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Based on document review and interview, it was determined for 1 of 3 (Pt #1) patients record reviewed who presented with a psychiatric diagnosis, the hospital failed to ensure the patients and staffs safety per policy. This has the potential to affect all patients, staff and visitors.

Findings include:

1. The policy noted "Care of Patient with Behavioral Health Needs" (revised 4/20) was reviewed on 4/14/22. The policy noted "Process: ... All patient (s) presenting for psychiatric assessment will be "wanded" with Garrett Wand checking for metal items. Any contraband found will be given to Security staff... will be completely undressed upon room placement and placed in a patient gown or paper scrubs. Wanding will occur again at this time. Clothing and personal belongings will be placed in patient belongings bag... placed in patient belonging bag... Any patient deemed at risk for violence... requires close observation..."

2. Pt #1 Date of Service (DOS): 2/20/22
Diagnosis: Bizarre/ Paranoid behavior. The record was reviewed on 4/12/22 at approximately 11:00 AM. The record noted Pt #1 presented for a psychiatric evaluation, was combative and required 4 point restraints upon admission. The record lacked documentation the patient was wanded, checked for contraband, belongings were secured and/or placed in a paper gown or scrubs.

3. During an interview on 4/14/22 at approximately 2:00 PM, the Director of Quality (E#8) reviewed Pt #1's record and verbally agreed the record lacked documentation the patient was wanded, checked for contraband, belongings were secured and/or placed in a paper gown or scrub and should have been.

Based on document review and interview, it was determined for 1 of 5 (Pt #1) patients records reviewed with restraints, the hospital failed to ensure restraints were ordered appropriately. This has the potential to affect all patients who are placed in restraints.

Findings include:

1. Pt #1 Date of Service: 3/26/22
Diagnosis: Bizarre/Paranoid Behavior. The record was reviewed on 4/143/22 at approximately 1:00 PM. A Physician's order dated 3/26/22 noted "Physical restraint as needed for pt (patient) and EMS (Emergency Medical Services) personnel safety- v/o (verbal order)..."

2. During an interview on 4/15/22 at approximately 12:00 PM, the Emergency Department Coordinator (E#4) reviewed Pt #1's record and verbally agreed the restraint order was written as a "as needed" order and should not have been.

Based on document review and staff interview, it was determined 1 of 30 (Pt #2) medical records reviewed, the Hospital failed to ensure verbal orders were signed by the physician before the physician, left the area, as per Hospital policy. This has a potential to affect all patients receiving care at the Hospital with current census of 9 patents.

Findings include:

1. Pt #2 Date of Service (DOS): 4/6/2022
Diagnosis: Cellulitis/Gangrene. The record was reviewed on 4/12/2022 at approximately 1:00 PM. As of 4/12/2022, the following verbal orders were not signed before the physician left the area: three on 4/9/2022 and one on
4/10/2022.

2. The Hospital policy titled "Physician Orders" (revised 5/13) was reviewed on 4/13/2022 at approximately 11:00 AM. It indicated "Verbal orders must be signed before the provider leaves the area."

3. During an interview on 4/12/2022 at approximately 1:30 PM, Director of Obstetrics (E #1) stated "I thought the policy was to sign a verbal order in 24 hours."

Based on document review and interview, it was determined for of patients records reviewed, the Hospital failed to ensure the medical record entries were legible and accurately completed. This has the potential to affect all patients who receive care in the Emergency Department.

Findings:

1. Pt #1 Date of Service (DOS): 2/20/22 and 3/26/22
Diagnosis: Bizarre/Paranoid behavior. The record was reviewed on 4/12/22 at approximately 11:00 AM. The following was observed:
a) The Emergency Physician Record dated 2/20/22 was observed to be illegible and not completed

2. Pt #7 DOS: 12/21/21
Diagnosis: Sexual Assault. The record was reviewed on 4/13/22 at approximately 2:40 PM. The following was observed:
a) The Emergency Physician Record dated 12/21/21 was observed to be illegible and not completed

3. Pt #21 DOS: 2/20/22
Diagnosis: Chest Pain. The record was reviewed on 4/14/22 at approximately 10:00 AM. The following was observed:
a) The Emergency Physician Record dated 2/20/22 was observed to be illegible and not completed

4. Pt #23 DOS: 1/3/22
Diagnosis: Back Pain. The record was reviewed on 4/14/22 at approximately 2:20 PM. The following was observed:
a) A Progress Note lacks documentation of a date and time

Based on document review and interview, it was determined for 2 of 3 (Pt #1, Pt #23) patients records reviewed who required a consult, the hospital failed to ensure consultations were conducted as ordered. This has the potential to affect all patients treated by the hospital with a current census of 9 patients.

