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Based on observation, interview, and record review, the facility failed to ensure a notice was posted that stated the facility did not have a doctor of medicine or a doctor of osteopathy present in the hospital 24 hours per day seven days per week; and the facility failed to ensure a notice to show how the facility would meet the medical needs of any patient with an emergency medical condition conspicuously in a place likely to be noticed by all individuals entering the dedicated emergency department (EMTALA notice). Findings include:

During an observation and interview on 7/10/19 at 11:32 a.m., the dedicated emergency department entrance and patient care area did not contain signage that the hospital did not have an MD or DO on site 24 hours per day seven days per week. In the patient care area, opposite the entrance and across the room, an 11x14 sign that contained EMTALA verbiage was taped to the window of an equipment storage room. The signage was not conspicuous and was not in an area that would likely be noticed by patients receiving care and services. Staff member E stated they had an 8x10 sign at the entrance of the emergency room patient care area, and stated she was not sure why it was no longer there. Staff member E stated, "we will make signs and post them at the entrances today."

Review of the facility policy titled EMTALA/Cobra Anti-Dumping/Transfer showed "...Signs will be posted in conspicuous areas at the Emergency Room and Front Office area in accordance with the EMTALA/COBRA rules."

Based on observation, interview, and record review, the facility failed to ensure a refrigerator maintained a temperature of forty degrees or below that was used to store lunch meats, cheeses, and to thaw meats. Findings include:

During the initial observation of the kitchen on 7/8/19 at 4:40 p.m., the single door refrigerator, used to thaw meats and store lunch meats and cheeses, thermometer showed the interior temperature of forty-two degrees. Staff member F stated that the refrigerator fluctuated in temperatures and the maintenance staff had addressed it in the past when the temperatures did not maintain correctly.

During an observation on 7/9/19 at 7:36 a.m., the single door refrigerator showed a temperature of forty-two degrees. Lunch meat, cheeses, and meat that was being thawed were in the refrigerator.

During an observation on 7/10/19 at 7:32 a.m., the single door refrigerator showed a temperature of forty-two degrees. Lunch meat, cheeses, and meat that was being thawed were in the refrigerator.

On 7/10/19, a request was made for the policy and procedure for refrigerator temperature guidelines and maintenance. No policy and procedure were submitted prior to the exit of the survey.

Based on record review and interview, the facility failed to review the patient care policies annually by the group of professional personnel required, to include the medical advisory group and the governing body. Findings include:

During a review of the facility's patient care policies and procedures, there was no documentation that showed the policies and procedures had been reviewed by the advisory group to include the Medical Director and the governing body.

Review of the facility Annual Review showed, "policy review conducted every quarter through 2018 for departments... Continue to implement compliance 360 program for policy review."

Review of the submitted Medical Staff Meeting Minutes for the months of January, March, April, June, July, September, October, November, December of 2018, and January of 2019, showed a review of some patient care policies, but the review was not comprehensive to include all policies, and not all policies reviewed had been approved.

During an interview on 7/9/19 at 3:00 p.m., staff member B stated the department heads reviewed the health care policies together in one day. She stated the Medical Director is on site one day per month for half a day and sees patients on those days.

During an interview on 7/10/19 3:42 p.m., staff member A stated the facility did not have documentation that showed the governing body and advisory committee had reviewed and approved all patient care policies and procedures annually. Staff member A stated the facility did not have a consistent system to ensure the patient care policies and procedures were reviewed and approved by the medical staff and the governing body annually.

Based on observation and interview, the facility failed to ensure insulin pens were labeled when opened for 2 (#s 21 and 22) of 23 sampled and supplemental patients. Findings include:

During an observation on 7/9/19 at 11:00 a.m., of the medication cart for the intermediate swing bed patients, the following was observed:

-For patient #21, a Levemir insulin pen with no open date
-For patient #22, a Levemir insulin pen with no open date

During an interview on 7/9/19 at 11:06 a.m., staff member G stated who ever had opened the insulin pen should label it with an open date.

During an interview on 7/9/19 at 11:10 a.m., staff member E stated the nurse that opened the insulin pen should be the one to label it with an open date.

Based on observation, interview and record review, the facility failed to ensure patient care beds and equipment were disinfected in the radiology department after each patient use, and failed to change gloves when going from a dirty task to a clean task for 1 (#23) of 23 sampled and supplemental patients. Findings include:

1. During an observation and interview on 7/9/19 at 10:36 a.m., the radiology department equipment and patient care areas were observed. In the patient care areas were Sani-Cloth HB wipes. Staff member C stated the PDI Sani-Cloth HB wipes were used to disinfect the patient tables and equipment in the radiology department. Staff member C stated he was not aware of the direct contact time for the use of the wipes to ensure the tables and patient equipment were disinfected between use. Review of the PDI Sani-Wipes HB product label showed the needed contact time for the wipes to disinfect a surface required the surface to remain wet for 10 minutes. Staff member C stated he used the wipes to clean the equipment, but did not keep the surface wet for ten minutes. The portable x-ray machine was observed to have the Sani-Cloth HB wipes stored for use on the machine.

