HospitalInspections.org

Based on observation of the Emergency Department, Outpatient Facilities, and Medical Surgical Nursing Unit and interview, it was determined the facility failed to maintain the building physical structure, safety, environment, and equipment in a state of good repair. The failed practice promoted the spread of infection and/or placed the patients at risk of fire. The failed practice had the likelihood to affect all patients, staff and visitors. Finding follow:

A. Observation of the Emergency Department on 04/15/24 showed the following:
1) At 1:08 PM, peeling wallpaper in front of the definitive observation unit.
2) At 1:16 PM, Emergency Room #4 showed to have holes in the walls.
3) At 1:08 PM, there was a hole in the door from a previously replaced deadbolt in the door leading into the radiology office.
4) At 1:17 PM, a rusty X-ray viewing box on the decontamination room.
5) At 1:25 PM, calcium build up in the sink of the medication room.
6) At 1:27 PM, bugs in the light fixture in front of the nurses' station.

B. The findings in A were verified by the Head of Maintenance on 4/15/24 at the time of observation.

C. Observation of the Outpatient Department on 04/15/24 showed the following:
1) At 1:29 PM, peeling and exposed wood on doors throughout the outpatient department.
2) At 1:31 PM, peeling counters in the endoscopy room.
3) At 1:35 PM, a rusty scope tester on the counters in the endoscopy department.

D. The findings in C were verified by the Head of Maintenance on 4/15/24 at the time of observations.

E. Observation of the Medical Surgery Department on 04/15/24 showed the following:
1) At 1:46 PM, the counter peeling on the nurses station.
2) At 1:47 PM, Room 110 had dirt and rust on the sink.
3) At 1:48 PM, wall penetration in room 110 under the white board.
4) At 1:49 PM, a rusty glove holder in the negative pressure room.
5) At 1:51 PM. unlocked breaker boxes in the hallways.
6) At 1:53 PM, a damaged sink, peeling laminate around the sink, items stored under the sink in the medication room.
7) At 1:57 PM, peeling on Formica on the nurses station cabinets and also damage to the floors behind the nurses station.

F. The findings of E were verified with the Head of Maintenance on 04/15/24 at the time of observation.

Based on observation, review of policies and procedures and interview, it was determined the facility failed to create and review policies and procedures on a biennial basis for:
1) Annual scheduled polarity and tension testing
2) Yearly door checks
3) Yearly load bank tests
4) Ceiling tile checks
5) Patient room water temperature checks

By not creating and reviewing the policies and procedures biennially, the facility had the likelihood to not be able to identify hazardous conditions and take steps to minimize the risks to patients and patient care staff. The failed practice had the likelihood to affect all patients admitted to the facility. Findings follow:

A. Review of the facility's policy and procedures on 04/15/2024 showed that the facility failed to create and maintain a policy and procedure for scheduling annual Polarity and tension testing. Documentation for annual Polarity and tension testing was requested and none was provided.
B. Review of the facility's policy and procedures on 04/15/2024 showed that the facility failed to create and maintain a policy and procedure for annually checking fire doors. Documentation for annually checking fire doors was requested and none was provided.
C. Review of facility's policy and procedure on 04/15/2024 showed that the facility failed to create and maintain a policy and procedure for yearly load bank tests for the generator. Documentation for yearly load bank tests was requested and none was provided.
D. Review of the facility's policy and procedures on 04/15/24 showed that the facility failed to create and maintain a policy and procedure for conducting ceiling tile checks. Documentation for ceiling tile checks was requested and none was provided.
E. Review of the facility's policy and procedures on 04/15/24 showed that the facility failed to create and maintain a policy and procedure for testing patient room water temperature checks. Documentation for water temperature checks was requested but none was provided.
F. The findings of A through E were confirmed in an interview with the Maintenance Supervisor on 04/15/2024 at 1:21 PM.

