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Based on observation and interview, the CAH failed to be in compliance with applicable Federal laws and regulations related to the health and safety of patients as evidenced by failing to ensure signs were posted conspicuously in places likely to be noticed by all individuals entering the emergency department (ED) specifying the rights of individuals under section 1867 of the Emergency Medical Treatment and Active Labor Act (EMTALA) with respect to examination and treatment for emergency medical conditions and women in labor, and to post conspicuously information indicating whether or not the hospital participated in the Medicaid program under a State plan approved under Title XIX. The hospital did not have signs posted in the area where patients presented to the ED by ambulance.

Findings:

On 01/27/2020 at 10:35 a.m. a tour of the ED failed to reveal EMTALA signage posted for patients entering the ED via ambulance could observe.


On 01/27/2020 at 10:35 a.m. in an interview S6RN ED Director confirmed there was no EMTALA signage in the ED or ambulance entrance area for patients entering via ambulance to observe.

Based on record review and interviews the CAH (critical access hospital) failed to ensure the Emergency Department (ED) staff are trained to ensure care provided by the ED staff meet the needs of its inpatients and outpatients. This deficient practice was evidenced by failing to ensure all staff who care to the psychiatric patients in the Emergency Department were trained in nonphysical intervention for the patients treated in the ED for 1 (S11RN) of 4 (S6RN ED Director, S11RN, S12 Security, S13 Security) emergency room staff personnel records reviewed.

Findings:

A review of the personnel record for S11RN failed to reveal documented nonphysical intervention training.

In an interview on 01/29/2020 at 10:20 a.m. S7HR confirmed S6RN worked in the emergency department. She further confirmed the personnel file for S6RN failed to contain documentation of nonphysical intervention training.

Based on observations and interviews, the CAH failed to ensure the facility was maintained to assure the safety of patients as evidenced by having 3 ceiling mounted air-condition vents with rust and peeling paint in the kitchen. One of the vents was noted to be directly over the serving table.

Findings:

On 01/28/2020 at 11:30 a.m. a tour of the kitchen revealed 3 ceiling mounted air-condition vents with rust and peeling paint. One of the vents is located directly over the serving table.

On 01/28/2020 at 11:30 a.m. in an interview S8DM verified the above findings.

On 01/29/2020 at 10:25 a.m. in an interview S14 Maintenance confirmed there was no documentation of attempting to resolve the vents prior to this survey.

Based on record review and interview, the CAH failed to ensure the RN supervised and evaluated documentation of patient assessments, for accuracy, on the inpatient unit. This deficient practice was evidenced by failure of the RN to ensure a descriptive assessment of the condition of a patient, who was found deceased, was documented in the patient's medical record for 1 (#20) of 2 (#19, #20) sampled patient death records reviewed from a total patient sample of 20.

Findings:

Review of Patient #20's electronic medical record revealed an admission date of 05/19/2019. Further review revealed the patient expired on 05/20/2019.

Review of Patient #20's LOPA referral form, dated 05/20/2019, revealed the cause of death and time of death was listed as Respiratory and Cardiac Arrest at 5:50 p.m.

Further review of Patient #20's entire electronic medical record on 01/29/2020, with the assistance of S15RN, revealed the following nurses' notes:

05/20/2019 11:14 a.m.: Patient refusing to allow nurse to put in another IV. Constantly pulling venti mask off and O2 (oxygen) saturation drops into 30's and 40's. MD aware.

05/20/2019 6:00 p.m.: Patient passed away. The note was documented by S3LPN.

S15RN confirmed, after comprehensive review of the patient's entire electronic medical record on 01/29/2020 at 9:30 a.m., that there was no assessment by S3LPN or S16RN (RN who was working at the time the patient expired) describing the patient's condition when she was found such as level of responsiveness, presence/absence of respirations and pulse, color, and temperature of patient's skin, etcetera.

In an interview on 01/29/2020 at 10:31 a.m. with S16RN, she confirmed she was the RN working on the inpatient unit on 05/20/2019 with S3LPN. S16RN indicated she remembered Patient #20 and reported the patient had been declining throughout the day on 05/20/2019. She further indicated Patient #20 had been DNR code status. S16RN confirmed she was in the room with S3LPN, Patient #20's assigned nurse, when she found the patient deceased. She reported the emergency room physician came to the inpatient unit and pronounced the patient.

In an interview on 01/29/2020 at 9:40 a.m. with S15RN, she confirmed a descriptive assessment of the patient's condition when she was found should have been documented by the nursing staff.

