HospitalInspections.org

Based on a review of facility documentation, observation and staff interview, the facility did not have a posted notice which stated that the critical access hospital did not have a doctor of medicine or doctor of osteopathy present in the hospital 24 hours per day, 7 days per week, and which indicated how the hospital would meet the medical needs of any patient with an emergency medical condition.

Findings were:

During a tour of the hospital on the morning of 6/12/19, with the Director of Quality, it was noted there was no posted notice regarding a physician not being on-site 24 hours per day/7 days per week as required by regulations.

In an interview with the Director of Quality during the tour, she stated that there was no such sign currently posted, and added, "I thought we used to have one that said that."

Based on observation and interview, the facility failed to maintain various areas of the hospital in order to ensure the safety of all patients, visitors and staff at the hospital.

Findings were:

"OSHA/Bloodborne Pathogen Regulations Policy #138-030-060" stated in part "The facility provides sufficient housekeeping and maintenance personnel to maintain the interior and exterior of the facility in a safe, clean, orderly, and attractive manner."

Facility policy entitled "Pest Control," effective 5/21/19, included the following:
" ...1. North Runnels Hospital District (the hospital) intends to maintain an environment that is clean, sanitary, and attractive for patients, visitors, and staff. This is accomplished by:
a. Daily cleaning of the hospital using infection control standards for cleaning.
b. Observing and responding to issues identified through routine rounding on the hospital.
2. Safety Officer/Plant Manager is responsible for coordinating a pest control program through a designated, hospital approved contracted service ...
b. The Pest Control program will be evaluated on an annual basis by Infection Control Practitioner ..."

During a tour of the of the hospital on the morning and afternoon of 6/11/19 and 6/12/19 with the Directors of Quality of Nursing at different times, the following infection control issues were noted:

Throughout the hospital:
- There was chipped plaster on walls including in patient care areas and in patient rooms. This makes thorough cleaning of the room or area impossible.
- Under sinks in patient care areas, medication rooms, radiology, and other areas there were stored supplies, including patient supplies. In addition, the wooden flooring of these cabinets had a thin layer of old paint that left large amounts of wood exposed. Once a permeable surface is exposed, there is no way to thoroughly clean the surface. Areas under sinks are prone to mold, mildew and other contaminants, and should be considered soiled environments.
- There were chipped cabinets in patient care areas, patient rooms and various departments and areas of the hospital. The permeable wood beneath was exposed which made thorough cleaning impossible.
- Ceiling tiles had water stains and/or were ill-fitting in numerous areas of the hospital, including medication rooms and patient supply areas. Once exposed to moisture, ceiling tiles can harbor mold, crumble and become a source of infection control issues.
- Light from outside the hospital was visible through external doorways, including in the kitchen and various hallways in patient care areas. These can serve as portals for pests, dirt, dust and debris.

In the patient nourishment area:
- There was ice build-up in the freezer section of the refrigerator which held patient food items. Ice in a refrigerator or freezer can pose a serious problem because it can keep the temperature in the unit too high, potentially spoiling the food in it. It can also lead to equipment malfunctioning.
- The ice machine was dripping, thus pooled water could harbor mold or bacteria. In the cabinet under the ice machine was a bucket and some paper towels to catch the drips.

In the medication room off the nursing station:
- There was an approximate 1-inch buildup of ice in the medication refrigerator.
- A stood/chair in the room had approximately 10" of foam filling exposed due to a tear in the vinyl covering. This permeable surface made thorough cleaning impossible.
- There were chipped cabinets, again making thorough cleaning impossible.

In patient rooms 103 and 106:
- Both rooms had vinyl baseboard that was coming away from the wall. Behind the gaping baseboard was visible dust and grime.
- Room 103 had floor tiles which were rising up and the joints of the tiles were dirty.

In Central Supply:
- Supplies were stored closer than 18" from the ceiling - sometimes as close as 6" from the ceiling. This can pose a fire hazard and endangers proper functioning of the fire sprinkler system.
- There was a large water-stained ceiling tile above the patient supply area.

In the Overflow Patient Supply Storage Closet #2:
- There were 4 crumbling ceiling tiles with old water stains over the small area which housed patient supplies.
- Opened external shipping containers with supplies stored to within 6" of the ceiling.

In the Radiology area:
- A live insect was noted in the x-ray room.
- Ceiling tiles throughout the area were stained and ill-fitting.

In the Lab area:
- Shelves were rusty thus making thorough cleaning impossible.
- A live insect was noted in the x-ray room.

