HospitalInspections.org

Based on record review and interview, the hospital's governing body failed to ensure emergency room (ER) providers followed the medical staff policies and procedures for contracted services and performed oversight appraisals of emergencies, the medical screening exam, initial treatment, and appropriate referrals. The failure to provide oversight of the emergency services, screening, treatment, and referral had the potential to affect all patients who presented to the ER with inappropriate patient care.

Findings include:

A review on 08/23/18 of three emergency room medical records for patient (P) 35, P44, and P45 showed they lacked a medical screening exam by a qualified provider. Further review revealed the nurse documented the ER provider was at the clinic and when called by the ER nurse the provider told the patient to go to the clinic to be seen.

A review on 08/24/18 of the hospital's quality assurance performance improvement (QAPI) meeting minutes (2017/2018) and QAPI data reports (2017/2018), the facility did not measure, analyze, or track quality indicators related to the completion of medical screening examinations in the Emergency Department performed by contracted services.

Review of the document titled "Medical Staff Bylaws and Medical Staff Rules and Regulations" (7/15) showed it was not updated as identified in the document. This document works in conjunction with the Medical Staff bylaws to guide the medical staff in the performance of their responsibilities. This document stated in section V, Item A, "Rules and Regulations should be reviewed every two years." The current approval date of the document is 07/16/15. The 07/16/15 bylaws, rules and regulations indicated the following for the emergency room provider medical screening exam: "All MSEs should be performed in the hospital by a qualified medical provider (OMP). Sumner Regional Medical Center recognizes a QMP as the following, Physician, physician's assistant, advance registered nurse practitioner, registered nurse, licensed practical nurse, or a medical intensive care technician who must be under physician direction."

Interview on 08/24/18 at 1:15 PM, the Chief Executive Officer (CEO) shared that they were not unaware if the contracted emergency services providers, appropriateness of the MSEs, and ER referrals to the clinic were ever discussed in the QAPI meetings, the medical staff meetings or the governing body meetings. The CEO was unable to provide documentation that inappropriate MSE had been identified and evaluated within the QAPI, medical staff or the governing body committees. Further interview with the CEO confirmed that there was no evidence to show that the Bylaws or Rules and Regulations had been approved since the 07/16/15 date and indicated that this just must have been an oversight by the Medical Staff.

Based on document review and interview, the facility staff failed to monitor processes of care which affected the performance of the hospital. This deficient practice placed patients, staff and visitors at risk of harm as the quality improvement program was not assessing processes of care as part of an ongoing program guided to improve health outcomes.

Findings include:

1. A review of facility documents, "2017/2018 Quality Assessment and Performance Improvement (QAPI) meeting minutes and data reports" the facility failed to identify, measure, analyze or track quality indicators that affected the provision of patient care and the performance of the hospital. The QAPI program did not include:

a. Measures or monitors for all equipment that should have been a component of a Preventative Maintenance (PM) program. The QAPI did not contain equipment of a non-electrical nature [i.e., weight machines in physical therapy, bicycle equipment in physical therapy and other mechanical items that patients interact with on a routine basis]. This deficient practice places patients at risk of harm as any piece of equipment that moves has the potential to cause injury if not maintained according to the manufacturers recommendations.

b. Measures or monitors for completed Medical Screening Examinations (MSEs) in the Emergency Department (ED) performed by contracted services. This deficient practice places the patient at risk of harm if not adequately stabilized prior to transfer or discharge from the ED.

c. Measure or monitors for the physical environment. The QAPI program did not include the fire egress door with a locking device behind the physical therapy department and the fire safety program within the health information department. This deficient practice places patients, visitors and staff at risk of harm if a fire emergency occurs and the locked door prevents a timely evacuation of the space.

A review of facility document, "2017/2018 QAPI meeting minutes, QAPI data reports and health information reports" the QAPI program failed to identify, measure, analyze or track quality indicators related to medical records and physician requirements of completing medical records in a timely manner. The QAPI program failed to identify physician medical record delinquency rates, physician performance in completing discharge summaries within 30 days after discharge and appropriateness of completing informed consents required at time of hospital admission. This deficient practice places patients at risk of harm as incomplete medical records may lead to delayed care or inappropriate care.

