HospitalInspections.org

Based on record review and interview, the facility failed to meet the Condition of Participation of having a governing body or persons responsible for the conduct of the hospital.
These failed practices could cause the facility to function ineffectively and could cause poor patient outcomes (higher mortality rates, increased medical complications, hospital readmissions, and infections) for patients of this facility.

The findings are:

A. The facility failed to appoint a chief executive officer (CEO) responsible for managing the hospital. Refer to Tag A-0049

B. The facility had no governing body to ensure that the medical staff as a group is accountable for the quality of patient care. Refer to Tag A-0053

C. The facility failed to have a governing body to meet with a leader of the medical staff as required. Refer to Tag A-0057

Based on interview and record review, the facility failed to meet the Condition of Participation to provide 24-hour nursing services by a registered nurse. These failed practices could cause poor patient outcomes (higher mortality rates, increased medical complications, hospital readmissions, and infections), injury or death to all patients of this facility.

The findings are:

A. The facility failed to provide adequate numbers of registered nurses to provide necessary nursing care to all patients within the facility. Refer to Tag A-0392

B. The facility failed to have a registered nurse assign nursing care to meet the patient care needs for all patients within the facility. Refer to Tag A-0397

C. The facility failed to ensure licensed nurses were adhering to policies and procedures; and were providing adequate supervision of clinical care for patients within the facility. Refer to Tag A-0398

Based on record review and interview the facility failed to have a governing body to ensure that the medical staff as a group were accountable to the governing body for the quality of patient care. This deficient practice could lead to poor patient outcomes (higher mortality rates, increased medical complications, hospital readmissions, and infections) for all patients of this facility.

The findings are:

A. During an interview on 04/15/2024, at 2:00 pm with Staff (S)1, Hospital Administrator, when asked for the names of the governing board and the chief executive officer (CEO), S1 replied "(name of Cabinet Secretary of the Department of Health S18) is the CEO and the Governing Body."

B. Record review of the document titled "State of (name of state) - Department of Health Facilities Governing Board (address of the state capital) Meeting Minutes-October 26, 2023", provided by the facility as the governing board meeting minutes for the facility titled "State of (name of state)-Department of Health Facilities Governing Board (address of Department of Health in the state capital-not at the facility itself), Meeting Minutes-October 26, 2023", revealed "Chair and Sole Board Member (name of Cabinet Secretary of the Department of Health S18)." Revealed theses were meeting minutes for the Department of Health, not for the facility individually. The facility did not have any representatives from the facility present during the meeting. The only facility specific issue listed was regarding privileging and credentialing of four employees. The facility operations were not addressed.

C. Record review of the document titled "State of (name of state) - Department of Health Facilities Governing Board (address of the state capital) Meeting Minutes-January 30, 2024", provided by the facility as the governing board meeting minutes for the facility titled "State of (name of state)-Department of Health Facilities Governing Board (address of Department of Health in the state capital-not at the facility itself), Meeting Minutes-January 30, 2024", revealed "Chair and Sole Board Member (name of Cabinet Secretary of the Department of Health S18)." Revealed these were meeting minutes for the Department of Health, not for the facility individually. The facility did not have any representatives from the facility present during the meeting. The only facility specific issue listed was regarding privileging and credentialing of one employee. The facility operations were not addressed.

D. During an interview on 04/15/24, at 2:00 pm, with Staff (S)1 Hospital Administrator, S1 was asked for evidence that the governing body or any administrators meet regularly with the medical staff to discuss quality of care. The facility did not provide any evidence of the facility meeting regularly.

Based on interview and record review the facility failed to have a governing body to consult directly with a member of the medical staff periodically. This deficient practice could lead to poor patient outcomes (higher mortality rates, increased medical complications, hospital readmissions, and infections) for all patients of this facility.

The findings are:

A. Refer to Tag A-0043 A through C

B. Refer to Tag A-0049 B

Based on record review and interview the facility failed to have a chief executive officer responsible for managing the hospital. The deficient practice could lead to the facility functioning ineffectively and cause poor patient outcomes (higher mortality rates, increased medical complications, hospital readmissions, and infections) for all patients of this facility.

The findings are:

A. During an interview on 04/15/2024 at 2:00 pm, with Staff (S)1, Hospital Administrator, when asked for the name of the chief executive officer (CEO), S1 replied "(name of Cabinet Secretary of the Department of Health S18) is the CEO..."

B. Record review of the document titled "State of (name of state) - Department of Health Facilities Governing Board (address of the state capital) Meeting Minutes-October 26, 2023", provided by the facility as the governing board meeting minutes for the facility titled "State of (name of state)-Department of Health Facilities Governing Board (address of Department of Health in the state capital-not at the facility itself), Meeting Minutes-October 26, 2023", revealed "Chair and Sole Board Member (name of Cabinet Secretary of the Department of Health S18)." Revealed these were meeting minutes for the Department of Health, not for the facility individually. The facility did not have any representatives from the facility present during the meeting. S18 is not identified as the CEO of the facility.