In the Dietary Services area/Kitchen:
- There was ice build-up in the walk-in freezer, including an approximate 8" icicle. Ice in a refrigerator or freezer can pose a serious problem because it can keep the temperature in the unit too high, potentially spoiling the food in it. It can also lead to equipment malfunctioning.
- The ceiling of the pantry where patient food items were stored had numerous decaying tiles.
- The paper goods supply closet was near an exterior door though which outside light was visible. This opening to the exterior could serve as a portal for pests, dust and debris.

In the Oxygen Storage Closet:
- There were 3 unsecured oxygen canisters. These posed a threat to patient safety.

In the Emergency Department:
- There was a large opening exposed to the crawl space behind the wall around the oxygen supply lines.
- Light could be seen under a door opening to the exterior of the building. The opening could serve as a portal for pests, debris and dust from outside.

The above findings were all confirmed during the tours with the Directors of Quality and Nursing, as well as the hospital consultant, and again on the afternoon of 6/12/19 in the office of the Director of Nursing.

Based on observation and interview, the facility failed to provide a sanitary environment by keeping the premises clean and orderly.

Findings were:

"OSHA/Bloodborne Pathogen Regulations Policy #138-030-060" stated in part "The facility provides sufficient housekeeping and maintenance personnel to maintain the interior and exterior of the facility in a safe, clean, orderly, and attractive manner."

Facility policy entitled "North Runnels Hospital District Housekeeping Manual," included the following:
"SUBJECT: Infection Control - Environmental Services
PURPOSE:
To control the spread of infection within the Hospital by maintaining a thoroughly clean and safe environment ...
INFECTION CONTROL PRACTICES:
Sanitation within the hospital environment depends on cleaning thoroughness and frequency ...
PATIENT ROOMS:
All upward facing horizontal surfaces shall be damp cleaned daily.
Hard floor surfaces shall be wet cleaned daily.
Tile floors shall be mopped daily, using approved germicide solution ...
Bathrooms shall be cleaned daily and special attention given to sanitizing commodes, all bars, handles and doorknobs ...


During a tour of the of the hospital on the morning and afternoon of 6/11/19 and 6/12/19 with the Directors of Quality of Nursing at different times, the following infection control issues were noted:

Throughout the hospital:
- Floors were not clean - at times extremely dirty - in patient care areas, storage areas including where patient supplies were stored, in patient restrooms, in medication rooms, and other areas.

In a visitor/patient restrooms off the main hallway:
- The floors were overtly dirty.
- Air vents were visibly dusty.
- In the men's restroom, there was a large stain on a light fixture. This may have been cited on the previous survey, but it was unclear to which light fixture the surveyor had referred.

In the medication room off the nursing station:
- The floor was visibly dirty.

In patient rooms 103 and 106:
- The floors were dirty in corners of the rooms. The bathroom of patient room 106 had a very dirty area on the floor which appeared overtly dirty.
- Both rooms had vinyl baseboard that was coming away from the wall. Behind the gaping baseboard was visible dust and grime.
- Room 103 had floor tiles which were rising up and the joints of the tiles were dirty.
- In room 103, there was visible dust and grime behind the air conditioning unit.

In the Blood Storage Area:
- The floor was visibly dirty.

In the Radiology area:
- The CT scan room had a thick layer of dust on some horizontal surfaces.

In the Emergency Department:
- The emergency department bathroom floor was dirty.

The above findings were all confirmed during the tours with the Directors of Quality and Nursing, as well as the hospital consultant, and again on the afternoon of 6/12/19 in the office of the Director of Nursing.

Based on observation, interviews and record review the hospital Board of Directors failed to assume full legal responsibility for determining, implementing, and monitoring policies governing the hospital's total operation and failed to ensure that the policies were administered so as to provide quality health care in a safe environment as evidenced by:

1. Failing to assume responsibility for the appointments and assignment of medical privileges for medical staff members as 4 of 4 physician and mid-level providers [Staff #7-10] lacked any request, or subsequent approval/denial of medical privileges. This placed any patients of the hospital in any department at risk of medical care being provided by a member of the medical staff who lacked the training and/or background to provide such medical care or service. (refer to C0241)

2. Failing to adopt, implement and enforce procedures which would mitigate possible workplace violence related to the safety of the work environment for nurses. (refer to C0241)

