM, Staff OO, ED Physician, stated that he expected the BNPs and D-Dimer to be completely quickly.

During an interview on 06/27/19 at 1:00 PM, Staff C, Chief Medical officer (CMO), stated that he was unaware that the laboratory stat results were delayed over six hours.

During an interview on 06/26/19 at 2:15 PM, Staff D, Chief Executive Officer (CEO), stated that he hadn't understood the importance of the stat labs.

Observation on 06/26/19 at 1:20 PM, outside of the ED entrance, showed the decontamination area with two non-functional shower heads and a non-functional drainage area.

During an interview on 06/26/19 at 1:30 PM, Staff CC, Manager of the ED, stated that the decontamination sprayers have not been working for a long time and there was no drainage for them.

During an interview on 06/26/19 at 3:00 PM, Staff LL, Infection Preventionist, stated that any contaminated patients that presented to the ED would not be able to be decontaminated. The sprayers were not working and the drainage was not appropriate.

During an interview on 06/26/19 at 2:15 PM, Staff D, CEO, stated that he was unaware that the emergency decontamination sprayers were not working.

Based on observation, interview and record review, the facility failed to:
- Make necessary repairs and have regular pest control services; (A-0701)
- Control temperature and humidity in four Operating Room (OR) suites that hindered the infection prevention environment; (A-0726) and
- Maintain an adequate amount of patient supplies to ensure an acceptable level of safety and quality. (A-724)

Due to the widespread and cumulative effect of these deficient practices that presented multiple hazards and directly affected the safety and well-being of all patients, staff and visitors, it was determined that 42 CFR 482.41 Condition of Participation: Physical Environment was out of compliance. The facility census was 51.

Based on observation, interview and record review, the facility failed to make necessary repairs and have regular pest control services. These failures effected the overall hospital environment, increased the potential to spread infection and placed the safety of patients, staff and visitors at risk. The facility census was 51.

Findings included:

Observation on 06/25/19 at 1:00 PM, in the cafeteria, showed approximately 20 ceiling tiles dripping water with one that showed visible mold. The dripping tiles were approximately two feet from the food bar.

During an interview on 06/26/19 at 2:00 PM, Staff M, Director of Environmental Services and Engineering Operations and Maintenance, stated that the three inch main steam pipe had a one inch leak in the tunnel and the steam continued to rise up through the kitchen and cafeteria. The steam caused the water on the tiles. He also stated that the temperature was 140 degrees in the tunnel and there was no funds for repair.

During an interview on 06/24/19 at 2:30 PM, Staff P, Director of Food and Dietary Services, stated that she has put in work orders to replace the tiles and repair the steam pipe and was told there was no funds to perform this repair and the vendors won't return due to lack of payment.

Observation on 06/25/19 at 12:50 PM, in the kitchen, showed approximately 50 dead roaches on the top of the main dishwasher and two live roaches on the wall in the cafeteria.

During an interview on 06/25/19 at 1:00 PM, Staff P, Director of Food and Dietary Services, stated that in the morning when she first arrived to work, the roaches were all over the floors, walls and near the food preparation area. She also stated that the exterminator had not been there for two months due to lack of payment.

During an interview on 06/26/19 at 2:00 PM, Staff M, Director of Environmental Services and Engineering Operations and Maintenance, stated that there was no exterminating process and the cockroaches were as big as his hand.

During an interview on 06/26/19 at 2:15 PM, Staff D, Chief Executive Officer (CEO), stated that he was aware of the tiles dripping with water, not aware of any mold and he had not observed any roaches.

Based on observation and interview, the facility failed to ensure that the day to day operations of the facility were maintained with enough dietary supplies, medical supplies and equipment when the facility failed to ensure that:
- The dietary department had adequate meat, produce, milk, juice, perishable and non-perishable food supply to provide required nutritional needs of patients admitted to the facility.
- The main storage room had adequate medical supplies and equipment to care for patients admitted to the facility.
- The central supply room had adequate medical supplies and equipment to care for patients admitted to the facility.
- The Electroconvulsive Therapy (ECT, an alternative treatment, also known as shock therapy, for individuals with major depression not helped by medication therapy or when medication therapy is contraindicated) had adequate supplies to perform procedures.
These failed practices by the facility to have adequate supply of food, medical supplies and equipment readily available had the potential to negatively affect the health and safety of all patients admitted to the facility. The facility census was 51.