Interview on 08/24/18 at 1:00 PM, the Quality Manager indicated that the QAPI program was undergoing some modifications transitioning from a monthly meeting to a quarterly meeting and some department information did not appear in the new quarterly format. The Quality Manager also indicated that Nursing was reviewing the Emergency Department records and had identified some documentation concerns that was being worked on. The Quality Manager confirmed that the other deficient items were not part of the quality meeting but may have been discussed in the safety or risk management meetings.

Based on document review and interview the facility failed to ensure that the "Medical Staff Bylaws and Rule & Regulations," were updated and maintained every two years as identified in the facilities documents. This deficient practice prevents the medical staff from enforcing their bylaws and carrying out their responsibilities.

Findings include:

1. A review of facility document titled "Medical Staff Bylaws and Medical Staff Rules & Regulations dated July 16, 2015" was not updated as required in the facility's document.

a. The Rules & Regulations indicated "this document works in conjunction with the Medical Staff bylaws to guide the medical staff in the performance of their responsibilities."

b. The Rules & Regulations indicated in section V, item A: "Rules and Regulations should be reviewed every two years."

Interview on 08/24/18 at 2:00 PM, the President & Chief Executive Officer (CEO) (3) stated "there was no evidence to show that the "Bylaws" or "Rules and Regulations" had been approved since the July 16, 2015 date identified on the documents". The CEO indicated this must have been an oversight by the Medical Staff.

Based on observation, staff interview, and policy and procedure review, the hospital failed to ensure nursing staff followed policy and procedure to maintain, monitor and check crash carts and remove outdated medications stored in two of three nursing departments, the inpatient unit (IPU) and the emergency room (ER) crash cart. The deficient practice had the potential to affect all patients admitted the inpatient unit and the ER who required emergency medications from the crash cart.

Findings include:

Observation on 08/21/18 of the IPU and the emergency room, between 2:30 PM to 4:15 PM revealed the following:

1. The IP crash cart contained two vials of Hydralazine Hydrochloride (a vasodilator to treat high blood pressure), 20 milligram (mg)/milliliter (ml), injectable, with an expiration date of 07/18.

2. The ER crash cart contained four vials of Hydralazine Hydrochloride, 20 mg/ml for injections with an expiration date of 07/18.

3. The ER crash cart contained one-liter bag of 5% Dextrose Injection (used to rescue patients with low blood sugar), 1000 ml with and an expiration date of "April 2018" or three and a half months ago.

The ER office medication cabinet contained one vial of 200 mg/2ml of Thiamine HCL, (a B vitamin that helps your body to use carbohydrates for energy), injectable, with an expiration date of 04/18 or three and a half months ago.

During an interview with the ER Registered Nurse RN/Charge Nurse verified the policy requires the IPU and ER nursing to check the crash carts monthly and remove and replace expired medications.

Review of the policy titled "Crash carts/Emergency Drug Trays," effective date; 01/24/17, indicated the following;
" ...Procedure All crash cart drugs should be checked for outdates at the first of each month. This includes ED (emergency department), first floor (IPU) and OF.


Review of the Emergency Department unit." Daily Crash Cart Checklist," revealed the following:

1 "June 2018, Emergency Department" daily checklist revealed nursing staff failed to check the crash cart on June 2, 3, 4, 6, 7, 9. 10, 12, 13, 15, 16, 17, 18, 19, 20, 21, 23, 24, 25, 26, 27, and 30 or for a total of 22 days.

2. "July 2018, Emergency Department" daily checklist revealed nursing staff failed to check the crash cart on July 1, 5, 7, 8, 9, 10, 12, 14, 15, 17, 18, 19, 21, 22, 23, 25, 27, 28, 29, and 31 or for a total of 20 days.

3. "August 2018, Emergency Department" daily checklist revealed nursing staff failed to document the cart was checked from August 1 thru August 16 and failed to check it on August 18th or for a total of 17 days.


Review of the "First Floor (Inpatient unit-(IPU)) "Daily Crash Cart Checklist," revealed the following:

1. "June 2018, IPU, daily checklist revealed nursing staff failed to check the crash cart on June 1to 5th, 7, 10, 12th to 20th, 23rd to 28th and 30th or a total of 23 days.

2. "July 2018, IPU daily checklist revealed nursing staff failed to check the crash cart on July 1st and 2nd, 4th to 11th12 to 24th, 27th to the 29th and the 31th or a total of 24 days.