Based on record review and interview, the CAH failed to ensure all drugs and biologicals were administered by, or under, the supervision of a registered nurse, in accordance with written and signed orders. This deficient practice was evidenced by failure of the nursing staff to administer PRN antihypertensives as ordered by the patients' physician for 1 (Patient #10) of 10 (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10) current inpatient records reviewed. Findings:

Review of the CAH's policy for Medication Administration revealed in part, medications omitted and the reason for omission are to be documented in the electronic medical record.

Patient #10
Review of Patient #10's EMR, navigated by S4RN, revealed the patient was an 86 year old female admitted to the hospital on 01/06/2020 for weakness after a stroke.

Review of Patient #10's physician's orders revealed an order for Hydralzine (Apresoline) injection 10 mg IV q 3 hours prn for hypertension prn for sbp>170 or dpb>110.

Review of the Patient #10 blood pressure on 01/27/2020 at 12:00 p.m. revealed a blood pressure of 178/84.

Review of Patient #10 Medical Administration Record revealed Apresoline was not administered to the patient for the elevated blood pressure. Further review of the EMR revealed no documentation the physician was notified of the elevated blood pressure and the reason why the patient's prn hypertensive medication was not administered.

An interview was conducted with S4RN on 01/28/2020 at 10:00 a.m. S4RN navigated the EMR and confirmed the findings that the Apresoline was not administered to the patient as ordered by the patient's physician.

Based on record review and interview, the CAH failed to ensure the nursing staff developed, and kept current, a comprehensive nursing care plan based upon ongoing assessments of patients' needs. This deficient practice was evidenced by failure to ensure patient care plans were inclusive of all medical diagnoses for 4 (#1, #2, #6, #8) of 10 (#1-#10) sampled patients reviewed for care plans from a total patient sample of 20.

Findings:


Review of the hospital policy titled, "Nursing Process Care Plan" revealed in part: I. Purpose: It is the responsibility of every nurse to actively contribute to the plan of care on each assigned patient. Care plans must be initiated, by a Registered Nurse, within 24 hours of admission.
III. General Information: Assessment: 3.a. The patient's plan of care will be personalized to meet individual patient care needs. b. Additional problems unique to the patient may be included and needs reassessed whenever warranted by the patient's condition. 4. Each patient's nursing care is based on identified nursing diagnoses, and/or patient care needs, patient care standards, and is consistent with the therapies of other disciplines.


Patient #1
Review of Patient #1's electronic medical record revealed an admission date of 01/21/2020. Further review revealed Patient #1 had a stool culture that was positive for C. difficile on 01/22/2020 and the patient had been placed on Contact Isolation Precautions on 01/22/2020.

Review of Patient #1's care plan revealed Actual infection with C. difficile and Contact Isolation Precautions were not identified as problems to be addressed on the patient plan of care. S15RN, who was assisting with electronic medical record navigation on 01/28/2020, confirmed Actual infection with C. difficile and Contact Isolation Precautions were not identified as problems on the patient plan of care.

Patient #2
Review of Patient #2's electronic medical record revealed an admission date of 12/24/2019. Further review revealed Patient #2 was placed on Droplet Precaution isolation on 01/27/2020 due to testing positive for Influenza A on 01/25/2020.

Review of Patient #2's care plan revealed Actual infection with Influenza A and Droplet Isolation Precautions were not identified as problems to be addressed on the patient plan of care. S15RN, who was assisting with electronic medical record navigation on 01/28/2020, confirmed Actual infection with Influenza A and Droplet Isolation Precautions were not identified as problems on the patient's plan of care.


Patient #6
Review of Patient #6's electronic medical record revealed an admission date of 01/23/2020. Further review revealed Patient #6 had a swallowing evaluation performed by Speech Therapy on 01/22/2020. Additional review revealed the patient had been diagnosed with Dysphagia and was receiving a mechanically altered consistency diet due to issues with swallowing.

Review of Patient #6's care plan revealed Dysphagia and requiring a mechanically altered consistency diet due to swallowing issues were not identified as problems to be addressed on the patient's plan of care. S15RN, who was assisting with electronic medical record navigation on 01/28/2020, confirmed Dysphagia and requiring a mechanically altered consistency diet due to swallowing issues were not identified as problems on the patient's plan of care.


Patient #8
Review of Patient #8's electronic medical record revealed an admission date of 01/13/2020. Further review revealed Patient #8 had a diagnosis of Diabetes Mellitus and was receiving insulin coverage, per sliding scale, for capillary blood glucose management.

Review of Patient #8's care plan revealed altered nutritional needs related to Diabetes Mellitus was not identified as a problem to be addressed on the patient's plan of care. S15RN, who was assisting with electronic medical record navigation on 01/28/2020, confirmed altered nutritional needs related to Diabetes Mellitus was not identified as a problem on the patient's plan of care.

