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Based on observation, interview, document review, and facility policy review, the facility failed to ensure supplies used for treating emergency cases were labeled with an opened and expiration date, expired items were discarded, and the crash cart was checked monthly per the facility policy. These failures had the potential to affect all patients who received care at the facility, with the likelihood to delay care of patients in an emergency case.

Findings included:

1. A facility policy titled, "Inventory Outdated Supplies/Medication Procedure," with an approval date of 11/10/2009, indicated, "6. Procedure When supplies are delivered to [facility name] and placed on shelves all supplies with an expiration date excluding high use items will be marked with a colored dot corresponding to the year for that color. They will further write in, using a black sharpie the month of expiration."

A facility policy titled, "Blood Glucose Monitoring," last revised 07/2023, indicated, "6.17 New bottles of test strips will be dated upon opening (month, day and year), and the discard date will be noted as 6 months after opening (month, day, year)."

An undated material insert for "StatStrip Glucose Hospital Meter Test Strips" indicated, "11. Expiration The expiration date is printed on the vial of test strips. Once opened, the StatStrip Glucose Hospital Meter Test Strips are stable when stored as indicated for up to 6 months or until expiration date, whichever comes first."

On 10/14/2024 at 11:31 AM, the surveyor observed an eSwab collection and preservation of aerobic, anaerobic, and fastidious bacteria was observed in the cabinet above the sink in Trauma One, with an expiration date of 06/30/2023.

On 10/14/2024 at 11:32 AM, an intubating stylet was observed on top of the respiratory cart in Trauma One, with an expiration date of 07/29/2024.

During an interview on 10/14/2024 at 11:38 AM, Registered Nurse (RN) #3 stated the eSwabs were utilized for wound cultures. RN #3 confirmed the expiration date was 06/30/2023. According to RN #3, staff did not obtain the eSwabs from that cabinet, that they obtained them from the medication room, which was why the expiration date could have been missed.

During an interview on 10/14/2024 at 11:40 AM, Respiratory Therapist #4 stated the stylets were rarely used, so the expired one was likely pulled out of the cart and placed on top since it was expired.

During a concurrent interview and observation of the crash cart in Trauma One of the Emergency Department (ED) on 10/15/2024 at 2:10 PM, the following expired items were noted:
- two 20 gauge intravenous (IV) catheters, with an expiration date of 07/31/2024;
- one 20 gauge IV catheter, with an expiration date of 09/16/2024;
- one 22 gauge IV catheter, with an expiration date of 07/31/2024;
- one 18 gauge IV catheter, with an expiration date of 09/30/2024;
- four 16 gauge IV catheters, with an expiration date of 01/31/2024;
- two 14 gauge IV catheters, with an expiration date of 04/30/2024;
- an IV start kit, with an expiration date of 07/31/2024;
- one 25 gauge eclipse needle, with an expiration date of 09/30/2024;
- one size 7 surgical glove, with an expiration date of 05/2024;
- one size 7 surgical glove, with an expiration date of 09/28/2024; and
- one pack of gauze sponges, with an expiration date of 08/01/2024.
The Emergency Department Nurse Manager (EDNM) confirmed the supplies found were expired. The EDNM stated the expectation was that staff inspected each item once a week for expiration dates.

During a concurrent interview and observation of the medication room in the ED on 10/15/2024 at 2:38 PM, the following expired items were noted:
- one IV catheter, with an expiration date of 04/15/2024;
- one peripheral IV catheter, with an expiration date of 06/30/2024; and
- one opened vial of glucose test strips, with no date opened or expiration date listed.
The EDNM confirmed the found supplies were expired. The EDNM stated that the nursing staff were expected to check for expiration dates in the medication room weekly as well as the crash carts. The EDNM acknowledged the glucose test strips were not dated, and that staff were expected to mark the container with an opened and expiration date.