C. Record review of the document titled "State of (name of state) - Department of Health Facilities Governing Board (address of the state capital) Meeting Minutes-January 30, 2024", provided by the facility as the governing board meeting minutes for the facility titled "State of (name of state)-Department of Health Facilities Governing Board (address of Department of Health in the state capital-not at the facility itself), Meeting Minutes-January 30, 2024", revealed "Chair and Sole Board Member (name of Cabinet Secretary of the Department of Health S18)." Revealed these were meeting minutes for the Department of Health, not for the facility individually. The facility did not have any representatives from the facility present during the meeting. S18 is not identified as the CEO of the facility.

Based on interview and observation, the facility failed to conspicuously post signs with the State agency's complaint line telephone number to which patients may call and file a complaint or grievance about the facility as part of their grievance process. This failed practice could lead to all patients being unaware of their rights to file a grievance.

The findings are:

A. During observation of the entire facility on 04/15/2024 at 1:30 pm, revealed the facility did not have any signs posted with the State agency's contact information to file a complaint or a grievance.

B. During interview on 04/15/2024 at 1:35 pm with Staff (S)1 Hospital Administrator, S1 confirmed the facility did not have any signs posted with the State agency's contact information to file a complaint or a grievance.

Based on interviews and record reviews, the facility failed to meet the staffing and delivery of care requirements by not providing adequate numbers of Licensed Registered Nurses to provide necessary nursing care to 1 (P (patient) 11) of 11 (P1-P11) patients. This deficient practice could cause injury, harm or death to all patients of this facility.

The findings are:

A. Record review of the facility's policy titled "Staffing Pattern of The Nursing Department Number N-1 Revised 6/2020" stated "To ensure adequate staffing of licensed registered professional nurses and qualified nursing personnel to meet the nursing care needs of the patients at [Name of Facility]". "The team approach is used in medical rehabilitation unit (MRU) with a registered professional nurse being the team leader and directly supervising the nurse-technicians on a 24-hour basis."

B. Record review of the facility's form titled "Incident Report" dated 11/10/23 regarding P11 revealed:

1. On 11/09/2023, Night Shift: 11/10/2023, Midnight to 11/10/2023 4:00 am, Staff (S) 21 Registered Nurse (RN) reported to the oncoming S19 RN that S2 Chief Finance Director was the only staff covering the Chemical Detox Unit (CDU). S2 is not an RN.

2. On 11/10/2023 at 3:31 am, P11 was reported to have a low blood pressure of 69/53 (a reading less than 90/60 is considered hypotension and could be considered dangerous when accompanied by other symptoms and should be evaluated immediately) obtained by unnamed Direct Care Technician. S19 asked S21 what interventions were undertaken. S21 stated "had only been covering the unit since 0400 [4:00 am] and that [S2] was covering unit since midnight." Per S19's report: "No R.N. on duty during this critical B.P. [blood pressure] to assess or intervene. No M.D. [medical doctor] was notified. No medications given."

C. During an interview on 04/17/2024 at 10:00 am, with S19 it was confirmed that on 11/10/2023 at 3:31 am, during the time P11 had a blood pressure of 69/53, the unit was being covered by S2 and there was no RN on duty in the unit. It was confirmed that P11 did not receive medical attention until after 6:30 am.

D. During an interview on 04/17/2024 at 10:00 am, with S19 it was confirmed that there were multiple days and night shifts (32) between 09/23/2023 through 04/26/2024 with only one RN scheduled for the facility.

E. During an interview on 04/17/2024 at 10:30 am, with S9 Registered Nurse confirmed there "is a lot of time that the building only has one RN on the schedule for day and night shifts." S9 further reported that the schedule was "padded" with an RN that was no longer on staff to make it look like there was sufficient staff covering the facility.

F. Record review of the registered nurse (RN) staff schedule 09/23/2023 through 04/26/2024, revealed there were five (5) night shifts that a RN was not scheduled to work on the CDU (Chemical Detox Unit); there were 11 day shifts that a RN was not scheduled to work on the CDU unit; there were nine (9) night shifts that a RN was not scheduled to work on the MRU (Medical Rehabilitation Unit); and there were six (6) day shifts that a RN was not scheduled to work on the MRU.

G. Record review of S22, Quick Response Staffing Agency RN personnel file, revealed S22's last day of work was 02/15/2024.