Based on record review and interview, the CAH failed to ensure all patient medical records were complete, accurately documented, readily accessible, and systematically organized. This deficient practice was evidenced by failure to ensure a death summary was documented in a deceased patient's medical record within 30 days of discharge for 1 (#20) of 2 ( #19, #20) death records reviewed out of a total patient sample of 20.

Findings:

Review of the hospital policy titled, "Delinquent Chart Policy", revealed in part: I. Purpose: To define the policy and procedure addressing delinquent medical records and the process of suspending physicians.
III. General Information: Timely entries in the medical record are important in order to be useful in a patient's care. A medical record is considered delinquent if it is not complete within 30 days of discharge. IV. Procedure: A. Medical records should be completed at the time of discharge.

Review of Patient #20's medical record revealed an admission date of 05/19/2019. Further review revealed the patient expired on 05/20/2019.

Review of Patient #20's entire electronic medical record on 01/29/2020, with the assistance of S15RN, revealed no documented evidence of a death summary in the patient's record. S15RN confirmed Patient #20 had expired on 05/20/2019. S15RN further confirmed there should have been a death summary in Patient #20's record and verified there was no death summary documentation in the patient's medical record.

Based on observation, interview, and record review, the CAH's infection prevention and control program failed to ensure a clean and sanitary environment that avoided potential transmission of infection was maintained. This deficient practice was evidenced by:
1) failure to ensure isolation precautions were maintained to reduce the risk of possible infection transmission for 2 (#1, #2) of 2 current observed inpatients, who were on isolation precautions, from a total patient sample of 20; and
2) failure to ensure patients were placed on isolation precautions, as soon as possible after notification of positive culture results in order to reduce the risk for possible transmission of the infections to others, for 2 (#1,#2) of 2 current inpatients sampled for being on isolation precautions, from a total patient sample of 20.

Findings:

1) Failure to ensure isolation precautions were maintained to reduce the risk of possible infection transmission for inpatients on isolation precautions.

Review of the hospital policy titled, "Contact Precautions", revealed in part: I. Purpose: To provide a safe environment for patients requiring contact precautions and for the hospital personnel caring for these patients. II..., III..., IV. General Information: A. Contact Precautions. 1. f. C difficile (Clostridium difficile) infection.
V. Procedure: B. In addition to Standard Precautions 1. Keep the door closed 2. Dedicate non-critical care equipment to a single patient when possible, otherwise, clean and disinfect equipment before use on another patient. 3. Wear gloves and gown before entering patient room. 4. During the course of providing care to any patient, change gloves after contact with infective material that may contain high concentrations of microorganisms before touching any other part of the patient's body or anything else in the patient's environment. 5. Remove gloves and gown before leaving the patient's room and wash hands immediately with an antimicrobial agent. Use a paper towel to open the door. C. Special considerations when caring for patients with C. difficile: 1. Hand hygiene should include only soap and water. Alcohol based sanitizers are not recommended for use after caring for these patients.

Patient #1
Review of Patient #1's electronic medical record revealed an admission date of 01/21/2020. Further review revealed Patient #1 had a stool culture that was positive for C. difficile on 01/22/2020 and the patient had been placed on Contact Isolation Precautions on 01/22/2020.

On 01/27/2020 at 10:30 a.m. an observation was made of S5HK. She was observed coming out of Room 111 with gloves on. She was observed reaching into her pockets, touching the keys to the housekeeping cart with her gloved hands, and she used her gloved hands to open the housekeeping supply cart with the keys. She also touched the outside of the cart with her gloved hands. She did not remove her gloves or perform hand hygiene during the observation.

On 01/27/2020 at 10:45 a.m. an observation was made of Patient #1's room. Contact isolation signage was observed on the patient's room door. S4RN, present during the observation, confirmed Patient #1 was on contact isolation precautions for C. difficile. S5HK was observed coming out of Patient #1's room with gloves on. S5HK was then observed touching the top of the housekeeping cart and the mop with the gloves she had been wearing in Patient #1's room. She touched the glove box and the clean linen cart with her contaminated gloves. She was observed going back into the room with the same gloves on. She did not remove her gloves and did not perform hand hygiene.

On 01/27/2020 at 10:46 a.m. S5HK was observed emptying trash bare-handed and she was further observed placing the trash bag collected from Patient #1's room on top of the housekeeping cart.

On 01/27/2020 at 10:48 a.m. S5HK was observed coming to the doorway of Patient #1's room, touching the housekeeping cart with her contaminated gloves.

On 01/27/2020 at 10:51 a.m. S5HK had washed her hands. She was then observed putting on her gloves, placing her hands in her pockets to get the keys that she had touched with the contaminated gloves earlier, and going back in to the housekeeping cart.

