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Based on observation, interview and policy review, the facility failed to ensure that five evacuation sleds (sleds used for patient evacuation from a single-story building or down the stairwell of a multi-floor building in an emergency situation) were accessible to staff and located in the proximity of patients, and failed to ensure staff were trained on the use of the sleds. These failures had the potential for delay in the evacuation of patients in an emergency situation. The facility census was one.

Findings included:

1. Review of the facility policy titled, "Hospital Fire Response Plan," revised 07/2014 showed the following direction for staff:
- The purpose was to provide a plan for hospital staff to follow in case of fire, outlining roles and responsibilities.
- Remove all people from immediate danger.
- All available persons on the unit, to include nurses, doctors, ancillary department members and volunteers will be made available to the department supervisor or charge nurse to assist in patient relocation.
- Patients in imminent danger should be immediately evacuated, with ambulatory (able to walk) patients moving first.
- As ambulatory patients are being guided to a safe area, all available staff should begin assisting non-ambulatory patients with the evacuation.
- Evacuation sleds can be used to move non-ambulatory patients.

Observation and concurrent interview on 08/21/18 at 12:20 PM on the Medical/Surgical inpatient unit, showed no evacuation sleds on the unit. Staff D, Infection Control Nurse, stated that the evacuation sleds were kept on the East side of the building and the inpatient unit was on the West side. She stated that there weren't any on the unit because the unit was on ground level and the patients could be evacuated through the exit doors.

Observation and concurrent interview on 08/22/18 at 1:30 PM showed two evacuation sleds in the maintenance department located in the basement of the facility. Staff D stated she thought there were a total of five evacuation sleds and that the other three were kept outside in a shed.

During an interview on 08/22/18 at 3:30 PM, Staff H, Licensed Practical Nurse (LPN) stated that she had been at the facility for 11 years but wasn't aware the facility had evacuation sleds, or what they were used for. She stated that in the event of a fire, a fireman would carry a non-ambulatory patient out of the building.

During an interview on 08/22/18 at 3:45 PM, Staff D, Infection Control Nurse stated that she wasn't aware of any training to staff regarding the use of the evacuation sleds, and that she thought the sleds had been in the facility since around 2015.

During an interview on 08/23/18 at 10:15 AM, Staff NN, Plant Operations Director stated that:
- Two evacuation sleds were in the maintenance room and the other three were kept in a closet down the hall from the maintenance room on the basement level;
- The evacuation sleds were obtained two to three years ago.
- Staff had not received hands on training related to use of the evacuation sleds.
- The inpatient nursing staff had not received any training related to the evacuation sleds.
- Drywall anchors (secure anchor point for stair wells for lowering patients safely down stairs for evacuation of multiple floors) for the stairwell on the second floor outpatient clinic were not installed.

During an interview on 08/23/18 at 2:15 PM, Staff C, Chief Executive Officer (CEO) stated that:
- Training for the evacuation sleds was completed.
- The facility had obtained the sleds several years ago.
- There was turnover with nursing staff, so new staff may not be aware of the evacuation sleds.
- Nursing may not have been trained.
- He would not expect the evacuation sleds to be used on the inpatient unit because it is on ground level.

The facility had five evacuation sleds for several years without hands on training. If in the event of a fire, the evacuation sleds would not be accessible to staff for patient evacuation, as they were not kept in patient care areas. The second floor outpatient clinic stairwell did not have the required anchor installation for the sleds to be properly and safely lowered down the stairs. These failures had the potential to delay the evacuation of patients to a safe area.

Based on observation, interview, record review and policy review, the facility's governing body failed to effectively provide oversight in the conduct of the facility when:
- A list of contracted services was incomplete and did not specify the scope of contractor responsibility.
- A current list of the scope of surgical services provided by the facility's Operating Room (OR), that was defined in writing and approved, was not available.
- All the required elements were not included on the OR Register that OR staff utilized.
- The current roster of each physician's specific surgical privileges were not readily available/accessible to the Operating Room (OR) staff where scheduling of surgical services was performed.
- The facility had five evacuation sleds (for transport of patients out of a single-story building or down the stairwell of a multi-floor building in an emergency situation) that were not easily accessible to staff, and training was not provided to all patient care staff.
- The pharmacy department failed to follow policy related to compliance with United States Pharmacopeia (USP) Chapter 797, for compounded sterile preparations.







