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Based on record review and interview the provider failed to ensure thirty of thirty sampled patients (1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29 and 30) had received notification of physician availability. Findings include:

1. Review of patients 1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29 and 30's electronic medical record (EMR) revealed all patients had not received written notification of a physician not being available in the hospital 24 hours a day.

Interview on 4/25/24 at 11:00 a.m. with chief nursing officer B regarding patients receiving physician availability revealed she had not been aware that patients needed to have notification for that.

Based on observation and interview, the provider failed to implement an effective preventative maintenance plan as evidenced by:
*One of one hand sink in isolation room 112 did not have a water supply.
*One of one hand sink in room 106 leaked water from the drain line onto the floor.
*No exhaust ventilation for bathrooms in patient rooms 102, 103/104 (with a shared bathroom), 106, 107, and 114.
*Window air conditioners had a black substance covering the adjustable louvers in patient rooms 105, 106, 112, 114, the trauma room, and the emergency room.
*Thirteen of 40 hand sanitizers located in the hallways outside of patient rooms for staff to sanitize their hands with were expired. Findings include:

1. Observation on 4/23/24 from 9:00 a.m. to 10:00 a.m. revealed:
*The hand sink in isolation room 112 did not have a water supply.
*The hand sink in room 106 leaked water from the drain line onto the floor.
*There was no exhaust ventilation for bathrooms in patient rooms 102, 103/104 (with a shared bathroom),
106, 107, and 114.
*Window air conditioners had a black substance covering the adjustable louvers in patient rooms 105, 106, 112, 114, the trauma room, and the emergency room.

Interview on 4/25/24 at 10:20 a.m. with director of maintenance C revealed:
*He had been the director of maintenance for about three months. He had been hired as a maintenance person about one year ago.
*He was not aware the sink in room 112 did not have running water.
*He was not aware the drain line to the sink in room 106 leaked water.
*He was not aware the mechanical exhaust ventilation for the bathrooms was not working.
*They cleaned the filters in the air conditioners periodically, but it was not scheduled or documented when that occurred.
*They did not clean the adjustable louvers or the inside of the air conditioners.
*They did not monitor the air conditioners for cleanliness.
*They checked patient rooms for cleanliness of floors and walls but did not check the sinks to verify they were functional.
*He had not received much training from the previous director or maintenance.
*He agreed they did not have an effective preventative maintenance plan.



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2. Random observations on 4/23/24 from 1:45 p.m. to 2:15 p.m. in the hallways of the hospital revealed:
*There were 40 Purell hand-sanitizing dispensers in the hallways of the hospital.
*Each dispenser had a bottle of hand sanitizer attached to it with an expiration date printed on the front.
*Thirteen of the 40 bottles of hand sanitizer observed were past their expiration date.

Interview on 4/24/24 at 9:45 a.m. with housekeepers I and J regarding the expired hand sanitizer bottles in the hallways revealed:
*It was their responsibility to replace the hand sanitizer bottles when they were empty.
*They would have checked the level of hand sanitizer in the bottles as they cleaned throughout the day.
*They were not aware there was an expiration date on the bottles.

Interview on 4/24/24 at 3:00 p.m. with maintenance/environmental services/emergency preparedness director C regarding the expired hand sanitizer bottles in the hallways revealed:
*The housekeeping staff were educated at general orientation to check for expired products.
*He expected the hand sanitizers to have been upon expiration.
*He agreed the hand sanitizer bottles were not being monitored for expiration dates.

Interview on 4/25/24 at 1:40 p.m. with administrator A regarding the expired hand sanitizer bottles in the hallways revealed:
*They had an over-supply of hand sanitizer left from the Covid-19 supplies they had received.
*She thought it was the housekeepers' job to monitor for expiration dates on the hand sanitizer bottles.
*Sometimes other staff would have replaced the bottles when they were empty.
*It was her expectation staff would discard expired products when found.
*She stated they did not have a specific policy for monitoring and discarding expired hand sanitizer

Based on interview and review of the governing body By-Laws, the provider failed to ensure the original dated and signed By-Laws were available for review. Findings include:

1. Review of a copy of the governing body By-Laws provided by administrator A revealed no:
*Date or signatures of the past or present governing body.
*Addendums to the By-Laws.
*List of the governing body members.

Interview on 4/24/25 at 2:00 p.m. with administrator A revealed she was not aware she had only provided a copy of the governing body By-Laws. She stated she would bring the dated and signed By-Laws for review.