3. Failing to ensure the physical plant/environment was a safe environment for patients, visitors and staff as the hospital had no functioning infection control program. Hospital tours revealed serious findings related to infection control, including excessive dirt, dust, debris and insufficient door seals. In addition, there was no functioning committee to oversee these issues or other infection control issues. Also, there were unsecured oxygen tanks stored inside the hospital, as well as other issues that affected the safety of all individuals in the hospital. (refer to C0278)

4. Failing to ensure the hospital met the requirements put forth by CMS related to the provision of care to post-acute care skilled nursing facility (SNF) care patients (swing-bed patients) for 5 of 5 such patients [Patients #11-15] as these patients did not receive: a) an assessment of patient activity requirements based on patient needs and interests, b) a comprehensive assessment of each resident's needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS, or c) an assessment of dental needs and the services of a dentist to provide emergency or routine dental services. (refer to C0385, C0388 and C0404 respectively)

These failed practices resulted in:
a) an unsafe and unsanitary environment of care for patients, visitors and staff;
b) the provision of patient care by providers who were not privileged to provide such care; and
c) swing-bed patients potentially not receiving assessments, care and services which could have affected their long-term outcomes.
The cumulative effect of these systemic deficiencies resulted in noncompliance with the Condition of Participation §485.627 Organizational Structure.

Based on a review of facility documentation and staff interviews, the facility failed to:

1. Assume responsibility for the appointments and assignment of medical privileges of medical staff members as 4 of 4 physician and mid-level staff credentialing files [Staff #7-10] lacked any request, or approval/denial of medical privileges. This placed any patients of the hospital in any department at risk of medical care being provided by a member of the medical staff who lacked the training or background to provide such medical care or service; and

2. Adopt, implement and enforce procedures which would mitigate possible workplace violence related to the safety of the work environment for nurses.

Findings were:

1. ...Failed to assume responsibility for the appointments and assignment of medical privileges of medical staff members as 4 of 4 physician and mid-level staff credentialing files [Staff #7-10] lacked any request, or approval/denial of medical privileges. This placed any patients of the hospital in any department at risk of medical care being provided by a member of the medical staff who lacked the training or background to provide such medical care or service.

North Runnels Hospital Governing Board Bylaws, last approved 5/21/18, included the following:
" ...ARTICLE VI - MEDICAL STAFF ...
Section 2. Purpose:
The purpose of the Medical Staff shall be:
A. To insure that all patients admitted to the Hospital receive the best possible professional care.
B. To promote high standards in the science, the art, and the ethics of medical and surgical practice within the resources available at the Hospital.
C. To initiate and maintain self government.
D. To provide a means whereby problems of a medico-administrative nature may be discussed by the Staff with the Board of Directors and the Administrator of the Hospital ...

All Procedures for application for membership and the processing thereof shall be in writing, and each amendment thereto by the Medical Staff or Board shall also be in writing ...

Section 5. Appointment to the Medical Staff: ...
2. Appointment to the Medical Staff shall confer on the appointee only such privileges as may be herein after provided for by the Board of Directors and Medical Staff ..."

A review of the "Bylaws, Rules and Regulations of the Medical Staff, North Runnels Hospital, Winters, Texas," last reviewed 10/8/1991, revealed the following:
" ...Section 3. Application and Appointment Procedure:
(a) Application for membership on the Medical Staff shall be presented in writing and shall state the qualifications and references of the applicant. The application shall also include a list of privileges requested, including specialty procedures such as nuclear medicine ...
ARTICLE V - STAFF APPOINTMENTS AND PRIVILEGES
Section 1. Appointments and Privileges.
(a) Any practitioner desiring to perform an appropriate service must apply for the specific privileges associated with the service and his applications will be evaluated in terms of his qualifications.
(b) When a practitioner who has been appointed to the staff desires to exercise privileges not included within his appointment, he shall include a request for additional privileges with this regular application for renewal or in a special application for modification of appointment together with all evidence of his qualifications to exercise the additional privileges. The burden of establishing a practitioner's qualifications for all aspects of his request for appointment, including the awarding of specific privileges, shall be upon the practitioner.
(c) The Board of Directors of the Hospital, or its duly authorized Committee, upon recommendation from the Chief of Staff of the Medical Staff, shall have the authority of curtailing privileges of any member of the Medical Staff, in which case the members hall be entitled to an evidentiary hearing and appeal as provided in Article IV, Section 1 ...

Approved by the Board of Directors of North Runnels Hospital District and North Runnels Hospital on the 11th day of July, 1988 ..."

Credential files were reviewed for 4 members of the medical staff: the hospital Medical Director and 3 mid-level licensed medical providers. Not one file included a list of medical privileges requested and approved or denied.