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Based on observation, interview, policy review and review of the United States Pharmacopoeia (USP) Chapter 797, the facility failed to ensure that the pharmacy staff followed policy related to USP compliance standards for compounded sterile preparations (CSP) and failed to ensure quality services were provided by the pharmacy when they failed to:
- Provide an adequate segregated compounding area (SCA, a separate area designated for drug compounding) for the Compounding Aseptic Containment Isolator (CACI), Mobile Isolation Chamber (MIC) with preparation of all hazardous drugs (chemotherapy) in relation to the other MIC within the same SCA;
- Reduce the risk of contamination, when a cart with a non-cleanable, chipped wooden surface, was stored inside the SCA.
These failures had the potential to increase the risk of cross contamination with infection and increase the risk of harm to any patients who received compounded medications. The facility census was one.

Findings included:

1. Record review of the USP, Chapter 797, dated 2013, showed that all hazardous drugs shall be prepared in a Biological Safety Cabinet (BSC, a negative pressure unit used to compound hazardous medications like chemotherapy) or a CACI. The ISO Class 5 BSC or CACI shall be placed in an ISO Class 7 area that is physically separated (i.e., a different area from other preparation area) and that particle shedding objects (wood) were prohibited in the SCA and the walls, ceilings, and shelving where to be cleaned and disinfected monthly.

Review of the facility's policy titled, "Mobile Isolation Chamber (MIC) Intravenous (IV, within the vein) Admixture & Sterile Compounded Preparations," revised 10/01/13, showed paper, cardboard and particulate materials are to be minimized in the area.

The wooden shelved cart should not be housed inside the SCA as it was a non-cleanable surface and could not be able to be cleaned and disinfected. The chipped area of the wooden shelf had the potential for particulate matter to become free within the SCA.

2. Observation on 08/23/18 at 1:45 PM of the Pharmacy, showed a separate room designated as the SCA, with the door left open into the pharmacy. Inside the SCA were two sterile compounding isolators positioned side by side. A wooden shelved cart was located inside the room with non intact chipped areas noted on the bottom shelf.

The MIC used to prepare chemotherapy drugs was not separate from the vicinity of the other isolator used to prepare other sterile compounding preparations.

During an interview on 08/23/18 at 2:00 PM, Staff U, Pharmacy Director, stated that the pharmacy prepared chemotherapy in one MIC and occasionally moderate risk preparations in the other isolator.

Based on observation, interview, and policy review the facility failed to ensure staff followed infection control policies and infection preventions standards when they failed to ensure:
- Expired supplies were not readily available for patient use.
- Frozen foods and spices were dated for expiration.
- Hair coverings covered all hair when worn by staff who prepared food in the Dietary Department.
- All hair was contained under the surgical cap while in the surgical suite.
These failures had the potential to increase the rate of facility-acquired infections for all patients, visitors and staff. The facility census was one.

Findings included:

1. Although requested, the facility did not have a policy regarding outdated/expired supplies.

Observation and concurrent interview on 08/21/18 at 12:15 PM, showed one oral suction tip (used to suction secretions out of the mouth) with the expiration date of 10/2016, and one opened (should be used immediately) suction tubing (long, plastic tube which connects the oral suction tip to suction) located on the crash cart on the Medical/Surgical unit. Staff D, Licensed Practical Nurse, (LPN), Infection Control Nurse, stated that the nurse that performed the daily check on the crash cart should look for outdated/expired supplies.

During an interview on 08/21/18 at 12:40 PM, Staff E, Registered Nurse (RN), stated that the crash cart was checked daily and that central supply department restocked the supplies, but the nurse who checked the cart should note any outdated supplies or equipment.

During an interview on 08/22/18 at 4:25 PM, Staff B, Interim Associate Chief Nursing Officer (IACNO) and Quality Director, stated that the expectation was for the nurse that checked the crash cart for functionality, should also check for outdated supplies.

Observation and concurrent interview on 08/22/18 at 8:40 AM in the Wound Care Clinic showed 12 sterile swabs (used to collect specimens for testing) with the expiration date of 05/22/18. Staff D, LPN, Infection Control Nurse stated that no expired supplies should be available for patient use.

2. Review of the facility's policy titled, "Surgical Attire," dated 07/2015, showed that all persons entering the semi-restricted and restricted area must wear clean attire and have hair covered by a cap or hood.

Observation on 08/22/18 from 10:00 AM to 10:30 AM, in a surgical suite, during a procedure, showed the vender for the pain pump (that the surgeon placed into the patient) was in the Operating Room (OR) suite with several strands of hair outside of her surgical cap.

During an interview on 08/22/18 at 2:19 PM, Staff II, RN, Surgical Services Director, stated that all hair should be contained under the surgical cap. Staff II stated that the vender present during the procedure should have had all her hair contained under the surgical cap while in the surgical suite.