Interview on 4/24/25 at 4:30 p.m. with administrator A revealed she had:
*Been unable to locate the dated and signed By-Laws.
*Contacted the governing body president, the administrator consultant, and the previous administrator. She stated those individuals were not aware the original signed copy was not available.
*She agreed it was important to have the original dated and signed governing body By-Laws, any addendums that had been added, and changes in the governing body members available.

Based on observation, interview, and policy review, the provider failed to ensure:
*Outdated supplies were not available for patient use in the emergency department, room 102, and in two of three ambulances.
*Outdated medications were not available for patient use in the ambulance service medication cupboard.
Findings include:

1. Observation on 4/23/24 at 9:30 a.m. of supplies in room 102 revealed:
*The room was set-up as a labor and delivery room.
*Outdated supplies included:-Thirteen single-use packages of lubricating jelly all with the expiration date of 11/2/22.
-One umbilical cord clamp expired 9/30/23.
-Three of eight speculums expired 12/27/23.

Interview on 4/24/24 at 9:35 a.m. with registered nurse (RN) G revealed there was no process to regularly check for outdated supplies in the labor/delivery room.

2. Observation on 4/23/24 at 10:05 a.m. in the emergency department non-trauma room revealed outdated. Those supplies included:
*One of two DeLee suction catheters expired in June 2020.
*One suction tubing expired on 9/1/22.
*One of four Salem Sump Duel Lumen stomach tube expired on 8/31/22.
*One 20 milliliter syringe expired on 2/1/22.

3. Observation on 4/24/24 at 2:05 p.m. of three of three facility owned ambulances. There were outdated supplies in two of three ambulances including:
*Ambulance 1191:
-One suction tubing expired on 4/12/24.
-Two intravenous (IV) start kits expired in March 2024.
-One I-gel airway size 2.5 expired on 3/16/24.
*Ambulance 1193:
-Three of three King LTS-D airways sizes 2.5 expired on 8/1/21, 5.0 expired on 1/11/21, and 3.0 expired on 2/1/23.
-Two I-gel airways size 2 expired in January 2023 and size 4 expired in October 2023.
-Suction tubing expired on 9/1/22.
-Nasopharyngeal airway sizes 14 french and 24 french expired on 3/28/24.
-Two IV start kits expired on 2/28/23.

4. Observation on 4/24/24 at 3:00 p.m. of the locked ambulance cupboard revealed three of three epinephrine injection single-dose auto injectors 0.15 milligram expired in March 2024,

Interview on 4/24/24 at 3:10 p.m. with ambulance director E revealed:
*Staff were assigned to different areas to check for outdated supplies and medications.
*She had not realized the checks for outdated supplies was not completed.
*The staff person in charge of checking for outdated medications had noted it on her checklist, but had not informed ambulance director E.





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5. Observation on 4/23/24 at 10:15 a.m. of supplies in the trauma room revealed:
*I-gel oral airway compartment contained the following:
-Size for a 25-35 kilogram (kg) patient expired on 11/2022.
-Size for a 10-25 kg patient expired on 1/2023.
-Size for a 5-12 kg patient expired on 3/2024.
-Size for a 2-5 kg patient expired on 11/2023.
*Chest tube kit contained the following:
-One dry seal chest drain expired on 11/7/22.
-Three 0 Perma-hand silk suture expired on 2/29/24.
-Two polyline minor procedure drapes expired on 8/30/22.
-Two sets of suction tubing expired on 9/1/22.
-Two #15 scalpels expired on 11/31/23.
-One # 15 scalpel expired on 12/31/22.
-Four 20 french trocar catheters expired on 7/1/22.
-One 32 french trocar catcher expired on 5/1/22.
*Vital signs monitor machine contained the following:
-Four packages of pediatric huggable electrodes (used to monitor the patient's heart rate and rhythm) expired on 8/19/23.
-One package of pediatric huggable electrodes expired on 10/28/23.
*Airway supplies compartment contained the following:
-An Ambu laryngeal mask size 5 expired on 2/5/22.
-An Ambu laryngeal mask size 3 expired on 3/17/22.
-One King LTS-D # 2 (laryngeal airway) expired on 11/1/22.
-One Centurion alligator forcep expired on 3/31/22.
*Suction machine supplies contained one Salem suction kangaroo port expired on 5/31/23.
*Glide Scope (a scope used to help with endotracheal intubation) equipment contained the following:
-One LoPro size 2 spectrum expired on 11/27/23.
-One Mac size 4 expired on 8/27/21.
-One Mac size 4 expired on 7/7/23.
*Crash cart equipment contained the following:
-One pediatric carbon dioxide detector expired on 3/27/24.
-One Ambu carbon dioxide detector for adults expired on 3/24/24.