In an interview with Staff #3, the Director of Quality, on the afternoon of 6/11/19 in the office of the Director of Nursing, she stated that maintaining the credentialing files of the medical staff had "been handed to her" when the individual who had previously been responsible left. She stated she did not realize that members appointed to the medical staff had to request privileges based on their experience, training and expertise, or that the medical executive committee and the governing board had to approve or deny the request. She stated, "I wasn't aware of what exactly was required."


2. ...Failed to adopt, implement and enforce procedures which would mitigate possible workplace violence related to the safety of the work environment for nurses.

Findings were:

Facility policy entitled "Safe Working Environment Policy," approved 8/7/1990, read as follows in its entirety:
"PURPOSE:
Federal State [sic] and local government regulations require that all employers provide a safe working environment for all employees. In addition, the Board of Directors and administration of North Runnels Hospital are committed to developing policies, programs, and procedures in order to provide a safe working environment within the health care setting. This policy furthers that goal.

POLICY:
It is the policy of North Runnels Hospital to provide a safe working environment for the employees of the facility. In order to ensure that the environment is safe all employees should report unsafe working conditions to the Administrator as soon as possible.

Responsibilities:
All Employees:
- Be aware of the working environment and report all unsafe working conditions to the Administrator.
Administrator:
- Evaluate the unsafe condition
- If condition does present a working environment hazard notify all appropriate personnel of the potential hazard.
- Develop a plan of action to rectify the hazard and make the work environment safe.
- Implement the plan and eliminate or reduce the working environment hazard to a safe level."

In an interview with the Director of Nursing on the afternoon of 6/11/19 in her office, she was asked about the safety of individuals -- especially nurses -- working on the night shift. North Runnels Hospital is located on the edge of Winters, Texas, a small community which had a population of 2474 individuals in 2017. The Director of Nursing responded to surveyor questions, stating, "I'm very concerned about the safety of the nurses working the night shift. It's usually just 3 people that are here -- all nurses. I've been trying to get an emergency button installed at the nursing station under the counter. That way, at least it would be a way to notify authorities without any obvious sign of someone calling or signaling... But we haven't gotten that yet." When asked if the access into the building was controlled at night, she answered, "We've been told to lock the doors. But we can't really lock the emergency department door. And it just really doesn't work with any of the doors. If we lock the ER door, we'd need to have a sign there that would say that the person outside would have to knock or notify us that they were there. And the sign would have to be well lighted. It really wouldn't work anyway. At any of the doors, if someone were outside, they could say anything they needed to to get into the hospital." When asked if the hospital had considered having cameras outside each door, as this surveyor has seen at other critical access hospitals, the Director of Nursing replied, "That would be a good idea. It would help... This is a small community with some issues related to drug use. We could so easily have a bad incident occur here, and it would probably happen on the night shift when there are only 3 female nurses in the hospital."

Based on a review of facility documentation, observation and staff interview, the facility failed to meet the Condition of Participation for §485.635 Provision of Services as evidenced by:

1. Failing to implement its infection control policies related to providing a sanitary and safe environment for patients, visitors and staff as significant tour findings revealed several serious infection control issues, including: dirty floors throughout the hospital, insects in the facility, dust and debris on horizontal surfaces, as well as behind baseboard separating from the wall. (refer to C0278)

2. There was no evidence of a functional infection control program at all as there was no evidence of an infection control committee which would oversee these issues. There was no evidence that staff were aware of any infection control issues in the hospital (refer to C0278).

3. There was no documented evidence of a list of hospital contracts or agreements, and thus no documented evidence of oversight of these services. (refer to C0291).

These failed practices resulted in all patients being placed at risk of possible infection or an adverse outcome. The cumulative effect of these systemic deficient practices resulted in noncompliance with the Condition of Participation §483.635 Provision of Services.

Based on a review of facility documentation, observation and staff interviews, the facility failed to provide a sanitary environment to avoid sources and transmission of infections and communicable diseases. The infection control officer failed to implement policies governing control of infections and communicable diseases.

Findings were:

"OSHA/Bloodborne Pathogen Regulations Policy #138-030-060" stated in part "The facility provides sufficient housekeeping and maintenance personnel to maintain the interior and exterior of the facility in a safe, clean, orderly, and attractive manner."