H. Record review of the registered nurse staff schedule dated 09/23/2023 through 04/26/2024, revealed S22 remained on the dayshift schedule for the CDU for 02/23/24, 02/24/24, 02/25/24, 02/28/24, and 02/29/24.

I. During an interview on 04/18/24 at 2:00 pm, with S2, S2 confirmed that S2 was the Administrator on Call (AOC) every other week. The AOC must be available to emergencies, staffing issues, patient issues. S2 confirmed that S2 had come into the unit when there was only one RN on staff to "sit" in the other unit." S2 stated this is to provide assistance for the staff. S2 confirmed they did not have a nursing or other medically related license or training which would be required by staff normally assigned to this unit.

J. During an interview on 05/21/2024 at 12:29 PM with S19, S19 confirmed the unit was left without a nurse last week (5/15/2024). S19 explained that the patient population requires nursing assessments at least three times a shift and if there are high risk detoxing patients (patients having severe withdrawals from alcohol or other substances) it can be as frequent as every 2 hours.

K. Record review of P11's medical record "MD Discharge Summary" "Transfer Note to [outside hospital name] November 10, 2023" revealed: "Patient with alcohol withdrawal to the point of psychosis. Suspect alcohol-related psychotic disorder with alcoholic hallucinosis..." "Objective Vital Signs: Pulse 57/min [heart rate 57 beats per minute]; BP [blood pressure] 106/66..." "Plan [facility name] is not a full-service hospital and does not have the necessary support service or capability to diagnoses and manage an acute psychotic disorder that can suddenly place a patient as risk of harm. While at [outside hospital name] patient should be assessed by psychiatrist who can assist with inpatient treatment and psychiatric stabilization." "The patient was discharged to [outside hospital name] where she left against medical advice."

L. An Immediate Jeopardy was called regarding the lack of nursing staffing on units at various times and days on 05/22/2024. This was accepted by the Centers for Medicare and Medicaid (CMS). The facility provided a plan of correction that was accepted on 05/23/2024. A revisit of the facility was performed on 05/29/2024 and the Immediate Jeopardy was declared to be cleared. The facility was notified on 05/29/2024 at 12:20 pm.











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Based on record review and interview the Facility failed to have a Registered Nurse assign Nursing Care to meet the patient care needs for all patients admitted to the facility. This deficient practice could cause neglect, harm or death to all patients if staffing is not appropriate based on the patients acuity.
The findings are:

A. Record review of the facility's policy titled "Staffing Pattern of the Nursing Department, Number N-1 Revised 6/2020 it stated, "Director of Nursing Department (DON) Schedules and coordinates clinical staffing patterns on each unit."

B. During an interview on 04/18/24 at 2:30 pm, with Staff (S)2 Chief Financial Officer (CFO) stated and confirmed that the schedule was and is still completed by S2 CFO. S2 confirmed she is not a registered nurse.

Based on record review, observation, and interviews, the facility failed to ensure Licensed Nurses were adhering to policies and procedures while caring for 1 (P (patient) 11) of 11 (P1-P11) patients being reviewed; the facility failed to ensure licensed nurses were providing adequate supervision of clinical care for 1 (P (patient) 5) of 11 (P1-P11) patients to ensure the patient received safe and appropriate urinary catheter (a tube that is inserted through the urethra into the bladder to drain urine) peri-care (daily cleaning around the tip of the penis where the catheter is inserted and the surrounding area) care. This deficient practice could lead to irritation, injury or illness of patients of the facility.

The findings are:

A. Record review of the facility's policy "Number: 40-2" titled, "Incident Reporting" "revised 2/23", revealed:
1. "2. The Incident Report form (exhibit attachment) shall be initiated and filled out as completely as possible"

2. "5. Incident reports shall be initiated by a staff member immediately upon awareness that an incident occurred and should be turned in no later than the end of the shift. Incident Reports involving patients will be routed to the appropriate Department Supervisor for review". "Once a report is completed, it is turned over to the Compliance Officer who will assign a report number and will ensure the following will occur:"

3. "LEVEL 1 REVIEW: Stand-up: All incidents are reported, and if necessary, trends identified. At the end of the month, information will be provided about the number, type and trends of incidents that occurred."

4. "LEVEL 2 REVIEW: Incident Review Team: ...All incidents will be discussed, and further actions implemented. If at any time during the process someone suspects abuse, neglect or exploitation, notifications will be made per the facility's abuse, neglect, or exploitation policy ....A log will be kept of incidents reviewed and assignments made to assure that timely follow-up is done per assignment".

5. "Minutes will be maintained of the meeting which will include the following: ...Incidents reviewed ...Plan and completion of corrective actions ...Status of incidents reviewed ...Identification of trends of problems, issues, and opportunities for improvement."