During an interview on 7/9/19 at 1:32 p.m., staff member D stated housekeeping cleaned the floors and counters in radiology, but did not clean the radiology patient tables or equipment.

Review of the facility policy and procedure titled Department Cleaning showed, "...the equipment will be maintained by the techs. All non-porous surfaces will be wiped down in one of the following manners: Using the PDI Sani-Cloth HB wipes, wipe down surfaces and keep visibly moist for 10 minutes... If a quicker turnaround time is needed, use DisCide Ultra spray disinfectant. Moisten a disposable towel and wipe down surfaces. Surfaces are effectively disinfected after one minute."


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2. During an observation on 7/10/19 at 7:36 a.m., staff members H and I performed peri care for patient #23. Staff members H and I washed hands and donned clean gloves upon entering the patient's room. Staff members H and I assisted patient #23 from her bed to the commode. When the patient had finished on the commode, staff member I cleansed patient #23's peri area and pulled up her pants wearing the same gloves used to cleanse the patient.

During an interview on 7/10/19 at 7:59 a.m., staff member I stated gloves should be changed after helping patients use the rest room and before doing anything else with the patient.

During an interview on 7/10/19 at 5:01 p.m., staff member E stated staff should change gloves after soiling gloves and wash hands before putting on clean briefs.

Review of the facility policy titled Handwashing and Hand Hygiene showed, "...F. Hand hygiene must be performed by staff when going from a dirty to a clean task while performing patient/resident care...4. Gloves will be removed after care/procedure has been provided and hand hygiene will be performed..."

Based on observation, interview and record review, the facility failed to show all female patients undergoing a radiology procedure were screened for pregnancy, and the results were documented in the patient medical record to ensure pregnant patients are not exposed to radiation hazards. Findings include:

During an observation and interview on 7/9/19 at 10:32 a.m., the radiology department equipment and patient care areas were observed. On the window of the staff procedure room in the radiology room was an 8x10 sign addressing safety advisory for pregnant patients. Staff member C stated he and the other tech asked female patients if they were pregnant or could be when they brought them back for their x-ray. Staff member C stated they did not document the response in the patient medical record, but he added he believed there was a check-off place in the computer system.

Review of the radiology policies and procedure titled Radiation Protection showed an area with the heading, Potentially Pregnant Patients with instructions for radiology staff to, "ask any female of childbearing age requiring an x-ray exam to be asked if it is possible that she may be pregnant. Her answer will be documented in Cerner. ...A "yes" answer is reported to the attending provider and their consent is necessary to proceed with the x-ray examination to proceed..."

Based on observation, interview, and record review, the facility failed to ensure staff used a gait belt when transferring a patient for 1 (#23) of 23 sampled and supplemental patients. Findings include:

During an observation on 7/10/19 at 7:36 a.m., staff members H and I assisted patient #23 from her bed to the commode, and from the commode to her wheel chair. Staff members H and I washed their hands and donned clean gloves upon entering patient #23's room. Staff members H and I assisted patient #23 to a sitting position on the edge of her bed. Staff members H and I then assisted patient #23 to a standing position by placing their arms under the patient's arms and lifting her up. Staff members H and I did not use a gait belt when assisting the patient to a standing position. When patient #23 was finished on the commode, staff member H and I assisted the patient from the commode to her wheel chair by placing their arms under the patient's arms and lifting her up. Staff members H and I did not use a gait belt when assisting the patient to transfer from the commode to the wheel chair.

During an interview on 7/10/19 at 2:15 p.m., staff member I stated she would normally use a gait belt but there had not been one available in the patient's room. Staff member H stated it must have slipped her mind.

During an interview on 7/10/19 at 5:00 p.m., staff member E stated it was the expectation that if a hand needed to be placed on the patient in any way, then a gait belt needed to be used.

Review of patient #23's care plan showed under interventions for assistance with ADLs "...needs limited to extensive assist of 1 with transfers and getting in and out of bed (use gait belt) ..."

Review of the facility policy titled Mechanical Lifts showed under procedure for "...transferring a patient/resident to and from; bed to chair, chair to toilet, chair to chair, or car to chair...partially able to bear weight, is cooperative and has upper extremity strength-Use the stand and pivot technique using a gait belt, may be done by 1 caregiver. Consider using the Sara lift..."