A review of the "Bylaws, Rules and Regulations of the Medical Staff, North Runnels Hospital, Winters, Texas," last reviewed 10/8/1991, revealed the following:
" ...Infection Control Committee Functions:
An Infection Control Committee composed of members of the Medical and Nursing Staffs and Administration carries on activities aimed at investigating, controlling, and preventing infections in the Hospital. It develops written procedures governing the use of aseptic techniques and procedures in all areas of the Hospital; regularly reviews food handling and laundry practices, disposal of environmental and patient wastes, traffic control, and visiting rules in high risk areas, sources of air pollution, and staff performance in practicing aseptic techniques and the handling and storage of patient equipment and supplies and culturing of autoclaves and sterilizers ..."

A review of the "North Runnels Hospital Infection Control Plan 2018-2019," included the following:
"POLICY:
1. The North Runnels Hospital ("the Hospital") Board of Directors, Administration, Medical Staff, and other hospital leaders are committed to activities directed toward safe, effective, quality patient care to include employees and visitors.
2. The hospital has an active, effective hospital-wide program for prevention and control of infection for all patients, health care workers, and visitors that utilizes established guidelines for the prevention of nosocomial infection in patients and prevention of exposure to healthcare workers ...
OBJECTIVES:
1. The purpose of the Infection Control Plan is to:
a. Establish a comprehensive hospital-wide interdisciplinary program using effective guidelines and methods to identify, report, investigate, control and prevent infections and communicable diseases.
b. Provide and maintain a sanitary environment to avoid sources and transmissions of infections and communicable diseases.
c. To establish coordination of monitoring and surveillance activities for the prevention and control relative to infections (nosocomial and community acquired) and infection control techniques and practices, with recommendations for prudent infection control measures based on data analysis ...
RESPONSIBILITY:
1. The assurance of a safe hospital environment that provides necessary resources to prevent and control infections is the ultimate responsibility of the Board of Directors, Chief Executive Officer, Infection Control Committee, and the Medical Staff.
2. The Infection Control Committee is an interdisciplinary committee and is responsible for infection control activities.
a. All activities of the Infection Control Committee are reported to the Governing Board through the Medical Staff.
b. The Infection Control Committee meets at least quarterly or more often if necessary.
c. Minutes of the meeting are recorded and maintained in the infection control office for a minimum of 2 years ...
4. The Infection Control Practitioner is responsible for: ...
d. Assuring at least quarterly meetings of the Infection Control Committee are held, with minutes recorded ...
SCOPE OF CARE: ...
3. Infection Control Management ...
vii. Monitors the physical plant for compliance with protocols for a clean and safe environment ...
INFECTION CONTROL SURVEILLANCE ACTIVITIES AND METHODOLOGY: ...
3. Areas of surveillance may include, but will not be limited to, the following: ...
f. Environmental Surveillance ..."

Facility policy entitled "Pest Control," effective 5/21/19, included the following:
" ...1. North Runnels Hospital District (the hospital) intends to maintain an environment that is clean, sanitary, and attractive for patients, visitors, and staff. This is accomplished by:
a. Daily cleaning of the hospital using infection control standards for cleaning.
b. Observing and responding to issues identified through routine rounding on the hospital.
2. Safety Officer/Plant Manager is responsible for coordinating a pest control program through a designated, hospital approved contracted service ...
b. The Pest Control program will be evaluated on an annual basis by Infection Control Practitioner ..."

Facility policy entitled "Linen Handling," effective 5/21/19, included the following:
" ... 2. Linens will be transported into the facility in impervious wrappers or containers so that cleanliness is maintained ...
4. Linen will be stored in clean storage areas in carts that remain covered when not in use ..."

Facility policy entitled "Infection Control General Guidelines for Pharmacy," included the following:
" ...ENVIRONMENT
The Pharmacy shall insure that effective measures are taken to identify, control and prevent infections ...
5. Housekeeping shall sweep and mop the entire Pharmacy area daily ...
1. Oral Solid Dosage Forms (Capsules and Tablets)
The majority of oral solids are dispensed in a unit-dose packaging, either by the manufacturers or in our own prepackaging device. These doses are pre-packaged and labeled in such a manner that it is not necessary for the person administering the dose to touch it by hand ...
2. Oral Liquids
Many oral liquids are dispensed in the unit dose form but because of the lack of availability of many of these preparations in the unit-dose form, the oral liquids will be dispensed in clean light-resistant containers in an amount relative to the dosage and are properly labeled as to contents and strength ...
4. Topical Medications
All topical medications are dispensed in the original container provided by the manufacturer. The entire preparation is dispensed and used only on one patient and will never be reused ..."