6. "LEVEL3 REVIEW: INTERNAL INVESTIGATION: If the Incident Review Team determines that an investigation should occur, the Compliance Officer will complete an investigation".

7. "LEVEL5 REVIEW: Quality Assurance Performance Improvement (QAPI): The Compliance Officer will track and trend all incidents and group them into categories/indicators. This information will then be entered into the facility's quality database each month and subsequently presented to the QAPI committee as requested. The QAPI committee will review and discuss trends regarding incidents."

B. Record review of the facility's form titled "Incident Report" "Revised 2/2023", revealed on 11/08/2023 at 8:35 am, P11 was found on "the floor, wrapped up in her blanket." This incident report was completed by a Registered Nurse (RN) along with an assessment of the patient completed. It was reported to the Supervisor at 12:50 pm on 11/08/2023. The following parts of the form were not completed: Section on third page "Did you take any actions" with no signature of reporting staff member and "Supervisor Actions" left blank also with no signature. There was no follow up by Supervisor, Compliance officer, or the Incident Review Team.

C. Record review of P11 medical record nursing flowsheet notes reveals: "Date of assessment: 11/08/2023 Time of Assessment: 06:50 AM; Level of Consciousness: confused." "Date of Assessment: 11/08/2023 Time of Assessment: 09:35 PM; Level of Consciousness: confused; Neurological Comment: Confused mumbling agitated. Comments: This patient has required 1:1 sitter due to agitation and impulsivity since the nurse came on shift. She has repeatedly tried to get out of bed and is unsteady on her feet. She has been provided the toilet snacks and medication..."

D. Record review of the facility's "Incident Report Revised 2/2023" This incident report was completed by the RN along with reassessment of P11, the report revealed on 11/10/2023 at 11:00 am, P11 had a blood pressure(measurement of the pressure or force of blood inside the walls of blood vessels) of 69/53 at 3:31 am on night shift. Refer to Tag A-0392 C and K.

1. The incident report was not completed in the following areas, "Supervisors Action" along with signature. "Investigation Results" remain blank along with no signature.

2. The form titled "Medical Staff Report" "Revised 2/2023" was left blank.

E. Record review of the facility's untitled and untimed, handwritten stand-up meeting minutes for the month of November did not mention either of these Incident reports reviewed by the Incident Review Team.

F. During interview on 04/17/2024 at 3:30 pm, S7 Medical Records Supervisor /Compliance Officer confirmed that the incident reports were not on the stand-up minutes in the month of November 2023, also S7 was asked to provide the meeting minutes for the Incident Review Team in regards to follow-up reviews of incident reports. S7 confirmed that there were no minutes for the Incident Review Team meetings.

G. During an interview on 4/18/20024 at 3:00 pm, with S1, Hospital Administrator, S1 stated there was a known issue with incident report follow up and a "meeting was started in February of 2024 to go over incident reports in depth with the team after stand-up meetings". S7 was asked for these meeting minutes as well, and was unable to provide.

H. Record review of the document titled "Quality Assurance/ Performance Improvement Committee Minutes" (QAPI) dated (November and December 2023 Data) Meeting date January 25, 2024", there was no record of S7 Compliance Officer tracking or trending all incidents and group them into categories.


I. During an interview on 04/16/24 at 10:00 with Staff (S)3, a urinary catheter care policy was requested. This policy was not provided.

J. Record review of the "Agency for Healthcare Research and Quality" (AHRQ) website https://www.ahrq.gov, "Catheter Care Do's and Don'ts" Publication 16(17)-0003-26-EF, dated March 2017, revealed the following guideline "Do perform peri-care using only soap and water or a similar gentle cleaning agent."

K. Record review of the Centers for Disease Control and Prevention (CDC) document "Indwelling Urinary Catheter Insertion and Maintenance" revealed "Meatal (opening at tip of penis that leads to the urethra where urine is drained) cleaning: soap and water is best...clean the meatus during daily bathing (do not clean with antiseptics)." (Gould CV, Infection Control Hospital Epidemiology, 2009).

L. Record review of the facility's document titled "Incident Report" regarding an incident with P5 on 01/31/24, during "dayshift" revealed that [brand name of environmental cleaning wipe with the active ingredient Hydrogen Peroxide 0.5% in the white cylindrical package] catheter (urinary catheter) care was performed on P5 with "alcohol wipes. However, the Direct Care Techs indicated that (brand name of environment cleaning wipe of environmental cleaning wipe with the active ingredient Hydrogen Peroxide 0.5% in the white cylindrical package) in the patients room were used for peri-care around the catheter insertion. The RN noted that the packaging clearly states "They [the wipes] are for cleaning equipment but nothing that is inserted into the body". The RN also noted that the "patient did complain that (their) penis burned."