Findings include:

1. Pt #1 Date of Service (DOS): 2/24/21
Diagnosis: Bizarre/ Paranoid behavior. The record was reviewed on 4/12/22 at approximately 12:30 PM. A Physician's order dated 2/24/22 at 11:00 PM noted "Psych (Psychiatric) eval (evaluation) am." The record lacked documentation a psychiatric evaluation was completed prior to discharge to a psychiatric facility on 2/25/22 at 7:00 AM.

2. Pt #23 DOS: 1/3/22
Diagnosis: Back Pain. The record was reviewed on 4/14/22 at approximately 2:20 PM. The Progress Note dated 1/3/22 noted "... pt is an unlikely a candidate for this procedure, but wishes surgery to evaluate her for surgery." The History and Physicial Examination conducted on 1/4/22 noted "... I will have Surgery see him/her as the family wish to talk with them..." A Physician's order dated 1/4/22 at 8:30 AM noted "Surgery Consult." The record lacked documentation of a surgical consult.

3. During an interview on 4/14/22 at approximately 2:00 PM, the Director of Quality (E#8 ) reviewed Pt #1's record and verbally agreed the psychiatric consult was not completed as ordered. E#8 stated "Because Pt #1 had a psych consult on 2/21, they felt Pt #1 could be discharged without it." E#8 reviewed Pt #23's record and verbally agreed the surgical consult had not been conducted and should have been.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of a Recertification survey conducted on April 18, 2022, the facility failed to provide and maintain a safe environment for patients, staff and visitors.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of a Recertification survey conducted on April 18, 2022, the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags.

A. Based on observation, document review and interview, it was determined the Hospital failed to ensure emergency carts were checked per policy. This has the potential to affect all visitors and in patients who receive care in the Hospital.

Findings include:

1. The policy titled "Daily Verification of Locked Emergency Carts" was reviewed on 4/14/22 at approximately 11:15 AM. The policy noted "All locked crash carts and emergency carts must be checked daily...The designated RN initials/signs the log in the appropriate space."

2. During a tour of the Surgery Department on 4/13/22 at approximately 11:15 AM with the Coordinator of Surgery (E #6) the following crash cart logs were requested. The "Same Day Surgery" crash cart logs were reviewed on 4/13/22 at approximately 3:30 PM. The logs lacked documentation of the required daily checks:

a) December 2021 lacked 8 out of 31 days
b) January 2022 lacked 2 out of 31 days
c) March 2022 lacked 1 out of 31 days

3. During an interview on 4/13/22 at approximately 12:45 PM with the Coordinator of Surgery (E #6), E #6 verbally confirmed the crash cart wasn't checked daily and should have been.


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B. Based on observation, document review and staff interview, it was determined the Hospital failed to ensure that oxygen cylinders were secured safety to avoid injury, property damage or fire in the facility. This has the potential to affect all patients receiving care at the Hospital with a current census of 9 patients.

Findings include:

1. Observational tours of the facility were conducted during the Survey On 4/12/2022 through 4/13/2022.
A. on 4/12/2022 at approximately 11:00 AM, a tour of the Intensive Care Unit (ICU) conducted with the Director of ICU (E #2). During the tour, two (2) oxygen cylinders approximately 2/3 full, were observed (1)standing free and (1) laying in a plastic tote unsecured in the clean utility room.
B. On 4/13/22 at approximately 10:30 AM, a tour of the OB unit was conducted with the Director of OB (E#1). During the tour, a Full Oxygen Cylinder was found laying unsecured on the floor in the Anesthesia Room.

2. During a review on 4/14/2022 of the Policy "Waste Gases Management Plan" (reviewed 06/18), the policy states under "Storage and Handling" that "Compressed Gas - Tanks of compressed gas will be stored upright and chained or otherwise secure to support system to minimize falling over."

3. During an interview on 4/12/2022 at approximately 11:15 AM , E #2 verbally agreed the oxygen cylinders should have been secured in a stand or secured to the wall with chains and kept in a secure area. E #1 verbally agreed that Anesthesia should have secured their oxygen tank in a stand or secured it to the wall with chains.

C. Based on observation, document review and staff interview, it was determined the Hospital failed to ensure that all mechanical, electrical, and patient-care equipment is maintained in safe operating condition. This has the potential to affect all patients receiving care at the Hospital with a current census of 9 patients.