Facility policy entitled "North Runnels Hospital District Housekeeping Manual," included the following:
"SUBJECT: Infection Control - Environmental Services
PURPOSE:
To control the spread of infection within the Hospital by maintaining a thoroughly clean and safe environment ...
INFECTION CONTROL PRACTICES:
Sanitation within the hospital environment depends on cleaning thoroughness and frequency ...
PATIENT ROOMS:
All upward facing horizontal surfaces shall be damp cleaned daily.
Hard floor surfaces shall be wet cleaned daily.
Tile floors shall be mopped daily, using approved germicide solution ...
Bathrooms shall be cleaned daily and special attention given to sanitizing commodes, all bars, handles and doorknobs ...


During a tour of the of the hospital on the morning and afternoon of 6/11/19 and 6/12/19 with the Directors of Quality of Nursing at different times, the following infection control issues were noted:

Throughout the hospital:
- Floors were not clean - at times extremely dirty - in patient care areas, storage areas including where patient supplies were stored, in patient restrooms, in medication rooms, and other areas.
- There was chipped plaster on walls including in patient care areas and in patient rooms. This makes thorough cleaning of the room or area impossible.
- Under sinks in patient care areas, medication rooms, radiology, and other areas there were stored supplies, including patient supplies. In addition, the wooden flooring of these cabinets had a thin layer of old paint that left large amounts of wood exposed. Once a permeable surface is exposed, there is no way to thoroughly clean the surface. Areas under sinks are prone to mold, mildew and other contaminants, and should be considered soiled environments.
- There were chipped cabinets in patient care areas, patient rooms and various departments and areas of the hospital. The permeable wood beneath was exposed which made thorough cleaning impossible.
- Ceiling tiles had water stains and/or were ill-fitting in numerous areas of the hospital, including medication rooms and patient supply areas. Once exposed to moisture, ceiling tiles can harbor mold, crumble and become a source of infection control issues.
- Light from outside the hospital was visible through external doorways, including in the kitchen and various hallways in patient care areas. These can serve as portals for pests, dirt, dust and debris.

In a visitor/patient restrooms off the main hallway:
- The floors were overtly dirty.
- Air vents were visibly dusty.
- In the men's restroom, there was a large stain on a light fixture. This may have been cited on the previous survey, but it was unclear to which light fixture the surveyor had referred.

In the patient nourishment area:
- There was ice build-up in the freezer section of the refrigerator which held patient food items. Ice in a refrigerator or freezer can pose a serious problem because it can keep the temperature in the unit too high, potentially spoiling the food in it. It can also lead to equipment malfunctioning.
- There were 2 boxes of expired beef and chicken bouillon available for patient and/or visitor use on the counter. The beef bouillon had expired on 5/8/17. The chicken bouillon had expired on 11/15/18.
- The ice machine was dripping, thus pooled water could harbor mold or bacteria. In the cabinet under the ice machine was a bucket and some paper towels to catch the drips.

In the medication room off the nursing station:
- The floor was visibly dirty.
- There was an approximate 1-inch buildup of ice in the medication refrigerator.
- A stood/chair in the room had approximately 10" of foam filling exposed due to a tear in the vinyl covering. This permeable surface made thorough cleaning impossible.
- There were chipped cabinets, again making thorough cleaning impossible.
- The following items were considered multi-dose medication containers and were open and available as patient medications:
Lidocaine opened 5/10/19
Amoxicillin tablets 250 mg opened 4/12/19
Prednisolone oral solution 15mg/5mL opened 4/29/19

In patient rooms 103 and 106:
- The floors were dirty in corners of the rooms. The bathroom of patient room 106 had a very dirty area on the floor which appeared overtly dirty.
- Both rooms had vinyl baseboard that was coming away from the wall. Behind the gaping baseboard was visible dust and grime.
- Room 103 had floor tiles which were rising up and the joints of the tiles were dirty.
- In room 103, there was visible dust and grime behind the air conditioning unit.

In the Blood Storage Area:
- The floor was visibly dirty.

In Central Supply:
- External shipping containers and other corrugated cardboard boxes were used to house patient and other hospital supplies. External shipping containers are exposed to numerous contaminants during shipment and can harbor and attract pests.
- Supplies were stored closer than 18" from the ceiling - sometimes as close as 6" from the ceiling. This can pose a fire hazard and endangers proper functioning of the fire sprinkler system.
- Boxes which stored open adult pull-ups and pads were left exposed to environmental contaminants, including air-borne contaminants from individuals who cough or sneeze, possible spills or debris in the surrounding area.
- There was a large water-stained ceiling tile above the patient supply area.