During an interview on 10/15/2024 at 7:20 PM, RN #7 stated generally expiration dates in the ED were checked every first Saturday of the month and the check included supplies in the patient rooms, medication rooms, trauma rooms, and crash carts. RN #7 stated glucose test strips should be dated. Per RN #7, the technician in the ED was responsible for glucometer checks, and if they opened the vial, they should date the vial when opened.

During a concurrent interview and observation of the laboratory on 10/15/2024 at 11:31 AM, the surveyor observed an eSwab collection and preservation of aerobic, anaerobic, and fastidious bacteria, with an expiration date of 07/17/2024, a specimen collection swab, with an expiration date of 09/17/2023, and one prothrombin time test, with an expiration date of 09/30/2024. The Laboratory Manager (LM) stated he did not know the expired swabs were in the drawer. The LM stated they were probably left over from testing during the pandemic. Per the LM, the night shift was responsible for checking the date of supplies in the laboratory.

During a concurrent interview and observation of the obstetric unit on 10/16/2024 at 10:09 AM, a container that contained a glucometer and test strips was noted to have two opened vials of test strips that were not labeled with an opened or expiration date. The CNO stated the glucometer test strips usually would be marked with an opened and discard date on the bottles and that the bottles found were not marked. Per the CNO, the nursery nurses were responsible for the supplies in the nursery.

During a concurrent interview and observation of the birthing cart in the nursery on 10/16/2024 at 10:22 AM, there were two gauge IV catheters that had an expiration date of 09/30/2024, one IV catheter that had an expiration date of 10/11/2024, and five 23 gauge needles, with an expiration date of 08/31/2024. The CNO acknowledged the supplies were expired.

During a concurrent interview and observation of the surgical department on 10/16/2024 at 10:42 AM, the following expired items were found:
- a bottle of hydrogen peroxide 3%, with an expiration date of 03/2020;
- four boxes of optical implants, with an expiration date of 03/2017;
- two boxes of optical implants, with an expiration date of 02/2017; and
- nine stainless steel surgical blades, with an expiration date of 09/30/2023.
The CNO acknowledged the expired supplies and stated that the exam room used to be utilized for patients when the facility did eye procedures, but they did not perform eye procedures anymore, and now physicians used it to dictate their notes.

2. A facility policy titled, "Crash Cart Preparedness," with an approval date of 10/19/2023, indicated, "6. Procedure 6.1 Drugs and supplies in the adult crash cart and pediatric bags will be checked monthly for out dates and condition of supplies and after each use."

The facility crash cart checklist for July 2024 indicated the crash cart should be checked every Sunday during the night shift. The checklist revealed documentation to indicate the crash cart was checked twice in July 2024.

The facility crash cart checklist for August 2024 indicated the crash cart should be checked every Sunday during the night shift. The checklist revealed no documentation to indicate the crash cart was in August 2024.

The facility crash cart checklist for September 2024 indicated the crash cart should be checked every Sunday during the night shift. The checklist revealed documentation to indicate the crash cart was checked once in September 2024.

The facility crash cart checklist for October 2024 indicated the crash cart should be checked every Sunday during the day and the night shift. The checklist revealed documentation to indicate the crash cart was checked once in October 2024.

Based on observation, interview, document review, and facility policy review, the facility failed to meet the conditions of participation for physical plant and environment. The facility failed to ensure patient care equipment was maintained in a safe operating condition for 1 (portable ultrasound machine #1251051) of 3 portable ultrasound machines observed in the Emergency Department (ED). The facility further failed to ensure proper temperature control in the food preparation area for 10 of 14 temperature logs reviewed. These failure had the likelihood to impact patient health and safety.

Findings included:

1. A facility policy titled, "Preventive Maintenance Program," revised 01/11/2024, revealed, "Policy: A Preventive Maintenance Program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff, and public. Policy Explanation and Compliance Guidelines: 1. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance services to ensure that the buildings, grounds, and equipment are maintained in a safe and operable manner. 2. The Maintenance Director shall assess all aspects of the physical plant to determine if Preventative Maintenance (PM) is required. Required PM may be determined from manufacturer's recommendations, maintenance requests, grand rounds, life safety requirements, or experience."

