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Based on policy review, personnel file review, and staff interview, it was determined the CAH failed to ensure services were provided in accordance with facility policy for 3 of 4 nursing staff whose personnel files were reviewed (Staff A, B, and C). This caused a lack of current competency assessment for the two staff reviewed. Findings included:

A CAH policy titled, "Evaluation/Competency Assessment," approved 5/31/23 was reviewed. It stated, "On-going evaluation and competency assessment will be conducted annually and coincide with an employee's annual performance appraisal." This policy was not followed. Examples included:

1. Staff A's personnel file was reviewed. Staff A was a current RN at the time of survey. Staff A's skills competencies included nursing tasks such as sterile technique, venipuncture, and managing intravenous lines. The most recent competencies were completed 1/29/22.

2. Staff B's personnel filed was reviewed. Staff B was a current RN at the time of survey. Staff B's skills competencies included nursing tasks such as sterile technique, venipuncture, and managing intravenous lines. The most recent competencies were completed 2/03/22.

3. Staff C's personnel filed was reviewed. Staff C was a current CNA at the time of survey. Staff C's skills competencies included nursing assistant tasks such as safe transfers, vital signs, and managing personal cares. The most recent competencies sheet was dated 2/05/22, however within the document, each skill was marked as "met" on 5/31/19. It was unclear when the competencies were completed.

The Risk Manager was interviewed on 4/25/24 beginning at 10:58 AM. When asked if these were the most current competencies for Staff A, B, and C, she stated they were. She confirmed the competencies were overdue.

The CAH failed to ensure nursing staff skills competencies were current.

Based on observation, CDC guidelines review, and staff interview, it was determined the CAH failed to prevent potential transmission of infectious waste in the SPD for 2 of 2 reprocessing rooms observed. This caused clean areas in the SPD to potentially become contaminated with waste product. Findings include:

A CDC document titled "Reduce Risk from Water from Plumbing to Patients," updated 9/11/19 and accessed 4/30/24, was reviewed. It stated, "Recent evidence indicates sinks and other drains, such as toilets or hoppers, in healthcare facilities can become contaminated with multidrug-resistant organisms (MDROs) ... Splashes may occur when water flow hits the contaminated drain cover or when a toilet or hopper is flushed. Splashes can lead to dissemination of MDRO-containing droplets, which in turn may contaminate the local environment or the skin of nearby healthcare personnel and patients." The document also stated, "Install and utilize hopper and toilet covers. These covers should be closed before flushing." These guidelines were not followed. An example included:

Observations of surgical reprocessing began on 4/25/24 at 9:20 AM in the SPD. The CST was observed pre-cleaning the surgical instruments in the reprocessing room. On the counter was a suction cannister with saline and blood from the finished case. At 9:30 AM the CST was observed to pour the fluid down the drain of the hopper (a large toilet like basin for flushing fluid). The hopper did not have a cover. Additionally, the endoscope reprocessing room contained another hopper which did not have a cover.

The IC Manager was interviewed on 4/25/24 at 10:58 AM and the above observations were reviewed with her. She confirmed the 2 hoppers observed did not have covers to prevent spray when flushing.

The CAH failed to ensure hoppers were covered to prevent spray of waste fluid and water.

Based on medical record review, hospital policy review, and staff interview, it was determined the hospital failed to ensure comprehensive assessments were completed for 1 of 1 swing bed patients (Patient #31) whose record was reviewed. Lack of a complete assessment had the potential for unmet patient needs. Findings included:

The CAH's policy, "Nursing Admission Assessment" dated 8/31/23, stated, "Each assessment shall include biophysical, psychosocial, environmental, self-care, educational, discharge planning and significant others when appropriate." This policy was not followed. An example includes:

Patient #31 was a 84 year old female admitted to swing bed on 9/8/2023 6/08/19 for a femur fracture. Patient #31's medical record included an admission nursing assessment. There was no documentation of an assessment for Patient #31 psychosocial needs.

The CAH's DON was interviewed on 4/25/24 beginning at 11:00 AM, and Patient #31's record was reviewed in her presence. She confirmed there was no documentation of an assessment of Patient #31's psychosocial needs.

The hospital failed to ensure swing bed admission assessments were complete to include psychosocial needs.