In the Overflow Patient Supply Storage Closet #2:
- There were 4 crumbling ceiling tiles with old water stains over the small area which housed patient supplies.
- Opened external shipping containers with supplies stored to within 6" of the ceiling.

In the Radiology area:
- The CT scan room had a thick layer of dust on some horizontal surfaces.
- A live insect was noted in the x-ray room.
- Ceiling tiles throughout the area were stained and ill-fitting.

In the Lab area:
- Numerous items were stored under the sink including large external shipping containers.
- There were uncovered towels, patient gowns, and bed linens in the patient bathroom. This left these items exposed to any liquid spills or splashes in the bathroom, as well as possible coughs and sneezers, among other things.
- Shelves were rusty thus making thorough cleaning impossible.
- Expired blood collection vials were found in the blood draw area and were being used for blood collection from patients.
- Numerous items were stored in the sink in the blood draw room.
- A live insect was noted in the x-ray room.

In the Dietary Services area/Kitchen:
- There was ice build-up in the walk-in freezer, including an approximate 8" icicle. Ice in a refrigerator or freezer can pose a serious problem because it can keep the temperature in the unit too high, potentially spoiling the food in it. It can also lead to equipment malfunctioning.
- The ceiling of the pantry where patient food items were stored had numerous decaying tiles.
- The paper goods supply closet was near an exterior door though which outside light was visible. This opening to the exterior could serve as a portal for pests, dust and debris.

In the Pharmacy:
- Numerous items were stored under the sink.

In the Oxygen Storage Closet:
- There were 3 unsecured oxygen canisters. These posed a threat to patient safety.

In the Emergency Department:
- There was a large opening exposed to the crawl space behind the wall around the oxygen supply lines.
- Uncovered patient linen was found
- Light could be seen under a door opening to the exterior of the building. The opening could serve as a portal for pests, debris and dust from outside.
- The emergency department bathroom floor was dirty.

In an interview with the Director of Nursing and the new Director of Infection Control on the afternoon of 6/11/19 in the office of the Director of Nursing, the Director of Infection Control stated she could not provide documented evidence that the infection control committee had been meeting. No minutes from this committee were provided for surveyor review.

Review of the 2019 Quality Improvement Meeting Minutes covering the last two months of 2018 and through February of 2019 revealed no discussion of infection control issues. No other quality minutes were available for surveyor review.

The above findings were all confirmed during the tours with the Directors of Quality and Nursing, as well as the hospital consultant, and again on the afternoon of 6/12/19 in the office of the Director of Nursing.

Based on a review of facility documentation, observation and staff interviews, the facility failed to maintain a list of all services furnished under contract or agreement. Thus there was no list which described the nature and scope of the services, the contract or agreement termination or a review of the quality of services.

Findings were:

There was no hospital policy provided for surveyor review which addressed the requirement of keeping a list of contracts or agreements into which the hospital had entered. Such list should include:
- the services being offered;
- The individual(s) or entity providing the service(s);
- Whether the services are offered on- or off-site;
- Whether there is any limit on the volume or frequency of the services provided; and
- When the service(s) are available.

In an interview with Staff #6, Executive Assistant, on the morning of 6/11/19 in the office of the Director of Nursing, she was asked if the hospital kept a list of contracted services or services provided through agreement. She stated in reply, "I don't know that I have a list like that. I've got a drawer that has a lot of contracts in it."

In a subsequent interview with Staff #3, the Director of Quality on the morning of 6/12/19 in the office of the Director of Nursing, she stated she believed there was no such list.

Based on a review of facility documentation, observation and staff interview, the facility failed to meet the Condition of Participation for §485.645 Special Requirements for CAH (Critical Access Hospitals) Providers of Long-Term Care Services ("Swing-Beds") as the hospital did not meet all requirements of §482.58(b) Skilled Nursing Facility Services as evidenced by:

1. Failing to perform an assessment of patient activity requirements based on patient needs and interests for 5 of 5 post-acute care skilled nursing facility (SNF) care patients [Patients #11-15] , and failing to document activities provided to these patients. In addition, the hospital could provide no policies addressing this issue. (refer to C0385)

2. Failing to complete a comprehensive assessment of each resident's needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS for 5 of 5 post-acute care SNF care patients [Patients #11-15]. The comprehensive assessment is the foundation of each patient's comprehensive care plan and is the basis for the provision of all care received by the patient. In addition, the hospital could provide no policies addressing this issue. (refer to C0388)

3. Failing to address the dental needs of each post-acute care SNF patient by ensuring a dentist was available to provide emergency or routine dental services for 5 of 5 patients [Patients #11-15. In addition, the hospital could provide no policies addressing this issue. (refer to C0404)

These failed practices resulted in patients not receiving assessments and services required for the hospital to qualify for approval from the Centers for Medicare & Medicaid Services (CMS) to provide post-acute care skilled nursing facility care. The cumulative effect of these systemic deficient practices resulted in noncompliance with the Condition of Participation §485.645 Special Requirements for CAH (Critical Access Hospitals) Providers of Long-Term Care Services ("Swing-Beds").

