HospitalInspections.org

Based on observation, interview and record review, the facility failed to have an updated internal and external communication plan established and lacked appropriate resources to send mass communications to staff in the event of activating emergency procedures/updates. Facility campus consisted of three different buildings connected by interior hallways with two of the buildings having two levels (basement and main floor). The facility provided care at a medical clinic, a specialty outpatient clinic, 20 licensed beds of inpatient treatment areas, an assisted living facility with 25 licensed beds, a child day care and various outpatient services and Emergency Room care. Facility inpatient census was 5. Facility staff roster included 201 employed staff.

Findings include:

A. Review of Emergency Operations Plan, and interview with Emergency Preparedness Coordinator on 2/6/23 at 4:03 PM revealed the facility did not have a current mass communication system for immediate notification of staff in the event of an emergency situation. The facility utilized staff cell phones and calling trees by each department manager. Tour of the facility at 4:30 PM revealed internal radios were not available in the departments for ready access to notify other staff of emergency needs. The current phone system being utilized as a paging system did not reach all areas of the facility.

-Review of Governing Board meeting minutes for previous six (6) months on 2/8/23, revealed no discussion/plan for financial allocation of resources for updating the current phone system.

-Review of Safety Meeting minutes from 11/21/22 stated "requested to move phone in the former nursing home wing break room, to the Clean Laundry area to have some access to hearing a page if you were in that room or nearby".

-Review of After Action Report on 2/9/23 at 9:00 from June 2022 following an emergency preparedness table top exercise for healthcare information technology, revealed analysis of areas for improvement for Operational Communications following the exercise as "determine other means to communicate should cell services/radios be down".

B. Interview with facility plant manager on 2/7/23 at 9:30 AM, revealed the facility had discussed options for upgrading communication systems, however no plan had been approved/established and the current system for external and internal communication was not meeting the needs of the facility and staff, as the paging over the phones (land lines) did not reach all areas where staff may be able to hear instructions. Plant manager said the facilty had been in discussion previously for upgrading but a system to meet the facility needs had not been determined.

-Interview with CFO (Chief Financial Officer) on 2/8/23 at 10:15 AM revealed that the facility had no current plans for purchasing/acquiring any communication devices/systems for staff, however, the budget meetings for the year would be starting in February for approval and the needs could be factored in for budget allocation.

-Interview with Director of Nursing on 2/8/23 at 4:15pm revealed some the the Administrative team had access to a web based messaging system, but it had not been rolled out to other department staff or the medical staff (physicians, advanced practice professionals) providing inpatient care and being on call for emergency services