During a concurrent interview and observation of the facility on 10/14/2024 at 9:30 AM, the surveyor noted a portable ultrasound machine, #1251051, in the hallway of the ED that had a preventative maintenance (PM) sticker with an expiration date of 12/2023. The Maintenance Supervisor stated the company that provided PM on the equipment had recently been at the facility, and he was not sure how the ultrasound machine was missed..

On 10/16/2024 at 11:30 AM, portable ultrasound machine #125051 was observed in the hallway of the ED. The Long-Term Care Administrator asked Registered Nurse (RN) #16 to remove the portable ultrasound machine from service and RN #16 was noted to roll the machine down the hallway.

During an interview on 10/16/2024 at 11:35 AM, RN #16 stated there was a newer ultrasound machine in the ED that would occasionally have a glitch and when it glitched, the older machine, #1251051, would be used. Per RN #16, the older machine was rarely needed and had been used occasionally since December 2023.

2. A facility policy titled, "Dishwashing Temperature," with an approve date of 07/31/2021, indicated, "a. The wash temperature shall be 150-165 [degrees] F [Fahrenheit]." The policy also indicated, "b. The final rinse temperature shall be 180 [degrees] F or above but not to exceed 194 [degrees] F."

A facility policy titled, "Food Safety Requirements," with an approved date of 07/31/2021, indicated, "Practices to maintain safe refrigerated storage include: i. Monitoring food temperatures and functioning of the refrigeration equipment daily and routine intervals during all hours of operation."

The "Sandwich Table Temperature Chart" for September 2024, revealed the required temperature was between 36 and 41 degrees F. Per the chart, there were 22 documented times when the temperature was not within range. Per the chart, "If the temperature is out of compliance, notify maintenance and the dietary manager." There was no evidence to indicate maintenance or the Dietary Manager (DM) were notified.

The "Walk-In Refrigerator Temperature Chart" for September 2024, revealed the required temperature was between 36 and 41 degrees F. Per the chart, there were four documented times when the temperature was not within range. Per the chart, "If the temperature is out of compliance, notify maintenance and the dietary manager." There was no evidence to indicate maintenance or the DM were notified.

The "Walk-In Freezer Temperature Chart," for September 2024, revealed the required temperature was between -10 and 0 degrees F. Per the chart, there was one documented time when the temperature was not within range. Per the chart, "If the temperature is out of compliance, notify maintenance and the dietary manager." There was no evidence to indicate maintenance or the DM were notified.

The "Reach In Cooler #2 Temperature Chart" for September 2024, revealed the required temperature was between 36 and 41 degrees F. Per the chart, there was six documented time when the temperature was not within range. Per the chart, "If the temperature is out of compliance, notify maintenance and the dietary manager." There was no evidence to indicate maintenance or the DM were notified.

The "Reach In Cooler #1 Temperature Chart" for September 2024, revealed the required temperature was between 36 and 41 degrees F. Per the chart, there was 37 documented times when the temperature was not within range. Per the chart, "If the temperature is out of compliance, notify maintenance and the dietary manager." There was no evidence to indicate maintenance or the DM were notified.

The "Dishwasher Temperature Chart," for September 2024, revealed the required minimum wash temperature was 150 degrees F and the minimum rinse temperature was 180 F. Per the chart, there was four documented times when the temperature was not within range. Per the chart, "If the temperature is out of compliance, notify maintenance and the dietary manager." There was no evidence to indicate maintenance or the DM were notified.

The "OB [obstetrics] Refrigerator [sic]/Freezer Temperature Chart," for September 2024, revealed the required refrigerator temperature was between 36 and 41 degrees F and the freezer temperature was between -10 and 0 degrees F. Per the chart, there was three documented times when the temperature was not within range. Per the chart, "If the temperature is out of compliance, notify maintenance and the dietary manager." There was no evidence to indicate maintenance or the DM were notified.

