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Based on observation, interview and policy review, the hospital failed to ensure medication safety when they failed to ensure the integrity of the contents of the anesthesia cart in Endoscopy Suite 1. These practices failed to provide safe and effective medication administration that potentially damaged the medication integrity and/or quality for all patients at the hospital. The facility census was one Acute care patient, four Swing Bed patients and two Observation patients for a total census of seven.

Findings included:

1. Observation on 09/26/23 at 9:10 AM, in Endoscopy Suite #1, showed that anesthesia drawer #1 was unlocked and had the potential for staff to access without accountabiliity.The medications in drawer #1 were Atropine (used to treat a slow heartbeat, reduction of saliva and fluid in the respiratory tract during surgery and used to treat insecticide or mushroom poisoning), Phynlephrine (used to treat sinus congestion), Glycotyrrolate (used to treat peptic ulcers or severe drooling caused by certain neurologic disorders) and Xylacaine (used to treat arrhythmias, pain and numbing of the skin).

2. During an interview on 09/26/23 at 2:19 PM, Staff Q, Director of Outpatient Services, stated the expectation for anesthetists was for them to have kept all medications locked with a lock mechanism.

3. During an interview on 09/27/23 at 11:39 AM, Staff D, Chief Nursing Officer, stated anesthesia staffs' expectations included securing all medications used by the Certified Registered Nurse Anesthetist (CRNA - administers and provides anesthesia services to patients before, during and after surgery).

4. Review of the hospital's policy titled, "Medication Administration," dated 05/26/23, showed the direction for staff to provide safe, effective and ethical medication practice that included accountability with medications not being left unattended and secured when not being administered.








18018

Based on policy review, medical record review, rules and regulation review and interview the hospital failed to ensure staff:
- Completed a History and Physical (H&P), within 30 days of two patient (#5 and #6) surgical procedures of six reviewed.
- Completed a fire risk assessment for six patient (#5, #6, #7, #8, #9 and #10) surgical procedures of six reviewed.
- Performed six patient (#5, #6, #7, #8, #9 and #10) surgical procedures without physician documented oversight of Certified Registered Nurse Anesthetists (CRNAs) of six reviewed. These failures had the potential to affect the quality of care for all patients that presented for surgical procedures. The facility census was one Acute care patient, four Swing Bed patients and two Observation patients for a total census of seven.

Findings included:

1. Review of the hospital's document titled, "General Rules and Regulations for the Medical and Dental Staff of Excelsior Springs City Hospital," last reviewed on 04/24/23, showed a complete H&P exam recorded in the chart was required on each patient having surgery, except in an emergency. If the H&P was not on the chart at the time of surgery, staff shall not allow the surgery to proceed. A short form H&P may be used for patients admitted for minor surgical procedures and for patients whose hospital stay was not expected to exceed 48 hours.

Review of the hospital's policy titled, "Medical Record Content," dated 04/23/23, showed the direction for staff to complete an H&P within 30 days prior to admission.

Review of the patient's Electronic Medical Surgical Records (EMSR) showed that Patient #5's EMSR dated 06/15/23, showed Staff BB, Urologist, failed to authenticate with a time, the patient's H&P prior to a cystoscopy procedure and Patient #6's EMSR dated 08/07/23, showed Staff DD, Orthopedic Surgeon, failed to complete the patient's H&P short form prior to a right knee arthroplasty procedure.

During an interview on 09/26/23 at 1:25 PM, Staff B, Director of Perioperative Services, stated that they expected the physicians to complete H&Ps within 30 days or a short form for update with the date, time and signature.

2. Review of the hospital's policy titled, "Fire Prevention and Management of Patient in the Operating Room (OR)," dated on 05/26/23, showed the direction for staff to document in the EMSR the fire risk assessment in the peri-operative record.

Review of the patient's EMSR, showed no fire risk assessment documented prior to the following surgical procedures:
- Cystoscopy (a procedure that examines the lining of the bladder and urethra) for Patient #5's EMSR dated 06/15/23;
- Cholecystectomy (gallbladder removal) for Patient #6's EMSR dated 08/07/23;
- Right Knee Arthroplasty (total joint replacement) for Patient #7's EMSR dated 07/31/23;
- Colonoscopy (a procedure to examine the large intestine) for Patient #8's EMSR dated 06/07/23;
- Esophagogastroduodenoscopy (EGD, a procedure to examine the oropharynx, esophagus, stomach and proximal duodenum) for Patient #9's EMSR dated 06/28/23; and
- Colonoscopy for Patient #10's EMSR dated 08/30/23.