3. "August 2018, IPU daily checklist" revealed nursing staff failed to check the crash cart on August 1st to 12th, 14, 16, 17 and 18 or a total of 16 days.

Review of the policy titled "Crash carts/Emergency Drug Trays," effective date; 01/24/17, indicated the following;
"Policy: Crash Cart locations...ED...should be checked every day by ED and RT (respiratory staff)...First floor (IPU)...should be checked every day by ED and RT staff.

Based on observation and interview, the facility failed to ensure that only authorized individuals had access to original patient medical records. This deficient practice places those patient records at risk for unauthorized access, potential alteration or theft of Personal Protected Health Information (PHI).

Findings include:

1. Observation on 08/21/18 at 10:40 AM during a tour of the physical environment showed an air handling/equipment room where patient medical records and patient imaging records were being stored in a common access room that also contained business office records, wood working equipment and other supplies. Patient medical records and imaging records were being stored on an unsecured shelf system open to any individual who had access to the overall space. This deficient practice places personal patient information including protected health information at risk of unauthorized access, potential alteration or even theft.

2. Observation on 08/23/18 at 3:45 PM during a tour of the health information department showed patient medical records were being stored on a rolling system that was accessible to the housekeeping staff and other individuals who could gain access to the space. This deficient practice places personal patient information including protected health information at risk of unauthorized access, potential alteration or even theft by staff members without a need to know patient health information.

Interview on 08/21/18 at 10:40 AM, the Facility & Security Manager stated, "that multiple staff members had access into the room where patient medical records and imaging records were being stored as they were being processed out of the facility."

Interview on 08/23/18 at 4:00 PM, two health information staff members indicated that housekeeping and nursing had access to the department after hours. Housekeeping cleaned the office space after the record management staff departed for the day.

Based on medical record review, policy review, and interview the facility failed to ensure that all patients admitted to the hospital had a properly executed informed consent completed for 3 of 30 closed medical records reviewed (Patient(P)5, P16 and P18). This deficient practice places the facility and patient at risk for treating and receiving treatment against a person's will or informed consent acknowledgement. In a review of 30 closed medical records, three were deficient

Findings include:

1. Review of P5's medical record showed the facility failed to obtain a properly executed informed consent for admission to the hospital.

a. P5's Consent for "Operation, Anesthetics and Other Medical Services" was dated 03/05/18 at 2139 [9:39 PM]. The consent was witnessed was by a staff Licensed Practical Nurse (LPN) and the signed section for the patient area had "unable to sign" documented.
b. P5's Consent for "Admission and Treatment" was dated 03/05/18 and had "unable to sign" documented and then signed by a staff LPN.
c. P5's "Acknowledgement of Receipt of Privacy Practices & Patient Rights" was dated 03/05/18 which had "unable to sign" documented and then signed by a staff LPN.
d. P5's "admission packet" indicated additional contact information for a family member (F1) with a telephone number listed.

There is no evidence that facility attempted to obtain telephone consent or any other methods to ensure someone was able to provide appropriate consent for the patient's treatment. This deficient practice places the patient at risk of receiving medical treatment against their will and desires.

2. Review of P16's medical record showed the facility failed to obtain a properly executed informed consent for admission to the hospital.

a. P16's Consent for "Operation, Anesthetics and Other Medical Services" was dated 06/02/18 at 1940 [7:40 PM]. The consent was witnessed by a staff LPN and the signed section for the patient area has "unable to sign".
b. P16's Consent for "Admission and Treatment" was on 06/02/18 and had "unable to sign" documented and then signed by a staff LPN.
c. P16's "Acknowledgement of Receipt of Privacy Practices & Patient Rights" dated 03/05/18 which had no signature, time or date.
d. P16's "Admission Packet" showed additional contact information for family members (F1, F2 and F3) with telephone numbers listed.

There is no evidence that facility attempted to obtain telephone consent or any other methods to ensure someone was able to provide appropriate consent for the patient's treatment. This deficient practice places the patient at risk of receiving medical treatment against their will and desires.