The "ER [Emergency Room} Refrigerator [sic]/Freezer Temperature Chart," for September 2024, revealed the required refrigerator temperature was between 36 and 41 degrees F and the freezer temperature was between -10 and 0 degrees F. Per the chart, there was six documented times when the temperature was not within range. Per the chart, "If the temperature is out of compliance, notify maintenance and the dietary manager." There was no evidence to indicate maintenance or the DM were notified.

The "Med/Surg [medical/surgical] Refrigerator [sic]/Freezer Temperature Chart." for September 2024, revealed the required refrigerator temperature was between 36 and 41 degrees F and the freezer temperature was between -10 and 0 degrees F. Per the chart, there was seven documented times when the temperature was not within range. Per the chart, "If the temperature is out of compliance, notify maintenance and the dietary manager." There was no evidence to indicate maintenance or the DM were notified.

During an interview on 10/16/2024 at 1:10 PM, the DM acknowledged the out-of-range temperatures on the charts for September 2024. The DM stated when things were too cold in the cold table, he found that staff took the temperature too close to the cooling source and not in the middle. The DM stated he did not document any follow up for the out-of-range temperatures and that he or maintenance were notified.

Based on observation, interview, and facility policy review, the facility failed to ensure patient care equipment was maintained in a safe operating condition, for 1 (portable ultrasound machine #1251051) of 3 portable ultrasound machines observed in the Emergency Department (ED).

Findings included:

A facility policy titled, "Preventive Maintenance Program," revised 01/11/2024, revealed, "Policy: A Preventive Maintenance Program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff, and public. Policy Explanation and Compliance Guidelines: 1. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance services to ensure that the buildings, grounds, and equipment are maintained in a safe and operable manner. 2. The Maintenance Director shall assess all aspects of the physical plant to determine if Preventative Maintenance (PM) is required. Required PM may be determined from manufacturer's recommendations, maintenance requests, grand rounds, life safety requirements, or experience."

During a concurrent interview and observation of the facility on 10/14/2024 at 9:30 AM, the surveyor noted a portable ultrasound machine, #1251051, in the hallway of the ED that had a preventative maintenance (PM) sticker with an expiration date of 12/2023. The Maintenance Supervisor stated the company that provided PM on the equipment had recently been at the facility, and he was not sure how the ultrasound machine was missed..

On 10/16/2024 at 11:30 AM, portable ultrasound machine #125051 was observed in the hallway of the ED. The Long-Term Care Administrator asked Registered Nurse (RN) #16 to remove the portable ultrasound machine from service and RN #16 was noted to roll the machine down the hallway.

During an interview on 10/16/2024 at 11:35 AM, RN #16 stated there was a newer ultrasound machine in the ED that would occasionally have a glitch and when it glitched, the older machine, #1251051, would be used. Per RN #16, the older machine was rarely needed and had been used occasionally since December 2023.

Based on interview, document review, and facility policy review, the facility failed to ensure proper temperature control in the food preparation area for 10 of 14 temperature logs reviewed. This had the likelihood to place patients at risk for consuming food that was not maintained correctly.

Findings included:

A facility policy titled, "Dishwashing Temperature," with an approve date of 07/31/2021, indicated, "a. The wash temperature shall be 150-165 [degrees] F [Fahrenheit]." The policy also indicated, "b. The final rinse temperature shall be 180 [degrees] F or above but not to exceed 194 [degrees] F."

A facility policy titled, "Food Safety Requirements," with an approved date of 07/31/2021, indicated, "Practices to maintain safe refrigerated storage include: i. Monitoring food temperatures and functioning of the refrigeration equipment daily and routine intervals during all hours of operation."

The "Sandwich Table Temperature Chart" for September 2024, revealed the required temperature was between 36 and 41 degrees F. Per the chart, there were 22 documented times when the temperature was not within range. Per the chart, "If the temperature is out of compliance, notify maintenance and the dietary manager." There was no evidence to indicate maintenance or the Dietary Manager (DM) were notified.