Interview on 4/23/24 at 2:20 p.m. with chief nursing officer B regarding the removal of expired supplies revealed:
*The night shift would have checked for outdated supplies on a monthly basis.
*They did not have a checklist to sign off on once the task had been completed.
*She had been aware that there were some outdated supplies.

Review of the provider's January 2007 Expiration Dates policy revealed:
*"Two days before the end of every month the nursing staff will remove any items that will be outdated. You should pull and item that has an expiration date for the upcoming month.(example: If it is December 30, you must pull items off for January also)"
*"This includes both emergency rooms, OB room, all patient rooms, nursing station, crash carts, med room, etc. The pharmacist will be in charge of all meds. Central supply will be in charge of the central supply room and IV room. We will use an expiration supply list as a reference to any items that has expiration dates, Duties are assigned as follows:"
-"Day shift nursing aid will be in charge of the large ER [emergency room], nursing station and patient rooms."
-"Night shift nursing aid will be in charge of the small ER and [obstetrics] OB room."
-"Night shift Nurse will be in charge of the crash carts and med room."

Based on record review, interview, patient checklist review, and policy review, the provider failed to ensure 7 of 30 sampled patients (9, 14, 15, 17, 19, 21, and 22) electronic medical records (EMR) had complete information to include: discharge summaries, separate records for swing bed, and complete nursing documentation. Findings include:

1. Review of patient 15's 4/6/24 inpatient record revealed she had been discharged to swing bed on 4/8/24. There was no physician summary for her inpatient stay.

2. Review of patient 17's 12/3/23 inpatient record revealed he had been discharged to home on 12/4/24. There were discharge instructions given by the nurse. There was no physician discharge summary.

3. Review of patient 19's 1/18/24 through 1/19/24 inpatient record revealed she had only one over midnight inpatient stay. She was admitted to swing bed on 1/19/24. There was no separate record started for her swing bed stay.

4. Review of patient 21's 4/15/24 swing bed admission record revealed:
*She had diagnoses that included cellulitis and a sacral ulcer.
*Her admission nursing assessment indicated:
*She had end stage dementia.
*She had a wound on her coccyx. There were no measurements or description of this wound.
*Her Braden Assessment Flowsheet indicated she had a risk factor of "Loss of appetite."
-"Patients with 1 or more Risk Factors are referred to Provider & Registered Dietitian (RD) for possible Nutrition Consult." A yes answer was chosen.
-No RD assessment was located.
The nursing narrative included "1850 [6:50 p.m.] Wound assessed on EZ graph with noc [nights] shift RN [registered nurse]. See paper chart. Aquaphor applied to buttock."

5. Review of patient 22's 4/17/24 swing bed admission revealed:
*Her initial nursing assessment indicated:
-She fractures of her right patella and left upper humerous.
-The Braden Assessment Flowsheet had not been completed
-The dietary assessment had not been completed.
-The initial wound status assessment indicated she had a blister to the lower part of her left shin.
-The measurements were length 2 cm (centimeter) and width 1 cm. It was dry with no odor.
-Factors that would affect wound healing was diabetes.
-Her risk factor for the provider and RD to be notified for a possible consult included multiple fractures.
*A 12 hour nursing assessment completed on 4/24/24 at 6:30 a.m. revealed no documentation regarding her left shin blister.
*A 12 hour nursing assessment completed on 4/24/24 at 6:30 p.m. revealed 3 areas marked on an outline of a body. Those areas were:
-"A" her left upper arm, "B" her right knee, and "C" her left lower calf. It indicated the wounds were from trauma, they were dry, and there was no odor.

Interview on 4/25/24 at 10:10 a.m. with chief nursing officer B revealed:*They had done record reviews on the documentation of activities of daily living and baths.
*No record reviews had been completed on nursing documentation.
*She agreed there was missing documentation in patient's records.





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6. Review of patient 9's electronic medical record (EMR) revealed:
*He:
-Had been admitted on 11/7/23 with a diagnoses of agitation/delirium.
-Had his brother sign his admission papers.
*There was document in patiet 9's EMR indicating who his power of attorney for healthcare was.

7. Review of patient 14's EMR revealed:
*She:
-Had been admitted on 2/2/19 with diagnosis of a gastrointestinal bleed and was placed on end of life care.
-Had her boyfriend sign her do not resuscitate (DNR)/do not intubate (DNI) form.
*There was document in patient 14's EMR indicating who her power of attorney for healthcare was.