Findings included:

During an interview on 06/19/19 at 10:03 AM, Staff P, Food Service Director, stated that:
- She had concerns with paying food vendors and it continued to be a concern.
- In 05/2019, the vendor that supplied dietary supplements (a product taken orally intended to supplement one's diet and is not considered food) and tube feedings (nutrition received via a tube place in the body) did not deliver the ordered products because they had not been paid.
- It was a "recurrent theme" of vendors not bringing the order for both food and supplements until the bill was paid and current.
- The issues of not being able to pay vendors started in 04/2019 soon after the facility was purchased by Staff DD, Facility Owner.
- With the current food supply in the storage room, walk-in refrigerator and walk-in freezer, the facility had enough food supplies to provide approximately seven days worth of menus to provide nutritional needs of the current inpatient census.
- The facility's current supply of milk, juice, and produce would be enough for approximately three to four days with the current inpatient census.
- Sometime in the month of May 2019, the facility ran out of milk supply and the facility did not have the "funds" available to pay the vendor.
- She had concerns with repairs that were needed with the walk-in freezer and three refrigerators that were not operational but there were no "funds" available for the needed repairs.

Observation on 06/19/19 at 10:22 PM of the dietary department showed:
- The store room that contained canned goods and other non-perishable food items showed a limited supply of the various canned goods and non-perishable foods.
- The walk-in freezer that contained meat and other food items showed a limited supply.
- The walk-in refrigerator that contained milk, juice, produce and other food items showed a limited supply.

During an interview on 06/19/19 at 10:52 AM, Staff R, Manager of Materials, stated that he has experienced challenges with the ordering process because of a lack of "operating cash flow" and currently the vendors will not bring ordered medical supplies and equipment until the bill was paid up front. Staff R stated that since the new owner, Staff DD, took over operational functions of the facility, the facility had experienced issues with the availability of "operational cash flow" to pay vendors for the necessary medical supplies and equipment needed to care and treat patients.

Observation on 06/19/19 at 11:02 AM of the main supply room and at 2:15 PM of the central supply room showed that:
- The facility was out of personal hygiene items, for example, shampoo/body wash, disposable razors, shaving cream, body deodorant, lotion, skin cleanser used to cleanse patients after they experience incontinency (inability to control urine, stool or both), and disposable underwear or extra-large briefs used for patients that are incontinent or either urine, stool or both.
- No supplies for wound care and treatment, for example, no cleaning agents/cleansers or wound dressing supplies neither sterile nor non-sterile various size/type of pads and tape were available to treat patients' various wounds.
- General supplies, for example, no 8 ounce (oz) or 12 oz sized Styrofoam disposable cups, plastic teaspoons, multifold towels, trash can liners, touchless paper towel rolls, cotton balls and either limited or no supply of non-sterile gloves of various types and sizes.
- No supply of various cardiac supplies, for example, Electrocardiogram (EKG, recording of the electrical activity of the heart) electrodes, EKG paper that records the activity of the heart and no five French pacing electrode kits (device used to regulate the heart's rate and rhythm).
- Limited or no supply of various intravenous (in a vein) supplies and/or equipment, for example, various kinds/volumes of IV solutions and various IV tubing and needles used to infuse IV solutions, medications or nutrition.
- Limited or no urinary supplies, for example, urinary hats (plastic container use to measure urine output), urinary catheter kits (a small flexible tube inserted into the bladder, used to drain urine) of various sizes, urine collection bags, catheter straps (straps used to keep the catheter tubing in place, placed around the patient's upper thigh) and specimen collection containers with lids (plastic container used to collect urine to be sent to the lab for testing).
- Limited or no respiratory supplies, for example, closed system tracheotomy (an emergency surgical procedure used to open the windpipe) kits, no chamber humidification hi-flow for adults (oxygen that is provided through a nasal cannula at a flow rate of up to 60 liters per minute and is both humidified and heated-the Intensive Care Unit had two current patient on hi-flow oxygen), incentive spirometer (a device used to keep lungs healthy after surgery or with various lung diseases), equipment to deliver inhaled medications, various oxygen tubing and manual resuscitator (Ambu bag, is a hand-held device used to provide positive pressure ventilation to patients who are not breathing or not breathing adequately).
- No splints or arm slings (device used to support and immobilize either a broken bone or injured arm/shoulder) of any size were available, these items were mainly used in the emergency department.
- No needles of various sizes or extension sets used to access porta-catheters (a small medical appliance that is installed underneath the skin in the chest region and connects the port to a vein and is used to administer medication and draw blood).

During an interview on 06/19/19 at 2:15 PM, Staff T, Central Supply Technician, stated that the facility recently had experienced issues with the various vendors delivering ordered medical supplies and equipment. Staff T stated the central supply storage room did not have any supplies to care for patients' various wounds.