During an interview on 09/26/23 at 2:19 PM, Staff Q, Director of Outpatient Services, stated they expected staff to assess the fire risk with documented date, time and signature prior to the procedure start.

3. Although requested, the hospital failed to provide guidelines that showed the physician's responsibilities for the oversight of CRNAs.

Review of the patient's EMSR, showed no physician oversight of CRNAs documented prior to the following surgical procedures:
- Cystoscopy (a procedure that examines the lining of the bladder and urethra) for Patient #5's EMSR dated 06/15/23;
- Cholecystectomy (gallbladder removal) for Patient #6's EMSR dated 08/07/23;
- Right Knee Arthroplasty (total joint replacement) for Patient #7's EMSR dated 07/31/23;
- Colonoscopy (a procedure to examine the large intestine) for Patient #8's EMSR dated 06/07/23;
- Esophagogastroduodenoscopy (EGD, a procedure to examine the oropharynx, esophagus, stomach and proximal duodenum) for Patient #9's EMSR dated 06/28/23; and
- Colonoscopy for Patient #10's EMSR dated 08/30/23.

During an interview on 09/26/23 at 1:25 PM, Staff B, Director of Perioperative Services, stated they expected the surgeons to sign off on the CRNAs.

During an interview on 09/27/23 at 11:39 AM, Staff D, Chief Nursing Officer, stated the surgeon performing the procedure and/or surgery had the responsibility to provide oversight of the CRNA and co-sign CRNAs' documentation.

Based on record review and interview the facility failed to ensure privileges and policies specified the Certified Registered Nurse Anesthetist (CRNA) was under the supervision of the operating practitioner for three (1,2, and 7) of three physicians who utilized CRNAs. The facility census was one Acute care patient, four Swing Bed patients and two Observation patients for a total census of seven.

Findings included:

1. Review of physician credentialing files for Staff 1, 2 and 3 showed no privileges for supervision of the CRNA.

2. During an interview on 09/27/23 at 11:15 AM, Staff S, Medical Staff Coordinator, stated physicians 1, 2 and 3 would be physicians who utilize CRNAs and should have supervised anesthesia staff. After review of the medical staff bylaws Staff S stated the supervision of CRNAs was not present in the bylaws and confirmed the privileges for the physicians did not indicate the supervision had been approved by the medical staff.

3. During an interview on 09/27/23 at 11:39 AM, Staff D, Chief Nursing Officer, stated the surgeon performing the procedure and/or surgery had the responsibility to provide oversight of the CRNA and co-sign CRNA's documentation. Staff D also stated the expectation of surgeons was to follow oversight requirements for CRNA services per the facility's Medical Staff Rules and Regulations.





36473

Based on observation, interview and policy review, the hospital failed to ensure staff followed infection control policies and infection prevention standards of practice when staff failed to:
- Provide a clean and rust (reddish-brown oxidation of metal that can harbor bacteria) - free kitchen.
- Provide a clean without exposed particle board (particle shedding) endoscopy clean room.
- Provide a clean and rust-free surgery soiled utility room.
These failed practices had the potential to expose all patients, visitors and staff to cross-contamination and increased the potential to spread infection. The facility census was one Acute care patient, four Swing Bed patients and two Observation patients for a total census of seven.

Findings included:

1. Review of the hospital's policy titled, "Surgery and Procedure Cleaning," dated 01/05/22, showed that the environmental staff (maintenance) were responsible for cleaning the soiled utility room monthly, to include storage, walls and ceilings.

Review of the hospital's policy titled, "Scope of Service," dated 11/03/22, showed that surfaces contaminated with microorganisms can serve as reservoirs of potential pathogens should be cleaned and the definition of "cleaning" was the removal of visible soil and organic contamination from a device or surface.

Observation on 09/25/23 at 2:30 PM, in the kitchen area, showed the following:
- Shedding plaster on the wall underneath handwashing sink #.
- Rusted garbage deposal switch container.
- Rusted area under a clean dish cart.
- Rusted and residue on the left inner side of the top "Combi" oven.
- Rusted areas under the raw meat refrigerator.
- Five rusted ceiling vents in the grill area.

During an interview on 09/25/23 at 2:45 PM, Staff R, Certified Dietary Manager, stated that staff cleaned weekly and they were unable to remove rust.

2. Observation on 09/26/23 at 9:30 AM, in the endoscopy clean room, showed damaged particle board around faucets to the right of the medivator (disinfects endoscopes).