Interview on 4/25/23 at 11:00 a.m. regarding the location of the power of attorney for healthcare documents for patient 9 and patient 14 revealed:
*She had tried to locate the documents, but was unable to locate them for patient 9 and patient 14.
*She agreed that people should not sign hospital forms for patients unless they are the power of attorney for healthcare and the provider should have had copy to support their wishes.

Based on observation, interview, and policy review, the provider failed to ensure infection control practices were maintained for:
*Hand hygiene and glove use by one of one registered nurse (RN) H and one of one physician assistant-certified (PA-C) F during care provided for patient 24.
*Terminal cleaning of the floors in patient rooms with an approved disinfectant.
Findings include:

1. Observation on 4/23/24 from 9:50 a.m. through 10:15 a.m. of RN H while she completed and electro-cardiogram (EKG) and placed intravenous (IV) access to patient 24 in the emergency department (ED). Those observations included:
*Patient 24 was lying on an ED bed.
*RN H had gloves on and completed an EKG.
*She removed the EKG machine leads from patient 24 and pushed the EKG machine to the other side of the ED room.
*Without changing gloves she:
-Removed an uncleanable blood pressure cuff from patient 24's right arm and placed it back in the vital sign machine basket.
-Gathered supplies from the supply cabinet to obtain IV access and take blood samples.
-Placed those supplies on an overbed table without placing a barrier first.
-Opened the packages that contained the IV abbocath, chlorohexadine prep swab, IV site dressing, tape, and sterile gauze 4 by 4's.
-Used the chlorohexadine prep swab to disinfect the skin of patient 24's right antecubital space. She did not swab in a back-and-forth motion for 60 seconds. She did not allow the chlorohexadine to dry prior to inserting the IV needle.
-After she had obtained IV access there was blood from around the IV site. She used an alcohol wipe to wipe the blood and placed it on the overbed table. She had blood smear on her right hand thumb and first finger of her gloves. She wiped it off with the same alcohol wipe she had used to wipe the blood away from the patient's IV access site.
-She continued to fill three tubes of blood for laboratory testing.
-Placed a dressing over the IV access site and taped the tubing to patient 24's arm.
-Gathered the used supplies and disposed of them.
-Did not sanitize the overbed table.
-Placed the blood pressure cuff on patient 24's left arm.
-Removed her gloves and without performing hand hygiene she took a pen out of her uniform pocket and placed identification stickers with the patients name on the blood tubes.

Observation on 4/23/24 at 10:00 a.m. of PA-C revealed he had gloves on, used his stethoscope to listen to patient 24's heart and lung sounds. After his physical examination, he left the room and removed his gloves, did not perform any hand hygiene, or disinfect the bell of his stethoscope, then started to document in the computer.

Interview on 4/23/24 at 4:00 p.m. with RN H confirmed the above findings. She stated she gets busy and forgets to remove her gloves and perform hand hygiene between tasks. She was not sure who sanitized the EKG machine after use. She had not realized she should have placed a barrier down or sanitized the overbed table prior to placing supplies on it.

Review of the provider's last revised 6/16/22 Infection Control policy revealed:
*Hand hygiene (hand washing or use of antiseptic gel or foam) should have been performed:
*After handling all bodily secretions.
*After removal of gloves.
*Any patient care equipment should have been sanitized between uses with PDI Sani-Cloth wipes and allowed to air dry.



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2. Interview on 4/23/24 at 2:45 p.m. with housekeepers I and J regarding the cleaning of a room after discharge revealed they used 3M 24H 3-in1 Floor Cleaner to mop the floors of rooms after discharge.

Review of the 3M 24H 3-in1 Floor Cleaner manufacturer's instructions for use revealed the product did not have an Environmental Protection Agency registration number and made no claim to kill germs or disinfect.

Interview on 4/23/24 at 3:00 p.m. with the maintenance/environmental services/emergency preparedness director C revealed housekeeping staff were to use 3M 25L HB Quat Disinfectant on the floors of rooms for terminal cleaning after a patient is discharged.

Interview on 4/23/24 at 3:30 p.m. with administrator A who was also the infection preventionist for the provider revealed she agreed that floors, should have been disinfected when terminal cleaning had been completed after a patient was discharged.

Review of the providers "Patient Room Terminal (Discharge/Transfer) Cleaning and Disinfection" policy dated 12/2023 revealed it did not specify what to use for mopping the floor after discharge. It stated, "Damp mop the floor starting at the far side of room and work toward the doorway."