Based on observation, review of National Fire Protection Association (NFPA) 101 standards and interview, it was determined the facility failed to ensure that the Generator was maintained in that an emergency stop switch was installed on the generator and there was no battery powered emergency light installed on the generator. The failed practice did not ensure the facility had the means of stopping the generator in the event of an emergency, the generator would be able to run in the event of an emergency and did not ensure the facility staff had the ability to view the generator in the event of an emergency. The failed practice had the likelihood to affect all patients, visitors and staff in the facility. Findings follow:

A. Review of NFPA 101 standards showed the facility was to provide battery-powered emergency lighting as required by NFPA 101, 2012 edition.

B. On 04/15/2024 at 3:05 PM observation of the emergency generator showed there was no covered emergency stop switch installed 10 to 15 feet away from the generator.

C. On 04/15/2024 at 3:10 PM, observation of the emergency generator showed there was no battery powered emergency light installed on the generator.

D. The findings in A through C were verified by the Head of Maintenance on 04/15/2024 at the time of the observations.

Based on review of Arkansas Department of Health - Pharmacy Services and Drug Control Branch Rules and Regulations Pertaining to Controlled Substances [12/01/2014], review of EPA'S (Environmental Protection Agency) Ban on Sewering Pharmaceuticals Introductory Fact Sheet and interview, it was determined the facility failed to follow accepted professional principles in that they wasted pharmaceutical narcotics in the sharps container instead of into a receptacle that would render them non-retrievable or in the sink, in three of three (Emergency, Outpatient Procedure and Medical/Surgical) departments toured. By not wasting the narcotics according to accepted professional principles, the facility was not in compliance with Arkansas Department of Health's Pharmacy Services and Drug Control Branch's Rules and Regulations Pertaining to Controlled Substances. The failed practice had the likelihood to affect all medications wasted in the facility. Finding follow:

A. Record review of Arkansas Department of Health - Pharmacy Services and Drug Control Branch Rules and Regulations Pertaining to Controlled Substances 12/01/2014, showed Controlled Substance waste should have been disposed of in a receptacle that would render it non-retrievable.
B. Record review of the EPA's Ban on Sewering Pharmaceuticals Introductory Fact Sheet, dated April 2022, showed effective August 21, 2019, EPA prohibited all healthcare facilities from disposing of their hazardous waste pharmaceuticals down the drain (e.g., no flushing or pouring down a sink). This "sewer ban" is in effect at healthcare facilities of all sizes in all states, territories, and Indian country. In addition to the sewer ban, EPA strongly discourages the sewering of any pharmaceutical, with very few exceptions by any type of facility (Sodium Chloride intravenous fluids, Lactated Ringers, etc).
C. During an interview on 04/15/2024 at 1:23 PM, Registered Nurse (RN) #1, when asked how they dispose of narcotic waste, they indicated the sharps container, or the sink was where they waste narcotics in the Emergency Department.
D. During an interview on 04/15/2024 at 1:31 PM, the Director of Outpatient Procedures, when asked how they dispose of narcotic waste, indicated the sharps container, or the sink was where they waste narcotics in Outpatient Procedure Department.
E. During an interview on 04/15/24 at 1:58 PM, the Assistant Director of Nursing, when asked how they dispose of narcotic waste, indicated the sharps container, or the sink was where they waste narcotics in the Medical/Surgical Department.

Based on review of policy, review of Medication Occurrence /Suspected Adverse Drug Reaction Form, review of Clinical Records and interview, it was determined the Facility failed to assure evidence of medication errors were recorded along with notification to the practitioner in two of two (#11 & #12) patients who received the wrong medication. The failed practice did not ensure the medical record would reflect exactly what medications the patients received in error and treatments the patients received in response to the error. Also, had these patients needed to be transferred to a higher level of care, their records would not have given the next care providers a clear and accurate picture of these patients' medical history. The failed practice had the likelihood to affect any patients who received medication in error. The findings follow:

A. Record review of the facility's policy titled, "Adverse Drug Reactions," revised 04/01/22, showed when a medication occurrence or a suspected adverse drug reaction happens, it was to be reported on a Medication Occurrence /Suspected Adverse Drug Reaction Form. Nowhere in the policy did it instruct the person that discovers the medication error to document what happened in the patients' medical records nor document the contact of, and instructions from, the physician responsible for the patients' care.
B. Review of Medication Occurrence /Suspected Adverse Drug Reaction Forms for the previous 6 months (October 2023- March 2024) showed 2 errors that involved a patient receiving the wrong medication. The errors were as follows:
1. On 01/24/2024 at 7:30 PM, Patient #11 was administered a dose of Advair, that was not prescribed.
2. On 12/31/2023 at 5:10 PM, Patient #12 was administered #2 Percocet 5/325 milligram, instead of the #2 Hydrocodone 5/325 milligram that was ordered.
C. Review of patient medical records on 04/16/2024 showed the following:
1. Patient # 11's did not have any documentation of Advair being administered.
2. Patient #12's record showed the patient was administered #2 Hydrocodone 5/325 milligrams instead of the oxycodone that was described in the error report.
D. During an interview on 04/16/2024 at 2:00 PM, the Director of Pharmacy verified the findings at A, B, and C.

Based on policy and procedure review, clinical record review and interview, it was determined the facility failed to have individualized care plans for 4 (#1, #3, #4, and #5) of 10 (#1-#10) patients. By not individualizing the care plans the facility could not ensure that the patients received care for all their needs. This failed practice had the likelihood to affect all patients cared for in the facility. The findings follow:

A. Review of clinical records on 04/17/2024 at 1:30 PM, showed Patient #1 and #3 had fall risk identified for both patients and there was no Fall Risk in the patients Nursing Care Plan.
B. Review of clinical records on 04/17/2024 at 1:30 PM, showed Patient #4 and #5 had skin breakdown listed as a potential problem by Braden score but, there was no Risk for Skin Breakdown plan in the Nursing Care Plan.
C. The findings in A and B were verified by Assistant Director of Nursing on 04/17/2024 at 1:30 PM.

Based on interview, the facility failed to have a current roster listing each practitioner's specific surgical privileges available in the surgical suite, for one of one Outpatient Procedure Department. By not having this information available to the staff and employees in the Outpatient Procedure Department, the staff and employees were not informed if the procedures they assisted with and scheduled for were procedures the physicians had been granted privileges to perform. This deficient practice had the likelihood to affect all patients admitted for procedures at the hospital. Findings follow:

During a tour of the Outpatient Surgical/Procedure Department on 04/15/2024 from 1:27 PM to 1:45 PM, the Director of the Outpatient Procedure Department was interviewed at 1:31 PM and was asked to provide a current roster listing each practitioner's specific surgical privileges. The Director did not have one nor did they know they needed to maintain one.

Based on observation, and interview, it was determined the facility failed to maintain a clean and sanitary environment in that they failed to keep hand washing sinks and sink areas clean, in three of three (Emergency Room, Outpatient Procedure and Medical/Surgical) departments toured. By not keeping the hand washing sinks and sink areas clean, the facility could not assure employees hands were clean to perform tasks like medication preparation, medication administration and patient care, to prevent the spread of infection. This failed practice had the likelihood to affect all patients receiving medications and patient care in these three areas. Findings follow:

A. During a tour of the facility on 04/15/2024 from 1:08 PM to 2:02 PM, observation showed the following:
1) Emergency Department's Medication Room:
The hand-washing sink was visibly dirty, with a dark grimy substance accumulated around the entire sink's edges and the backsplash where it attached to the counter. Where the backsplash met the counter, a brown thick liquid substance accumulated between the back of the sink and the backsplash. The faucet head had white, brown, and green substances built up around it.
2) Outpatient Procedure Room #1:
The hand-washing sink was visibly dirty, with a dark substance accumulated around small portions of the sink's edges. The faucet head had white and light brown substances built up around it.
3) Medical / Surgical Floor Medication Room Sink:
The hand-washing sink was visibly dirty, with white and brown substances in the sink and a dark grimy substance accumulated around the entire sink's edges and the backsplash where it (used to be) attached to the counter. The back splash on the left and back side of the sink was warped, pulling apart from the backsplash and had a black accumulation soaked into the particle board behind the Formica. There were cracks around the sink in the countertops. The faucet head had white, brown, and green substances built up around it.
B. The findings of A were verified at the time of observation with the Director of Nursing.


