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Based on facility policy review, record review and interview, the facility failed to keep emergency equipment readily available and periodically tested for treating emergency cases.

Findings included:

Facility based policy titled, "Crash Cart Inspection" stated in part, "Purpose: To insure that the crash carts are maintained and fully stocked at all times for emergency situations.
Procedure:
1. Nursing at shift change (one per 24 hours)
a. Will do a 24 hour defibrillator check by turning on the defibrillator, turning the joules to 20-50, pressing the charge button, and discharging the unit. A tracing is to be run during the process and initialed by the RN. The strip is then placed in the crash cart log book that is on the cart."

Crash Cart checks for the inpatient area had the following dates without a nurse check in the last five months:
June 16, 17, 21, 24 and 25 of 2016
July 1, 2, 5, 11, 17, 18, 19, 21 and 22 of 2016
August 4, 5, 8, 9, 13 and 21 of 2016
September 1, 4, 15, 19, 20 and 30 of 2016
October 1 and 18 of 2016.

The above was verified with the CNO and CEO on the afternoon of 10/19/16.

Based on observation, interview and record review the facility failed to ensure emergency supplies were readily available when expired supplies were available for use.
Findings Include:

Observations during a tour on 10/19/16 of the facility's nursing departments revealed the following:

Hallway supply storage area (next nurses station):
(1) Quick Tracheostomy Kit expired 3/16
(1) Lumbar Puncture Tray had expired 4/30/16
(1) Water Seal Chest Drain had expired 2/16
(2) Idoform Packing Strips had expired 2/16
(1) Saline Fleets Enema 4/5 Fl. oz. had expired 04/2015
(1) Plain Packing Strip 1inch X 5 yards had expired 9/2015
(3) Adaptic Dressings had expired 9/2015


Emergency Room 2:
(1) Derma bond Pen had expired 06/2016
(1) Umbilical Cord Clamp had expired 05/2015
(3) Three Culture Swabs had expired 03/22/16
(3) Three Culture Swabs had expired 04/2016

Emergency Department Trauma Room:
(3) 24 Gauge Intravenous Catheters had expired 08/2016
(1) Yankauer had expired 05/2016

Central Supply:
(3) Iodoform Packing Strips had expired 02/2016

During the facility tour on 10/19/16, Staff #1, Director of Nursing, confirmed the findings. When asked for the facility policy on handling the expired items, Staff #1 stated, "We do not have a specific policy for the expired supplies."

Based on observation during a tour of the facility with the facility Administrator, the hospital failed to ensure a clean and orderly environment as the following was observed.
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Findings were:
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The "General Cleaning and Sanitation" policy states, "All patient and non-patient rooms shall be thoroughly cleaned and/or disinfected, keeping in mind Standard Precautions and infection Control. All pertinent Environmental Services Department procedures shall be referred to in the Environmental Services Manual. These should include cleaning for all specialty areas including, but not limited to the Emergency Department, the Sterilization Area and all patient care and patient support areas."

The following were observed on the tour of the facility on the morning of 10/19/16:
· Patient rooms # N21 and N22 night stands with chipped wood making it impossible to clean effectively
· The nourishment station with dirt and dust build-up on the ice machine and on the vent of the ice machine.
· In patient room N22: Dust build-up was noted on the overhead bed light, the suction equipment, and TV stand.
· In the Physical Therapy room: Dead bugs on were on the window sill and tears in the mattress were observed.
· In ER room 2: Dust build-up on the overhead light and dust build-up on suction equipment. This could lead to patient complication and/or infection control issues.
· In the public access restroom: Baseboards under the toilet had separated from the wall.
· In the CT room: Two oscillating fans noted with dust built up throughout and dust on empty contrast bottles on a side stand.
· In the X-ray room: X-ray table and with dust and dirt build-up, dust build-up on the handing X-ray machine, and side cart with supplies had dust build-up throughout.
· Bone Density machine with dust build-up throughout.
· IV Pumps Storage Room: Six (6) ceiling holes around pipes leading up to the attic were observed. This open areas could provide an entry point for pests and contaminates.

The above findings were confirmed by the Administrator on the morning of 10/19/2016.

Based on record review and interview, the facility failed to ensure effectively maintain a system for controlling infections related to sterilization of equipment and supplies.

Findings included:

On a tour of the sterilization area at 9:35 am on the morning of 10/20/16, dirty instruments were cleaned in the same room as laboratory equipment running microbiology cultures. When asked about the process of sterilization, staff #2 stated, "I come in here and the [dirty] equipment is already in here." When asked what the policy was, she stated, "We don't have one."

In an interview with staff #2 on the morning of 10/20/16, when asked about training/education staff #2 received related to sterilization, staff #2 stated they had no recent documented training.

The above was confirmed with the CEO and CNO on the morning of 10/20/16.

Based on interview and record review the facility failed to provide an on-going activities program to enhance her/his sense of well-being and to promote or enhance physical, cognitive, and emotional health when the Activity Designee did not have the required training and was not receiving consultations from a Recreational Therapist or a qualified Activities Professional. (Staff #20)

Findings Include:


During an interview on 10/19/16 in the morning, in the facility conference room, Staff #20, Activities Designee stated, "I do activities when I'm here... I work three days a week...I haven't received any training...." When asked if she attends the Care Plan meeting Staff #20 stated, "I don't attend...Do I need to?" When asked who provides the activities when she is off and if that person was trained to provide the activities, Staff #20 stated, "Staff #22 sometimes does the activities...he wasn't trained...he does it out of the kindness of his heart..."

During an interview on 10/20/16, in the facility conference room, Staff #1, Director of Nursing confirmed the findings and stated, "I thought my nursing license covered the activities requirements...the nurses interact with the patients all day long, I guess we just aren't documenting it..."

Based on interview and record review the facility failed to develop a comprehensive care plan for (2) two out of (4) four patient's care plans reviewed for Activities. (Patient #15, 17, 18 and #21)

Findings Include:


Review of Patient's #15, 17, 18 and #21's Care Plans reflected Activities had not been entered on the problem list and interventions had not been initiated.

During an interview on 10/20/16, in the facility conference room, Staff #1, Director of Nursing confirmed the findings and stated, "The activities are not on the Care Plans ..."