3. Review of P18's medical record showed the facility failed to obtain a properly executed informed consent for admission to the hospital.

a. P18's Consent for "Authorization for Blood Transfusion" was dated 06/13/18 at 0900 [9:00 AM] and was witnessed by a staff LPN. The section for the patient area had "unable to sign".
b. P18's Consent for "Admission and Treatment" was on 06/13/18 documented "unable to sign" in the patient signature block and was then signed by a staff LPN.
c. P18's "Acknowledgement of Receipt of Privacy Practices & Patient Rights" was dated 06/13/18 was documented as patient "unable to sign" and then witnessed by a staff LPN.
d. P18's "Admission Packet" showed additional contact information for family members (F1) with a telephone number listed.

There is no evidence that facility attempted a telephone consent or any other methods to ensure someone was able to provide appropriate consent for the patient's treatment. This deficient practice places the patient at risk of receiving medical treatment against their will and desires.

Review of the facility policy titled "Consent, Informed (9/15)" showed "A general consent form should be signed by all patients presenting themselves to the hospital, when possible, at the time of admission." The policy outlines steps for competent patient, incompetent patients and minors. The policy stated an exception to the informed consent process when there is an emergency treatment situation but requires the patient's next of kin or guardian would be requested to sign the consent. The policy also describes a process for a telephone consent that is allowed as long as it is witnessed by two staff members. This deficient practice shows the facility did not follow their policy in regard to getting the patients informed consent before providing medical treatment and care.

Interview on 08/23/18 at 3:55 PM, the Quality Manager indicated an unawareness if the facility's policy details who can sign a consent if the patient is unable but is aware of the telephone consent process. The Quality Manager provided a copy of the informed consent process and confirmed that the consents in the admission packets for the patients identified did not contain a properly executed process or follow the process outlined in the facility's policy.

Based on medical record review, policy review, and interview, the facility did not ensure that providers completed the medical record within 30 days of discharge by failing to document the patient's final diagnosis for 1 of 6 closed records reviewed (Patient (P) 23).

Findings include:

Review on 08/23/18 of Patient 23's medical record lacked evidence that the discharge summary and final diagnosis was completed within 30 days of discharge. Initial review of the closed medical record on the facility's computer system showed the record was not verified and did not contain a physician/provider signature.

Review on 08/23/18 of facility document "Medical Staff Rules and Regulations" (7/15) showed in section VIII Discharges, "The chart will be considered delinquent if not completed within thirty (30) days of the discharge date."

Interview on 08/23/18 at 8:35 AM with Staff Member 13 confirmed that the discharge summary must be completed within 30 days after discharge. Staff Member 13 stated that the provider of behavior health services is normally on top of documentation and has not had a history of delinquent records.

Based on observation and interview the facility did not ensure that overall hospital environment was maintained for the safety and well-being of all patients, staff, and visitors.

Findings include:

On 08/21/18 at 11:20 AM, during a tour of the physical environment, it was observed that a corridor behind the physical therapy department was approximately 50 feet in length and had a door at the end of the coordinator marked exit. This door was locked with a thumb latch device that did not require a key or tool to unlock the door. There was no identification or instructions to staff, patients or visitors that the door was locked for security purposes or how to unlock this door.

Interview on 08/21/18 at 11:20 AM, Staff Member 19 confirmed that the door was locked for security purposes, the door was considered a fire egress door, and the door did not have instructions on how to unlock the door in case of emergency use.

Based on observation and interview, the facility did not ensure that the hospital met all fire safety requirements for the safety and well-being of all patients, staff, and visitors.

Findings include:

On 08/21/18 at 11:20 AM, during a tour of the physical environment, it was observed that a corridor behind the physical therapy department was approximately 50 feet in length and had a door at the end of the coordinator marked exit. This door was locked with a thumb latch device that did not require a key or tool to unlock the door. There was no identification or instructions to staff, patients or visitors that the door was locked for security purposes or how to unlock this door.

On 08/23/18 at 3:45 PM, during a tour of the health information department, it was observed that the department space was an internal compartment which was not sprinkled, did not have a fire pull alarm station, or contain a fire extinguisher. The staff had to exit the department and travel approximately 30 feet to the nearest fire alarm pull station and fire extinguisher.

Interview on 08/24/18 at 8:45 AM, Health Information Staff members confirmed that the department did not have a fire extinguisher in the compartment and would have to leave the department to pull an alarm and grab an extinguisher in the event of a fire emergency.

Based on observation, document review, and interview, the facility did not ensure that all equipment was maintained at an acceptable level of safety and quality.