47891

Based on observation and interview, it was determined the facility failed to assure the environment was maintained in a clean and sanitary manner in that in the Emergency Department Room Five there was an x-ray viewing box with rust spots exposed and the door to the room was worn to bare wood. By failing to maintain these items in a clean manner the facility could not ensure this room was sanitary for use. This failed practice had the likelihood to affect all patients treated in Emergency Department Room Five. The findings follow:

A. Observation during a tour of the Emergency Department Room Five on 04/15/2024 at 1:15 PM, showed there was a large x-ray viewing box with rust spots along the bottom panel.
B. Observation during a tour of the Emergency Department Room Five on 04/15/2024 at 1:15 PM, showed the door was worn to bare wood with no sealant left.
C. The findings in A and B were verified with the Director of Nursing at on 04/15/2024 at 1:15 PM.



Based on observation and interview, it was determined the facility failed to assure the environment was maintained in a clean and sanitary manner in that in the Emergency Department Room One, the floor seem was broken and peeling showing black material in the broken seem. The floor was cut and scored in many places with black material in the damaged spots. By failing to maintain these items in a clean manner the facility could not ensure this room was sanitary for use. This failed practice had the likelihood to affect all patients treated in Emergency Department Room One. The findings follow:

A. Observation during a tour of the Emergency Department Room One on 04/16/2024 at 11:25 AM, showed the seam of the floor was broken and peeling back exposing black material.
B. Observation during a tour of the Emergency Department Room One on 04/16/2024 at 11:25 AM, showed the floor had many cuts and scores in the floor exposing black material.
C. The findings in A and B were verified with the Director of Nursing at on 04/16/2024 at 11:30 AM.

Based on observation, review of Arkansas State Board of Health Rules for Critical Access Hospitals Section 56: Physical Facilities, Rehabilitation Therapy Department, review of personnel files and interview, it was determined the facility failed to provide the physical facilities that were necessary to meet the needs of the patients, and failed to assure no individuals were hired who had been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law, in one of one Rehabilitation Therapy Departments. By not providing sufficient physical facilities, the facility could not assure they were meeting the rehabilitation patients' needs, prior to being discharged. Failure to perform criminal background checks did not assure each patient would be protected from abuse, neglect, exploitation, misappropriation of property, or mistreatment. See C1612 and C1622 for details.

Based on review personnel files and interview, it was determined prior to May 2023, the facility failed to assure three of three (#1-#3) Physical Therapists (PT), two of two (#1-#2) Physical Therapist Assistants (PTA), one of one (#1) Occupational Therapist (OT), one of one (#1) Occupational Therapist Assistant (OTA), one of one (#1) Speech Language Pathologist (SLP) and two of two (#1 and #2) Physical Therapist Technicians (PT Tech) were screened to assure no individuals were hired who had been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law. Failure to perform criminal background checks did not assure each patient would be protected from abuse, neglect, exploitation, misappropriation of property, or mistreatment. The failed practice had the likelihood to affect all patients admitted to the facility for swing bed services. Findings follow:

A. Review of personnel files showed the following:
1) PT #1 was hired on 03/25/2021 and did not have a criminal history background check prior to working with patients;
2) PT #2 was hired on 08/09/2021 and did not have a criminal history background check prior to working with patients;
3) PT #3 was hired on 03/14/2023 and did not have a criminal history background check prior to working with patients;
4) PTA #1 was hired on 03/11/2019 and did not have a criminal history background check prior to working with patients;
5) PTA #2 was hired on 03/02/2021 and did not have a criminal history background check prior to working with patients;
6) OT #1 was hired on 04/20/2021 and did not have a criminal history background check prior to working with patients;
7) OTA #1 was hired on 11/08/2021 and did not have a criminal history background check prior to working with patients;
8) SLP #1 was hired on 01/28/2021 and did not have a criminal history background check prior to working with patients;
9) PT Tech #1 was hired on 02/16/1995 and did not have a criminal history background check prior to working with patients; and
10. PT Tech #2 was hired on 02/16/1995 and did not have a criminal history background check prior to working with patients;
B. During an interview on 04/17/2024 at 10:40 AM, the Administrative Assistant/ Human Resources verified the findings at B, and stated the facility started doing criminal background checks on all new hires starting May 2023.