S4RN, present during the observation, verified the above referenced observations.

In an interview on 01/27/2020 at 10:52 a.m. with S5HK, she indicated she had performed hand hygiene with hand sanitizer and had not washed her hands with soap and water.

Patient #2
Review of the hospital policy titled, "Droplet Precautions", revealed positive lab testing for Influenza A required the patient being placed on Droplet Precaution Isolation. Further review of the guidance for Droplet Precaution Isolation revealed the door to the patient's room should remain closed at all times.

Review of Patient #2's electronic medical record revealed an admission date of 12/24/2019. Further review revealed Patient #2 was placed on Droplet Precaution isolation on 01/27/2020 due to testing positive for Influenza A on 01/25/2020.

On 01/27/2020 at 10:33 a.m. an observation was made of Patient #2's room. Signage on Patient #2's room indicated the patient was on Droplet Precaution Isolation. S2DON reported the patient was on Droplet Precaution Isolation due to testing positive for Influenza A. The patient's door was observed to be open to the hallway and the patient could be heard coughing in the room.

In an interview on 01/27/2020 at 10:40 a.m. with S2DON, she confirmed the patient's room door should have been closed due to the patient being on Droplet Precaution Isolation.


2) Failure to ensure patients were placed on isolation precautions as soon as possible after notification of positive culture results to prevent infection transmission.

Patient #1
Review of Patient #1's electronic medical record revealed the patient was seen in the ED on 01/21/2020 for Hyponatremia related to acute diarrhea. Further review revealed the patient was admitted to rule out C. difficile infection. Additional review revealed the patient was placed on observation status on 01/21/2020. A stool culture was obtained on 01/22/2020 and was positive for C. difficile. S15RN, electronic medical record navigator, confirmed the patient was not placed on Contact Isolation Precautions for C. difficile until 01/22/2020.

In an interview on 01/28/2020 at 10:00 a.m. with S15RN/Infection Control Officer, she confirmed patients who came into the hospital who were symptomatic with multiple episodes of diarrhea would have been placed on empirical Contact Precaution Isolation when ruling out C difficile. S15RN confirmed Patient #1 should have been placed on Contact Isolation Precautions until C. difficile cultures had been obtained/resulted.

Patient #2
Review of Patient #2's electronic medical record revealed an admission date of 12/24/2019. Further review revealed Patient #2 tested positive for Influenza A on 01/25/2020. Additional review revealed the patient was not placed on Droplet Precaution Isolation until 01/27/2020 (2 days after testing positive for Influenza A on 01/25/2020).

In an interview on 01/29/2020 at 10:50 a.m. with S15RN/Infection Control Officer, she confirmed nursing staff could place patients on isolation precautions and could obtain MD orders for isolation at a later time. S15RN confirmed there was a delay in placing Patient #1 and Patient #2 on appropriate isolation precautions after having positive culture results for C. difficile ( Patient #1- Contact Isolation Precautions) and Influenza A (Patient #2 - Droplet Precaution Isolation).

Based on record review and interview, the CAH failed to ensure the current patients classified as swing bed patients were informed of their SNF patients' rights for 8 of 8 (Patients #2, #4, #5, #6. #7, #8, #9, #10) sampled swing bed patients reviewed from a total patient sample of 20. Findings:


Review of the patient rights supplied to the current swing bed patients in the CAH revealed the following SNF patient rights were not include in the information provided to the patients:

The resident has the right to be informed of, and participate in, his or her treatment, the right to be informed, in advance, of changes to the plan of care.

The resident has the right to choose his or her attending physician.

The resident has the right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents.

The resident has the right to share a room with his or her spouse when married residents live in the same facility and both spouses consent to the arrangement.

The facility must provide immediate access to a resident by immediate family and other relatives of the resident, subject to the resident's right to deny or withdraw consent at any time;

The facility must provide immediate access to a resident by others who are visiting with the consent of the resident, subject to reasonable clinical and safety restrictions and the resident's right to deny or withdraw consent at any time;

The resident has the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility for the resident through a means other than a postal service, including the right to: Access to stationery, postage, and writing implements at the resident's own expense.

The resident has the right to be informed, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of the items and services that are included in nursing facility services under the State plan and for which the resident may and may not be charged.

The resident has the right to personal privacy and confidentiality of his or her personal and medical records.

An interview was conducted with S1Adm on 01/29/2020 at 10:45 a.m. S1Adm reported the patient rights for the swing bed patients were included in the patient's admission packet at one time. She further reported when the marketing department revised the admission packet, the swing bed patients' rights must have inadvertently been left out of the packet. S1Adm reported the admission packet was revised in the summer of 2019.