Findings include:

1. On 4/13/2022 at approximately 10:15 AM, an observational tour of the facility was conducted. The following equipment was found to be out of date for yearly biomed checks:
a. ICU Ice/ water machine was last checked on 4-12-2019.
b. OB patient refrigerator missing Biomed check label
c. OB patient Ice/water machine missing Biomed Check label
d. OB Clean utility room, Mindray Accutor 7 vitals machine was missing Biomed Check label
e. OR patient ice/ water machine missing Biomed Check label

2. On 4/14/2022 at approximately 12:45 PM, The facility policy "Equipment Management and Preventative Maintenance Policy" (reviewed date 12/20) was reviewed. The policy noted, "Biomed will be responsible for performing annual (or manufacturer's recommended) safety checks and maintenance on the equipment designated for patient use."

3. On 4/13/2022 at approximately 12:15 PM, an interview with the Director of OB (E #1) was conducted. E #1 stated, " I am not sure what our policy states, but I believe these are supposed to be check yearly." E #1 verbally agreed that the items were not checked annually and were missing the appropriate Biomed labels.

A. Based on observation and interview, it was determined the Facility failed to ensure patient equipment was maintained to prevent cross-contamination. This has the potential to affect all patients receiving care at the Hospital with a current census of 9 patients.

Findings include:

1. On 4/12/2022 between 10:00 AM and 12:00 PM, an observational tour of the Facility ICU was conducted. Inside Intensive Care Unit (ICU) room 3, there was a Yanker Suction catheter inside of an open sterile package and connected to wall suction.

2. On 4/12/2022 at approximately 10:10 AM, the manufacturer packaging was reviewed and stated "Item is considered Sterile until open."

3. During an interview on 4/12/2022 at approximately 10:50 AM, with the Director of ICU (E#2) stated "This room is cleaned. That shouldn't be like that and the staff know that."

4. On 4/13/2022 between 1:00 and 1:45 PM, an observational tour of the OB (Obstetric Unit) was conducted with the Obstetric Director (E #1). On the tour, the Anesthesia cart in the OB Surgical Suite contained (2) disposable 6.5 mm (millimeter) Endotrachael tubes in an open sterile package with a 10 ml (milliliter) syringe attached to each Endotrachael tube, in the second drawer.

5. During an interview on 4/13/2022 at approximately 2:00 PM, Director of Obstetrics (E #1) stated "sterile packages should never be open prior to use."

B. Based on observation, document review, and staff interview, it was determined the Facility failed to ensure infection control and medical supplies were labeled properly and unexpired to ensure proper disinfection of patient care areas and equipment. This has the potential to affect all patients receiving care at the Hospital with a current census of 9 patients.

Findings include:

1. On 4/12/2022 at approximately 11:30 AM an observational tour of the Intensive Care Unit (ICU) was conducted with the Director of ICU (E #2). a.) In the Soiled Utility room, 4 unlabeled spray bottles (1) contained approximately 5 fluid ounces of liquid, (2) contained approximately 30 fluid ounces of liquid, (1) contained approximately 1 gallon of liquid were observed on the shelf unlabeled as to the date opened. b.) One container of Prolystica Enzymatic Cleaner with approximately 2/3 of a gallon left was expired on 11/1/21 and one container of Prepzyme Enzymatic Cleaner with approximately 20 milliliters left, expired on 2/2021.

2. On 4/13/2022 at approximately 11:00 AM an observational tour of the Medical/ Surgical Unit was conducted with the Director of OB (E#1). At the nurses station there were Fifteen (15) Hemoccult screening test cards found with an expiration date of 11/2013 and One (1) 15 milliliter vial of Hemoccult Developer with an expiration date of 04/2015.

3. On 4/14/2022 at approximately 12:00 PM the policy titled "Medication, Biologics, and Supplies Outdates" was reviewed. The policy noted " Process - A. Medication biologics, and medical supplies will be checked monthly for outdates (expired dates). These will be disposed of per manufacturer's recommendations or returned to manufacture for credit. "

4. During an interview on 4/12/2022 at approximately 11:35 AM, E #2 stated that, " Those belong to housekeeping, but I will make sure they know to label with open date sticker and look at expiration dates." E#1 stated on 4/13/2022 at approximately 12:15 PM that, "I am not sure that we use those cards anymore. But, they should have been checked for expiration and disposed of properly."



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5. During a tour of the Emergency Department (ED) on 4/13/22 at approximately 10:00 AM with the ED Coordinator (E#4) and the Director of ED (E#9), trauma room #1 was observed to have a defribrilator and suction machine on top of the crash cart. Underneath the defribrilator and suction machine, dust and multiple pieces of broken glass were observed.