Findings include:

On 08/21/18 at 11:25 AM, during a tour of the physical environment, it was observed that equipment in the physical therapy treatment room did not have evidence of being inspected as a part of a preventative maintenance program. Items including a NuStep machine, a Bi Step machine, bicycles and weight machines, did not have any preventative maintenance or other inspections to verify the equipment had been inspected or maintained according to the manufacturer's recommendations for safety.

Review on 08/22/18 of the facility's document "Inspection Summary" (3/18) did not include the identified devices in the physical therapy department on the list of equipment managed, inspected or maintained by the contracted service provider.

Interview on 08/22/18 at 1:20 P, Staff Member 19 indicated that the non-electrical equipment identified was missed and was not part of the preventative maintenance program that the contracted vendor was performing. Staff Member 19 confirmed that non-electrical equipment in the physical therapy department had not been identified as a required component of a preventative maintenance program.

Based on observation, interview, and record review, the hospital failed to ensure the Infection Control (IC) nurse followed the hospital's policies and procedures for infection control when the IC nurse failed to monitor, investigate, and prevent or control the opportunity for the spread of infection related to the staffs' use of toilet bowl cleaners during one of one terminal room cleaning observations and the disinfection of blood glucose monitoring devices for one of one random observation. The deficient practice had the potential to affect all patients admitted the inpatient (IP) nursing unit patient rooms and those who were ordered blood glucose finger sticks.

Findings include:

1. Observation on 08/21/18 at 12:55 PM showed Housekeeper Staff 28, during the terminal clean of IP nursing unit room 112, squirt "Kling" toilet bowl cleaner into the toilet bowl that was half full of water. Staff 28 then proceeded to squirt cleaner above the water line and around the rim of the toilet bowl , let it stand for approximately 1 minute, before using the toilet brush to clean the bowl, and then flushed the stool.

Interview during this observation, Staff 28 explained that the Kling product has a one-minute kill time. However, Staff 28 shared that the hospital ordered the wrong toilet bowl cleaner and showed a label stating that it requires a contact time (amount of time a product needs to be present on a surface in order to be effective against the germs) of 10 minutes. Staff 28 was unaware that the Kling toilet bowl cleaner required a 10-minute contact time and verified she did not back flush the toilet to remove the excess water.

Review of the manufacturer's directions for use on the "Kling Toilet Bowl Cleaner" bottle during Staff 28's interview showed the contact time was for 10 minutes.

Review of the housekeeping "Patient Bathrooms Task Routine/Standard" indicated the following; "3. Toilet & Plumbing, Spray hospital approved disinfectant on toilet seat and outside of bowl ...and leave wet....do bathroom last. Clean inside of toilet bowl by flushing toilet and back flushing toilet and back flushing to remove as much water as possible. Put 2 ounces (oz) of solution on wand and clean entire bowl including under the rim and let stand for recommended time."

2. Observation on 08/23/18 at 11:30 AM. showed Licensed Practical Nurse (LPN) 25 take the blood monitor kit (a device used to test blood glucose (sugar) levels) and glucose testing strips and supplies stored in a kit). LPN 25 sat the kit on a towel on the countertop next to the patient's bed and gathered the monitor and supplies from the kit.
During the testing, LPN25 picked up the meter from the kit, removed the test strip, removed gloves, applied alcohol, and walked out of the patient's room with the glucose kit under their arm. LPN 25 then walked into the dirty storage room to clean the monitor. Observation revealed LPN 25 use a Clorox wipe to clean the monitor. LPN 25 did not clean or remove the supplies in the kit or use the wipe to clean the inside of the kit that had been exposed to blood.

Interview with LPN 25, immediately after cleaning the monitor, verified he/she did not remove the supplies or clean the entire kit after it was contaminated by the blood on the strip. LPN 25 stated staff are to immediately clean equipment with a Clorox wipe after the exposure to blood.

Interview on 08/24/18 at 12:30 PM, the Infection Control (IC) Nurse shared he/she has just recently took over the IC nurse position and is developing her surveillance to include the cleaning of the glucometer.

Review of the hospital's policy titled, "Equipment, Cleaning and Storage of Patient Care Equipment," Effective Date: 05/17/18, provided the following information:

"Clean equipment should be stored in clean storage area/room...When equipment is shared, disinfection of equipment should take place prior to next patient use. Staff should use hospital-approved disinfectant for patient equipment, allowing adequate contact time according to manufactures instructions...Semi Critical equipment...Follow the manufacturer's instructions allowing adequate contact time".