Based on observation, review of Arkansas State Board of Health Rules for Critical Access Hospitals Section 56: Physical Facilities, Rehabilitation Therapy Department, and interview, it was determined the facility failed to provide the physical facilities that were necessary in one of one Rehabilitation Therapy Departments. By not providing sufficient physical facilities, the facility could not assure they were meeting the rehabilitation patients' needs, prior to being discharged. This failed practice had the likelihood to affect all patients who received services from the Rehabilitation Therapy Department. Findings follow:

A. Record review of Arkansas State Board of Health Rules for Critical Access Hospitals Section 56: Physical Facilities, Rehabilitation Therapy Department showed the following shall be provided:
1. Physical Therapy. If physical therapy is part of the service, the following at least, shall be included:
a. Individual treatment area(s) with privacy screens or curtains. Each such space shall have not less than 70 square feet of clear floor area;
b. Exercise area and facilities;
c. Clean linen and towel storage;
d. Storage for equipment and supplies;
e. Separate storage for soiled items; and
f. Handwashing stations for staff either within or at each treatment space (one handwashing station may serve several stations).
2. Occupational Therapy. If this service is provided, at least the following shall be included:
a. Work areas and counters suitable for wheelchair access;
b. Handwashing stations;
c. Storage for supplies and equipment; and
d. An area for daily living activities shall be provided. It shall contain an area for a bed, kitchen counter with appliances and sink, bathroom, and a table/chair.
3. Speech, Hearing, and Audio Therapy. If this service is provided, at least, the following shall be included:
a. Space for evaluation and treatment of patients. The space shall be protected with acoustical treatment of walls and finishes;
b. Space for equipment storage and supplies.

B. During a tour of Rehabilitation Therapy Department on 04/17/2024 from 1:00 PM to 1:56 PM, observation showed a very small rehabilitation gym with very little space for patient evaluation, treatment or storage. The treatment table was pushed into a corner and had approximately seven other pieces of equipment stored on it. Pushed up against it were two bedside tables with equipment on them, and pushed up next to those, were two more pieces of large equipment. There were walkers leaning against the file cabinets. The sink area counter was covered with small pieces of equipment, tools and manipulation tools for therapy. When asked to see the storage room for equipment, observation showed a small closet in a hallway outside of therapy that was only large enough to house a small amount of equipment.

C. During an interview on 04/17/2024 at 1:56 PM, the Director of Rehabilitation was asked where they perform Activities of Daily Living rehabilitation therapy.
The following were questions that were asked, and the answers received:
1. Where do you perform shower training for a patient that will go home to a shower?
It was explained they had one shower that was large enough, and had a handheld shower head, to roll a wheelchair into. It was in a patient's room, so if someone was occupying the room, the likelihood was a patient that needed showering therapy, would go home without it. Many of the rooms in the hospital had bathtubs that were not appropriate for all patients to shower in. Many of the rooms had a shower, with a large lip, and were too small for a wheelchair and a therapist to fit in there with them to properly (safely) transfer, etc.
2. Where do you rehabilitate patients that will go home and cook for themselves?
It was explained they did not have a specific kitchen counter with appliances to practice those skills.
3. Where do you rehabilitate patients that have steps in/out of their homes?
It was explained they did their best to re-create the patient's homelike environment, so they may go to the loading dock to practice stairs, but the safety issue was it only has one railing and if the weather was bad, they weren't able to utilize them. It was explained they did have a set of rehabilitation stairs but can't use them due to lack of space.
4. Where do you rehabilitate patients that need to get in and out of their beds when they go home?
It was explained, they did the best they can with the hospital beds, but hospital beds were different from regular beds in patients' homes.
5. Does the Speech Therapist have a designated area to evaluate and treat Speech patients?
It was explained they did not, they used the main office/treatment room or the patient's room.