Observations made throughout all days of the survey on the different patient care units and the emergency department showed that each unit had limited medical supplies and equipment to care for patients, however; when the supplies ran out the main storage room and central supply room either had no replacements or limited supplies.

The lack of available cash flow to pay various vendors for the day to day operations needed for the proper care and treatment required from patients, placed all patients at the facility with an increased risk for negative outcomes related to their safety and well-being. The lack of needed food, medical supplies and equipment placed all patients at the facility at increased risk in not meeting their nutritional needs, personal hygiene needs, IV needs, respiratory needs, wound care needs, cardiac needs, urinary catheter needs and porta-catheter needs.

During an interview on 06/27/19 at 1:00 PM, Staff C, Chief Medical Officer (CMO) and Interim Chief Executive Officer (CEO), stated that they have daily meetings every morning to stay updated on the funds needed before services were cut off.

Review of the surgical and Electroconvulsive Therapy (ECT, an alternative treatment, also known as shock therapy, for individuals with major depression not helped by medication therapy or when medication therapy is contraindicated) schedule showed that on 05/29/19, 34 ECT scheduled treatments were canceled.

During an interview on 06/19/19 at 12:37 PM, Staff FF, Director of the Operating Room (OR), stated that on 05/29/19, 34 ECT treatments were canceled due to lack of electrodes (conductors used to establish electrical contact between the patient and the non-metallic part of the circuits). She also stated that she had contacted Staff M, Director of Engineering, Operations and Maintenance regarding the shortage.

During an interview on 06/19/19 at 11:07 AM, Staff M, stated that there were no working accounts to purchase supplies.

During an interview on 06/27/19 at 1:00 PM, Staff C, CMO and Interim CEO, stated that he was unaware of how many ECTs were canceled.

The ECT treatments were scheduled procedures that were essential for behavioral health patients. The cancellation was detrimental in the continuity of care by interrupting this process in the middle of their treatments. The facility performed approximately 160 ECTs per month.




36473

Based on observation, interview and record review the facility failed to ensure Operating Room (OR) temperatures and humidity were within policy specified ranges. Temperature and humidity control helped provide an electrically and microbial (organisms which cause infections) safe environment. These failures had the potential to ensure safe infection control practices to prevent infections and communicable diseases. The facility performed an estimated 69 surgeries per month. The facility census was 51.

Findings included:

Review of the Association of Perioperative Registered Nurses (AORN), dated 2018, showed the following direction for air exchange guidelines for surgical suites:
- A minimum of 20 air exchanges that equaled positive air flow;
- Temperature 68-73 degrees Fahrenheit (F, unit of temperature); and
- Humidity at 60% maximum.

BMReview of the document titled, "OR Room Summary," showed that between 05/01/19 and 06/19/19 excessive surgical suite temperatures ranging between 75 - 86 degrees and excessive humidity ranging between 63 - 85% showed the following air temperature and humidity excesses for the following:
- OR#1 on 05/02/19, 05/13/19, 05/16/19, 05/20/19, 05/21/19, 05/22/19, 06/03/19, 06/06/19 and 06/12/19;
- OR #2 on 05/02/19, 05/09/19, 05/16/19, 05/20/19, 05/21/19, 05/22/19, 06/03/19, 06/05/19 06/06/19, 06/14/19, 06/17/19, 06/18/19 and 06/19/19;
- OR #3 on 05/02/19, 05/14/19, 05/20/19, 05/21/19, 05/22/19, 06/03/19, 06/05/19 and 06/06/19; and
- OR #4 on 05/02/19,05/20/19, 05/21/19, 05/22/19, 06/03/19 and 06/06/19.

Review of twelve emails from Staff FF, Director of the OR, to Staff M, Director of Environmental Services and Engineering Operations and Maintenance, showed that she reported air temperature and humidity excesses in the OR.

During an interview on 06/19/19 at 12:37 PM, Staff FF, Director of the OR, stated that the air control in the OR was limited and when she saw the abnormal temperatures and humidity levels, she contacted Staff M to adjust. When they adjusted, it can take one to two hours for it to correct. The temperatures rise when more people enter the OR suites.

During an interview on 06/19/19 at 3:00 PM, Staff M, Director of Environmental Services and Engineering Operations and Maintenance, stated that when Staff FF contacted him he made the adjustments. The chiller system was old technology and there was no central control. He has contacted administration regarding this and was told there was no money in the budget.

These failures had the potential to lead to negative outcomes for patients with surgical incisions and increased the risk of cross contamination placing all patients, visitors and staff at risk for infection.