Based on medical record review, staff interview, and policy review, the hospital failed to ensure staff followed policies and procedures to provide an appropriate medical screening exam (MSE) for three of 15 sampled patients (Patient P39, 44 and 45) who presented to the emergency room (ER) for treatment. The failure to provide an MSE to determine if an emergency medical condition existed and had the potential to place all patients who presented to the ER at risk for an appropriate screening and treatment of an emergency medical condition.

Findings Include:

1. Review on 08/23/18 at 9:00 AM of P39's ER medical record showed the patient presented to the ER on 10/26/17 at 10:35 AM with a complaint of a fever. Further review of the registered nurses documentation revealed at "1040-pt over to clinic without being seen by DR." P39's ER record lacked documentation the provider performed a medical screening exam.

Interview on 08/23/18 at 11:15 AM, the Assistant Director of Nursing (ADON)/Quality Manager (QM) shared P39 has a provider in the clinic, so when the nurse called the clinic to tell the provider P39 was in the ER, the provider told the nurse to have P39 come the clinic to be seen. Further interview with the ADON on the same day at 12:45 PM confirmed P39's medical record was an example of poor documentation. The ADON/QM shared the hospital had provided training to the nurses regarding proper documentation in the ER chart but was unable to provide the dates of the training, material presented to the staff or evidence the inadequate ER documentation concern/training was discussed in nursing minute meetings, the medical staff or the governing body meeting minutes.

2. Review on 08/23/18 at 11:30 AM of P44's ER medical record showed the patient (child) presented to the ER on 06/21/18 at 7:49 AM with complaints of a fever. The nurse documented the following nurses note at 8:07 AM, "pt (patient) to ED with mom, mom voiced that pt with fever since noon yesterday with highest at 103. Pt given Tylenol fever reduce. Pt fatigued..." The ED nurse noted at 8:27 AM, "...APRN notified, pt to be seen at clinic and mom ok with going to clinic...8:29 AM pt out with mom." The nurse documented: "Patient left prior to Dr. Exam."

Interview on 08/23/18 at 11:45 AM, the ADON/QA verified the P44 and 45 presented to the ED the morning of 06/21/18 prior to the clinic offices opening. She shared the nurse took the patient's information and documented the chief complaint and called the provider in the clinic who told the nurse to tell the patient's mother to bring the child to the clinic to be seen. The ADON/QA verified an MSE was not completed in the ED by an ED provider.

3. Review on 08/23/18 at 11:35 AM of P45's ER medical record revealed the patient (mom) presented to the ER on 06/21/18 at 7:50 AM with complaints of an ear infection. The nurse documented vital signs and the P45's allergy to penicillin and sulfa. The ED nurse documents the following at 8:12 AM, "Pt to ED with son, pt voiced that she had drainage coming from left ear for the last two days. Pt took Claritin without relief. Pt with tube in ears since age 3. Ear with clear drainage, tub visible. 8:27 AM...ARNP notified of pt. Pt to go to clinic and pt ok with being seen over there. 8:29 AM-pt walked out with son." Nurse then documented the "Patient left prior to Dr Exam."

During an interview with the ADON/QA on 08/23/18 at 11:45 AM verified the P44 and 45 presented to the ED the morning of 06/21/18 prior to the clinic offices opening. She shared the nurse took the patients information and documented the chief complaint, took vital signs, documented P45's her allergies and called the provider in the clinic who told the nurse to tell P45 to go to the clinic to be seen. The ADON/QA verified a complete MSE was not completed by the ER Provider.

Review of the hospital's policy "Medical Screening Examination for Emergency Department," effective date 02/28/17, indicated the following; "All MSEs should be performed in the hospital by a qualified medical provider (QMP). Sumner Regional Medical Center recognizes a QMP as the following, Physician, physician's assistant, Advance registered nurse practitioner, Registered nurse, licensed practical nurse, or a medical intensive care technician who must be under physician direction.

In the latter two instances the physician must make the determination of whether an emergency medical condition (EMC) exists, based on the information provided by the nurse or MICT..Documentation of the MSE; A registration of all patients presenting to the ED requesting examination or treatment should be maintained. The log should contain; ...A medical record should be kept on all patients presenting to the ED..."