3. Review of the facility policy titled, "Dating of food items," dated 10/14/15, showed:
- All food will be labeled and dated in a manner that ensures food safety and quality and helps prevent cross-contamination.
- Date foods when they are received with the receiving date.
- Store products with the earliest use-by or expiration dates in front of products with later dates.

Review of the facility policy titled, "Patient Meal Service," dated 06/2011, directed staff to wear appropriate hair coverings at meal service.

Observations on 08/22/18 at 9:45 AM in the Dietary Department, showed multiple bags of frozen foods in the walk in freezer without expiration dates, and multiple opened spices in a cabinet and in a dry storage area without expiration dates.

4. Observation on 08/23/18 at 9:45 AM, showed multiple dietary staff prepared food with hair coverings that did not cover all of their hair.

During an interview on 08/22/18 at 10:15 AM, Staff MM, Dietary Manager, stated that the frozen bags would not hold a date written on them, and confirmed there were several opened spices without dates. Staff MM confirmed that staffs' hair was not contained under the hair coverings.



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Based on interview and record review, the facility failed to maintain a complete list of services under contract or agreement, which included the nature and scope of those services. These failures increased the potential for patient care services by arrangement to be inappropriately utilized. The facility census was one.

Findings included:

1. Review of the first facility list of contracts/agreements provided by Staff A, Chief Nursing Officer (CNO), showed a typed written list of 26 services. The second list of contracts/agreements provided by Staff A showed a hand written list of 12 contracted services. There was no indication of the nature or scope of the services provided on either list. Neither list included an agreement for nuclear medicine imaging services, for the outside reference laboratory, or tele-dermatology (use of medical information exchanged from one site to another via electronic communications using two-way video to review and improve a patient's clinical health status) used by the facility.

During an interview on 08/22/18 at 3:45 PM, Staff A, stated that the lists provided did not contain the nature and scope of services. He confirmed that the facility used tele-dermatology.

The facility provided two different lists of contracted services, which did not match and which varied in services provided.

Based on observation, interview and policy review, the facility failed to have a current list of the scope of surgical services provided by the facility's Operating Room (OR) that was defined in writing and approved by the governing body and/or responsible individual, and failed to ensure that all the required elements were included on the OR Register that OR staff utilized. These failed practices had the potential to affect all patients seeking surgical services at the facility. The facility census was one.

The severity and cumulative effects of these failed practices resulted in the facility's overall non-compliance with requirements set forth at 42 CFR 485.639 Condition of Participation: Surgical Services.

Findings included:

1. Review of the facility's policy titled, "Scope of Services - Surgical Services," showed no reference number, effective date and did not include who it was approved by.

During an interview on 08/23/18 at approximately 12:45 PM, Staff A, Registered Nurse (RN), Chief Nursing Officer (CNO), Chief Operating Officer (COO), stated that the facility did not have a current approved policy for the scope of surgical services.

2. Review of the OR Register that the OR staff utilized, showed that the paper copy did not contain the required elements for preoperative/postoperative diagnosis and review of the electronic OR Register spreadsheet that OR staff utilized, showed that the electronic spreadsheet did not contain the required element for postoperative diagnosis.

During an interview on 08/22/18 at 2:30 PM, Staff II, RN, Surgical Services Director, stated that the paper OR Register did not contain the required element for pre/postoperative diagnosis and the electronic OR Register spreadsheet did not contain the required element for postoperative diagnosis.

During an interview on 08/23/18 at approximately 12:45 PM, Staff A, RN, CNO, COO, stated that he and the Director of Quality utilized the facility's computer software that generated an OR Register from information that staff entered into the system that contained all the elements, and he did not know why the OR staff used the paper OR Register or an OR Register spreadsheet that was not generated by the computer's software.

Based on observation and interview, the facility failed to have the current roster of each physician's specific surgical privileges readily available/accessible to the Operating Room (OR) staff where scheduling of surgical services was performed. This failed practice had the potential to place all patients at risk seeking surgical services at the facility. The facility census was one.

Findings included:

1. Nurse and Staff LL, RN, OR Nurse, stated that they did not know how to access the current physician's specific surgical privileges or where they were located.

During an interview on 08/22/18 at 2:20 PM, Staff II, RN, Surgical Services Director, stated that the current roster listing each physician's specific surgical privileges, was locked in her office in a file drawer.

Observation on 08/22/18 at 2:22 PM, showed the facility's current roster that listed each physician's specific surgical privileges, was kept locked in the OR director's office in a file drawer.

During an interview on 08/23/18 at approximately 12:30 PM, Staff A, RN, Chief Nursing Officer (CNO), Chief Operating Officer (COO), stated that the current roster that listed each physician's specific surgical privileges should not be kept locked up in Staff II, Surgical Service Director's office.