Based on a review of facility documentation and staff interviews, the facility failed to to provide an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each resident. In addition, the hospital failed to ensure the activity program was directed by a qualified activities director. These deficient practices were found for 5 of 5 swing-bed patients [Patients #11-15].

Findings were:

Review of the hospital document entitled "Swingbed Program - Significant Time Frames to Remember," revealed the following:
"...7. Dietary and Activities person must do initial assessment within 72 hours of admission to swingbed..."

A review of other facility policies related to swing-bed patients revealed no additional policies addressing the provision and/or documentation of activities for these patients.

A review of the medical records of Patients #11-15 revealed the records did not include an activities assessment to determine the patients' interests and ability to perform specific activities in order to assist in designing a care plan to meet the physical, mental and psychosocial well-being of the swing-bed patients.

In an interview with the Director of Nursing on the morning of 6/12/19 in her office regarding swing-bed patients, she stated, "The person who's providing activities for these patients is studying to qualify as an activities director."

In an interview with Staff #5, the hospital's new swing bed coordinator, on the morning of 6/12/19 in the office of the Director of Nursing, she stated, "I know there are no activities assessments in the charts. She [individual providing some activities] might have documented what she actually did... So what you're telling me is that I'm going to have to write a bunch more policies to address all this..."

The above findings were all confirmed in an exit interview with the Director of Nursing, Director of Quality and hospital consultant.

Based on a review of facility documentation and staff interview, the facility failed to ensure each swing-bed patient received a comprehensive assessment which included any of the required components for 5 of 5 swing bed patients [Patients #11-15].

Findings were:

Review of the hospital document entitled "Swingbed Program - Significant Time Frames to Remember," revealed no mention of the requirement of performing a comprehensive assessment on each swing-bed patient.

A review of other facility policies related to swing-bed patients revealed no additional policies addressing the provision and/or documentation of a comprehensive assessment for these patients.

A review of swing-bed patient medical records revealed no comprehensive assessment in 5 of 5 of the records [Patients #1-5].

In an interview with Staff #5, the hospital's new swing bed coordinator, on the morning of 6/12/19 in the office of the Director of Nursing, she stated, "We haven't really been doing the comprehensive assessment... So what you're telling me is that I'm going to have to write a bunch more policies to address all this..."

In an interview with the Director of Nursing, Director of Quality and the hospital consultant on the afternoon of 6/12/19 in the office of the Director of Nursing regarding swing-bed patients, they all confirmed that the records of these patients included no documented evidence of completion of a comprehensive assessment.

Based on review of facility documentation and staff interviews, the hospital failed to ensure a dentist was available to each patient qualifying for post-critical access skilled nursing facility (SNF) care for 5 of 5 patients [Patients #11-15].

Findings were:

Review of the hospital document entitled "Swingbed Program - Significant Time Frames to Remember," revealed no mention of the requirement of performing an assessment of the dental needs of each swing-bed patient.

A review of other facility policies related to swing-bed patients (post-critical care SNF care patients) revealed no additional policies addressing the provision of dental care services for these patients.

A review of services provided to the hospital by contract or agreement revealed no such contract/agreement for dental services.

A review of patient medical records revealed no assessment of the dental needs and/or did not address the provision of dental services for 5 of 5 post-critical access SNF patients (swing-bed patients) [Patients #1-5].

In an interview with Staff #5, the hospital's new swing-bed coordinator, on the morning of 6/12/19 in the office of the Director of Nursing, she stated, "I don't know how we're going to be providing dental care, but no, we haven't been doing assessments on that... So what you're telling me is that I'm going to have to write a bunch more policies to address all this..."

In an interview with the Director of Nursing, Director of Quality and the hospital consultant on the afternoon of 6/12/19 in the office of the Director of Nursing regarding swing-bed patients, they all confirmed that the records of these patients included no documented evidence of an assessment of dental care needs or the provision of dental services for the above patients.