6. During an interview on 4/13/22 at approximately 10:00 AM, E#9 stated "That should have been cleaned off. I think the glass is from ampules (glass containers with a scored neck which have to be broken to open)."

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A. Based on observation, document review and interview, it was determined the Hospital failed to ensure expired food items were not available for patient use. This has the potential to affect all staff, patients, and visitors serviced by the Hospital.

Findings include:

1. An observational tour was conducted of the Dietary department on 4/12/22 at approximately 1:40 PM with Food Service Director (E #5). The following items were found to be expired:

--Lettuce in the Produce cooler expired 4/4/22
--Worcestershire sauce in the Cook's cooler expired 3/22/2019
--Horseradish sauce in the Cook's cooler expired 3/29/22

2. The policy "Date marking Ready-To-Eat, Potentially Hazardous Food" (revised 9/25/2020) was reviewed 4/13/22 at approximately 2:00 PM. The policy noted "Serve or discard refrigerated, ready-to-eat, potentially hazardous foods within 5 days or according to the Food Label and Storage Guide."

3. During an interview on 4/12/22 at approximately 2:00 PM E #5 stated "yes anything that is expired or past the beyond use date should be discarded and not be available for patient use...those items will be discarded."

B. Based on document review, observation and interview, it was determined the Hospital failed to ensure unlabeled medications were not available for patient use. This has the potential to affect all patients serviced by the Hospital with a current census of 9 patients.

Findings include:

1. The policy "Administration of Medication" (revised 8/2020) was reviewed 4/13/22 at approximately 2:45 PM. The policy noted "Medications are labeled...A. Any time that medications are prepared outside of the patient's bedside, the container of use must be labeled (i.e. syringe, medication cup...)

2. An observational tour was conducted of the Outpatient Infusion/Special Procedures on 4/12/22 at approximately 2:00 PM with the Clinical Coordinator of Outpatient Infusion (E#7). In the top drawer of the medication/supply cart located at the nurses station was 3 insulin syringes out of the packaging with clear fluid drawn up in them (unlabeled).

4. During an interview on 4/12/22 at approximately 2:15 PM with E#7 stated "No, those syringes should not be in there unlabeled...even though it's just normal saline."

Based on document review and interview, it was determined the Hospital failed to ensure an appropriate discharge planning process. As a result, it was determined the Condition of Participation, 42 CFR 482.43, Discharge Planning was not in compliance:

Findings include:

1. The Hospital failed to ensure appropriate medical information was provided to the patients and receiving facility prior to transfer. See A-0813

2. The Hospital failed to ensure discharge planning was appropriately conducted. See A-0814 A.

3. The Hospital failed to ensure discharges were evaluated for effectiveness and incorporated in the Quality Assurance Performance Improvement (QAPI) program. See A-0814 B.

Based on document review and interview, it was determined for 3 of 4 (Pt #1, Pt #1, Pt #9) patients records reviewed who were transferred, the hospital failed to ensure appropriate medical information was provided to the patients and receiving facility prior to transfer. This has the potential to affect all patients who transfer to another facility.

Findings include:

1. The "State of Illinois Region 1B Authorization to Transfer" form was reviewed on 4/12/22. The form noted documentation of the Physician who accepted the transfer, the accepting facility, accepting facilities representative, patient notification of the benefits, risks and the mode of transport. The form noted "The Individual May Not Be Transferred Unless Each of The Following Are Met:..." and has check boxes to indicate the hospitals capability to care for the patient, name of person receiving report and the physician and patients signed consent.

2. Pt #1 Date of Service (DOS): 2/20/22
Diagnosis: Bizarre/Paranoid behavior. The record was reviewed on 4/12/22 at approximately 11:00 AM. The record note Pt #1 was transferred and lacked a completed State of Illinois Region 1B Authorization to Transfer form and documentation patient records were sent to the receiving facility.

3. Pt #1 DOS: 2/24/22
Diagnosis: Bizarre/Paranoid behavior. The record was reviewed on 4/12/22 at approximately 12:30 PM. The record note Pt #1 was transferred and lacked a completed State of Illinois Region 1B Authorization to Transfer form and documentation patient records were sent to the receiving facility.

4. Pt #9 DOS: 3/27/22
Diagnosis: Sexual Assault. The record was reviewed on 4/13/22 at approximately 3:30 PM. The record lacked a completed State of Illinois Region 1B Authorization to Transfer form and documentation patient records were sent to the receiving facility.

5. During an interview on 4/14/22 at approximately 2:00 PM, the Director of Quality (E#8) reviewed Pt #1's and Pt #9's charts and verbally agreed the records lacked documentation the Authorization to Transfer form was completed and should have been.