During an interview on 09/27/23 at 10:45 AM, Staff F, Infection Preventionist, stated that they expected staff to complete a maintenance ticket request when they saw repairs needed.

3. Observation on 09/26/23 at 10:00 AM, in the surgical unit, showed two rusted cabinets in the scrub sink area, rusted ceiling grill, sink with mold and discoloration and molded water-damaged particle board next to a shelf in the soiled utility room.

During an interview on 09/26/23 at 2:19 PM, Staff Q, Director of Outpatient Services, stated that staff should have put in a ticket for maintenance when items were in need of repair.

During an interview on 09/27/23 at 10:50 AM, Staff G, Environmental Services Director, stated that they monitor the soiled utility room and round all areas monthly.

Based on policy review, record review and interview the facility failed to:
- Complete a comprehensive quality of life activities assessment, which identified specific individualized activity interest for four current Swing Bed (Swing Bed - a Medicare program in which a patient can receive acute care services, then if needed Skilled Nursing Home Care) patients (#15, #16, #17 and #18) out of four patients reviewed for a comprehensive quality of life activities assessment.
- Provide specific, individualized activity interests that stimulated the patient's physical and mental well-being for four current Swing Bed patients (#15, #16, #17 and #18) out of four patients reviewed for specific, individualized activity interests of the patient.
- Develop a comprehensive activity care plan, which included activity interests and interventions for four current Swing Bed patients (#15, #16, #17 and #21) out of four patients reviewed for a comprehensive activity care plan.
These failed practices had the potential to affect all Swing Bed patients by failing to stimulate their minds, body and social interests. The facility census was one Acute care patient, four Swing Bed patients and two Observation patients for a total census of seven.

Findings included:

1. Review of the facility's polity titled, "Comprehensive Assessment, Care Planning and Discharge Plan - Swing Bed," undated showed staff directives in part:
- To assure the patient receives the necessary care and services to attain or maintain their highest practicable level of physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. Excelsior Springs Hospital (ESH) performs an assessment to develop a plan of care to meet the needs of the patient during admission up to and including discharge.
- Each patient has an individualized interdisciplinary plan of care. The interdisciplinary plan of care is based on the comprehensive assessments of the interdisciplinary team members. It is developed after completion of the assessments but within 14 days of admission.
- An Interdisciplinary Team approach is used in caring for the patients of the Swing Bed Program.
- The Interdisciplinary Team assists in the assessment of the patient's psychosocial status. The patient's customary routine is documented, including the cycle of daily events, eating patterns, activities of daily living (ADL) patterns and involvement patterns. The current emotional status is assessed including the patient's sense of initiative and involvement, unsettled relationships and past roles. The patient's legal status, marital status, family and cultural/ethnic factors are assessed. The patient's personal and social adjustments and response to illness is assessed.
- Interventions directed toward meeting the set goals are developed and documented on the care plan. The result and response to the interventions are documented within the care plan or the progress notes. The care plan is assessable to all caregivers. The patient's response to the interventions and progress toward goals is continuously reassessed or evaluated, revised and documented.
- The development of effective goal oriented, individualized care plan assists patients to function at the highest possible level and allows the ethical delivery of hospitalized care in a manner that emphasizes dignity in keeping with the mission and values of ESH.

2. Review of Patients' Electronic Medical Health Records (EMHR) showed:
- Patient #15 was admitted to the facility's Swing Bed program on 09/22/23, for rehabilitation services/therapy status post fall;
- Patient #16 was admitted to the facility's Swing Bed program on 09/18/23, for rehabilitation services/therapy status post left hip fracture;
- Patient #17 was admitted to the facility's Swing Bed program on 09/15/23, for rehabilitation services/therapy status post stroke; and,
- Patient #18 was admitted to the facility's Swing Bed program on 09/18/23, for rehabilitation services/therapy.

Patient #15's, #16's, #17's and #18's EMHR showed staff failed to conduct a comprehensive quality of live activity assessment of the patients to assist in identifying the patients' activity interests and staff failed to develop a comprehensive activity care plan for the patients during the patients stay in the facility's Swing Bed program.

3. During an interview on 09/27/23 at 12:42 PM, Staff D, Registered Nurse, Chief Nursing Officer, acknowledged the facility's Swing Bed program does not include neither an activity assessment nor an activity Care Plan for patients admitted to the facility's Swing Bed program. Staff D stated the facility was under the impression the element for activity assessment and Care Plan for activities for Swing Bed patients had been removed from the regulations for Swing Bed programs.