Based on document review and staff interview, the facility did not develop an emergency preparedness plan that was based on a community-based risk assessment utilizing an all hazards approach.

Findings include:

A review on 08/24/18 of the facility's document titled, "Emergency Operations Plan" dated 06/18 did not contain a community-based risk assessment that utilized an all-hazards approach. The plan indicated, "The Kansas area is threatened by many hazards with the potential to cause a considerable number of injuries to the local population and disruption of health care services. These hazards include: Natural events, such as tornadoes and floods; Technological events, such as hazardous materials accidents and Human-caused hazards, such as acts of terrorism". There was no identification that the hazards identified in the Emergency Operations Plan were based from a community risk assessment and has not taken an all hazards approach based on a completed risk assessment.

Interview on 08/21/18 at 11:00 AM, Staff Member 1 indicated unawareness of the emergency management plan requirements until a recent fire marshal inspection in the skilled nursing unit. Staff Member 1 stated that the facility was currently working to update the existing plan with the requirements. Staff Member 1 explained that the facility has not conducted a community-based risk assessment.

Based on document review and interview, the facility did not develop an emergency preparedness plan that was based on a community-based risk assessment that addressed the patient population, persons at risk and the continuity of operations after an event has occurred.

Findings include:

Review of the facility's document titled, "Emergency Operations Plan" dated 6/18 did not contain a community-based risk assessment that utilized an all-hazards approach. The plan indicated, "The Kansas area is threatened by many hazards with the potential to cause a considerable number of injuries to the local population and disruption of health care services. These hazards include: Natural events, such as tornadoes and floods; Technological events, such as hazardous materials accidents and Human-caused hazards, such as acts of terrorism". There was no identification the Emergency Operations Plan was based from a community risk assessment and has not addressed the patient population being served (behavior health, geriatric, pediatric, skilled nursing, and surgical patients).

Interview on 08/21/18 at 11:00 AM, Staff Member 1 indicated unawareness of the emergency management plan requirements until a recent fire marshal inspection in the skilled nursing unit. Staff Member 1 stated that the facility was currently working to update the existing plan with the requirements. Staff Member 1 explained that the facility has not conducted a community-based risk assessment.

Based on document review and staff interview, the facility did not develop emergency preparedness policies and procedures based on a community-based risk assessment utilizing an all hazards approach.

Findings include:

Review of the facility's document titled, "Emergency Operations Plan" dated 6/18 did not contain a community-based risk assessment that utilized an all-hazards approach. The plan stated, "The Kansas area is threatened by many hazards with the potential to cause a significant number of injuries to the local population and disruption of health care services. These hazards include: Natural events, such as tornadoes and floods; Technological events, such as hazardous materials accidents and Human-caused hazards, such as acts of terrorism". The policies and procedures currently in effect did s not address all hazards that would be identified in a comprehensive risk assessment. The facility has emergency preparedness policies for fires and tornadoes but did not address all hazards that their patient population may experience.

Interview on 08/24/18 at 1:30 PM, Staff Member 7 confirmed that a risk assessment had not been completed and an all hazards approach was not an event in the current plan. Staff Member 7 explained that the facility has not addressed hazards such an earthquakes or mass shootings.

Based on document review and staff interview, the facility did not ensure that the policies and procedures addressed the provision of needs for staff and patients in relation to sewage and waste disposal.

Findings Include:

Review on 08/24/18 of facility's document, "Emergency Operations Plan" dated 6/18 did not show evidence that sewage and waste disposal needs had been addressed, planned or was being considered in the plan updates.

Interview on 08/24/18 at 1:30 PM, Staff Member 7 explained that plan did not address sewage or waste disposal needs.

Based on document review and staff interview, the facility did not ensure that the policies and procedures addressed a system to track the location of on-duty staff during an emergency.

Findings include:

Review on 08/24/18 of facility's document, "Emergency Operations Plan" dated 6/18 did not show evidence of a process to track or ensure communication methods to contact on-duty staff members during an emergency.

Interview on 08/24/18 at 1:30 PM, Staff Member 7 explained that plan did not address the tracking or communication of on-duty staff members and shelter in place patients. Staff Member 7 indicated their best method would be to utilize a 'runner' to go between areas and communicate the needs of incident command. there was no plan in place for emergency communication with staff.