A. Based on document review and interview, it was determined for 1 of 3 (Pt #1) patients records reviewed who were transferred, the hospital failed to ensure discharge planning was appropriately conducted. This has the potential to affect all in-patients and out-patients who are transferred from the hospital.

Findings include:

1. The policy titled "Patient Assessment and Reassessment" (revised 12/2020) was reviewed on 4/12/22. The policy noted "Discharge Planning... 3. The Discharge Planning/Care Conference team will meet Monday through Friday... review active discharge planning cases... 7. Following is a list of automatic referrals/high risk screening for Social Service: ...Attempted Suicide/Overdose... Psychiatric Diagnosis... Substance Abuse Diagnosis..."

2. The policy titled "Discharge Planning, Care Conference" (revised 3/2020) was reviewed on 4/12/22. The policy noted "The purpose of the team conferences are: ... Determine the patient's functional capacities and assess the needs for a supervised environment, home care, or services of other agencies... Determine the need for medical follow-up when the patient leaves the hospital... Each inpatient will have a Discharge Planning/Care Conference documentation form as part of their medical record."

3. Pt #1 Date of Service (DOS): 2/20/22
Diagnosis: Bizarre/Paranoid behavior, overdose and allegations of sexual assault. The record was reviewed on 4/12/22 at approximately 11:00 AM. The record noted Pt #1 was transferred from the Emergency Department (ED) and involuntarily admitted to the Intensive Care Unit (ICU) for close monitoring due to acute psychosis (a mental disorder characterized by a disconnection from reality) until an inpatient psychiatric facility accepted the patient. A faxed refusal of care from the inpatient psychiatric hospital (H#1) dated 2/20/22 noted the referral could not be processed due to the following "The Petition is not valid due to... The Certificate is not valid due to... The Intake Referral form is... Not Provided... COVID test... medical clearance..." and information on restraint use. The record lacked documentation of the intial referral or attempt to resubmit the requested information to H#1. The record lacked documentation Pt #1 was screened as high risk and/or the Social Worker was notified or involved in the discharge planning process. The Daily Focus Assessment Report dated 2/21/22 at 12:20 PM "called H#1... and stated we still needed the bed, stated the bed is still available but the sending facility (H#2) would have to resubmit for bed..." The Discharge Summary dated 2/21/22 by the Hospitalist (MD#4) noted "The patient stated he/she was raped... The patient has been accepted by (H#2, Hospital with Sexual Assault Nurse Examiners). The patient has been transferred to H#2 and then from there, the patient will be transferred to H#1... for inpatient psychiatric services."

4. During an interview on 4/14/22 at approximately 12:50 PM, MD#5 9 (psychiatrist) stated "My recommendation was for her to go to an inpatient psychiatric hospital for treatment. She was way psychotic and delusional... Her behavioral health condition trumped anything else."

5. During an interview on 4/14/22 at approximately 12:30 PM, the Director of Quality (E#8) reviewed Pt #1's record and verbally agreed the record lacked referral documentation, lacked documentation of a referral to the social worker nor was the social worker was involved in Pt #1's discharge plan and verbally agreed Pt #1 was transferred to the wrong level of care based on the psychiatric needs noted in the discharge plan.

B. Based on document review and interview, it was determined for 1 of 1 (Pt #1) patient record reviewed who was transferred from the Intensive Care Unit, the hospital failed to ensure discharges were evaluated for effectiveness and incorporated in the Quality Assurance Performance Improvement (QAPI) program. This has the potential to affect all patients who receive care by the hospital with a current census of 9 patients.

Findings include:

1. Pt #1 DOS: 2/20/22
Diagnosis: Bizarre/Paranoid behavior, overdose and allegations of sexual assault. The record was reviewed on 4/12/22 at approximately 11:00 AM. The record lacked documentation Pt #1 was transferred to the appropriate level of care based on the primary psychiatric/medical needs as noted on the discharge plan, nor was the discharge plan was evaluated for effectiveness.

2. During an interview on 4/12/22 at approximately 11:45 PM, the Emergency Department Coordinator (E#4) and the Director of Emergency Services (E#9) reviewed Pt #1's record and verbally agreed the record lacked documentation the discharge plan was reassessed for effectiveness.

3. During an interview on 4/14/22 at approximately 12:30 PM, E#8 reviewed Pt #1's record and verbally agreed Pt #1 had not been transferred to the appropriate level of care based on the psychiatric/medical needs noted in the discharge plan. E#8 verbally agreed the hospital did not ensure the discharge plan was reassessed for effectiveness.