Based on document review and interview, the facility did not ensure that the policies and procedures addressed evacuation from the facility including consideration of care and treatment needs of evacuees, staff responsibilities, transportation and means of communication with external sources.

Findings include:

Review on 08/24/18 of facility's document, "Emergency Operations Plan" dated 6/18 did not show evidence that addressed evacuation from the facility including consideration of care and treatment needs of evacuees, staff responsibilities, transportation and means of communication with external sources.

Interview on 08/24/18 at 1:30 PM, Staff Member 7 explained that plan did not address evacuation from the facility including consideration of care and treatment needs of evacuees, staff responsibilities, transportation and means of communication with external sources.

Based on document review and staff interview, the facility did not ensure that the policies and procedures addressed the use of volunteers or the process for integrating other designated health care professionals during an emergency.

Findings include:

A review on 08/24/18 of facility's document, "Emergency Operations Plan" dated 6/18 did not show evidence that addressed the use of volunteers or how to integrate designated health care professional during an emergency. The plan did not include a process on credentialing additional medical staff or other licensed healthcare practitioners during an emergency.

Interview on 08/24/18 at 1:30 PM, Staff Member 7 explained that plan did not address a process on utilizing volunteers or a process on integrating other healthcare providers.

Based on document review and staff interview, the facility did not ensure the policies and procedures addressed an effective communication plan with local, state or federal agencies during an emergency. The policies and procedures did not address the means or methods that would be employed to communicate with external agencies during an emergency.

Findings include:

A review on 08/24/18 of facility's document, "Emergency Operations Plan" dated 6/18 did not show evidence that addressed a communication plan with local, state or federal agencies during an emergency event or methods and means that would be employed to communicate with external agencies.

Interview on 08/24/18 at 1:30 PM, Staff Member 7 confirmed that plan did not address means of communication with external sources during an emergency. Staff Member 7 indicated that if phone lines were down, they would have to use cell phones. Staff Member 7 indicated they did have radios for internal use, but no alternatives methods for communicating to external agencies.

Based on document review and staff interview, the facility did not ensure the policies and procedures address an effective communication plan with local, state or federal agencies during an emergency. The policies and procedures did not address the means or methods that would be employed to communicate with external agencies during an emergency.

Findings include:

A review on 08/24/18 of facility's document, "Emergency Operations Plan" dated 6/18 did not show evidence that addressed a communication plan with local, state or federal agencies during an emergency event. The plan did not address the methods or means that would be employed to communicate with external agencies.

Interview on 08/24/18 at 1:30 PM, Staff Member 7 confirmed that plan did not address means of communication with external sources during an emergency. Staff Member 7 indicated that if phone lines were down, they would have to use cell phones. Staff Member 7 indicated they did have radios for internal use, but no alternatives methods for communicating to external agencies.

Based on document review and interview, the facility did not ensure the policies and procedures address an effective communication plan with local, state, or federal agencies during an emergency. The policies and procedures did not address the means or methods that would be employed to communicate with external agencies during an emergency.

Findings include:

Review on 08/24/18 of facility's document, "Emergency Operations Plan" dated 6/18 did not show evidence that addressed a communication plan with local, state or federal agencies during an emergency event. The plan did not address the methods or means that would be employed to communicate with external agencies.

Interview on 08/24/18 at 1:30 PM, Staff Member 7 explained that plan did not address means of communication with external sources during an emergency. Staff Member 7 indicated that if phone lines were down, they would have to use cell phones. Staff Member 7 indicated they did have radios for internal use, but no alternatives methods for communicating to external agencies.

Based on document review and interview, the facility did not ensure the policies and procedures addressed how the emergency operations plan would be tested or analyzed within the facility.

Findings include:

A review on 08/24/18 of facility's document "Emergency Operations Plan" dated 6/18 did not show evidence that addressed a method for conducting drills, for testing the emergency operations plan, for analyzing the results of a drill/tabletop exercise or timeframe in which such drills should be conducted.

Interview on 08/24/18 at 1:30 PM, Staff Member 7 indicated the facility had just experienced a live emergency event where the local VA Home had to evacuate residents and the facility housed 19 of those residents for 2 days in their facility. The facility had documented this event but had not completed the after-action report. Staff Member 7 explained that the facility had not completed any additional drills or tabletop exercises in 2018.