The "Walk-In Refrigerator Temperature Chart" for September 2024, revealed the required temperature was between 36 and 41 degrees F. Per the chart, there were four documented times when the temperature was not within range. Per the chart, "If the temperature is out of compliance, notify maintenance and the dietary manager." There was no evidence to indicate maintenance or the DM were notified.

The "Walk-In Freezer Temperature Chart," for September 2024, revealed the required temperature was between -10 and 0 degrees F. Per the chart, there was one documented time when the temperature was not within range. Per the chart, "If the temperature is out of compliance, notify maintenance and the dietary manager." There was no evidence to indicate maintenance or the DM were notified.

The "Reach In Cooler #2 Temperature Chart" for September 2024, revealed the required temperature was between 36 and 41 degrees F. Per the chart, there was six documented time when the temperature was not within range. Per the chart, "If the temperature is out of compliance, notify maintenance and the dietary manager." There was no evidence to indicate maintenance or the DM were notified.

The "Reach In Cooler #1 Temperature Chart" for September 2024, revealed the required temperature was between 36 and 41 degrees F. Per the chart, there was 37 documented times when the temperature was not within range. Per the chart, "If the temperature is out of compliance, notify maintenance and the dietary manager." There was no evidence to indicate maintenance or the DM were notified.

The "Dishwasher Temperature Chart," for September 2024, revealed the required minimum wash temperature was 150 degrees F and the minimum rinse temperature was 180 F. Per the chart, there was four documented times when the temperature was not within range. Per the chart, "If the temperature is out of compliance, notify maintenance and the dietary manager." There was no evidence to indicate maintenance or the DM were notified.

The "OB [obstetrics] Refrigerator [sic]/Freezer Temperature Chart," for September 2024, revealed the required refrigerator temperature was between 36 and 41 degrees F and the freezer temperature was between -10 and 0 degrees F. Per the chart, there was three documented times when the temperature was not within range. Per the chart, "If the temperature is out of compliance, notify maintenance and the dietary manager." There was no evidence to indicate maintenance or the DM were notified.

The "ER [Emergency Room} Refrigerator [sic]/Freezer Temperature Chart," for September 2024, revealed the required refrigerator temperature was between 36 and 41 degrees F and the freezer temperature was between -10 and 0 degrees F. Per the chart, there was six documented times when the temperature was not within range. Per the chart, "If the temperature is out of compliance, notify maintenance and the dietary manager." There was no evidence to indicate maintenance or the DM were notified.

The "Med/Surg [medical/surgical] Refrigerator [sic]/Freezer Temperature Chart." for September 2024, revealed the required refrigerator temperature was between 36 and 41 degrees F and the freezer temperature was between -10 and 0 degrees F. Per the chart, there was seven documented times when the temperature was not within range. Per the chart, "If the temperature is out of compliance, notify maintenance and the dietary manager." There was no evidence to indicate maintenance or the DM were notified.

During an interview on 10/16/2024 at 1:10 PM, the DM acknowledged the out-of-range temperatures on the charts for September 2024. The DM stated when things were too cold in the cold table, he found that staff took the temperature too close to the cooling source and not in the middle. The DM stated he did not document any follow up for the out-of-range temperatures and that he or maintenance were notified.

Based on interview, document review, and review of the medical staff bylaws, the facility failed to ensure peer reviews were conducted for 1 (Physician Assistant [PA] #18) of 11 credential files reviewed. The failure had the likelihood to have unqualified personnel on staff at the facility.

Findings included:

A letter addressed to PA #18 signed by the Chief Executive Officer and dated 04/19/2024, revealed at the 04/19/2024 meeting of the Board of Trustees, PA #18's application for staff privileges was reviewed and a decision was made to grant PA #18 mid-level privileges as a hospitalist under the supervision of Medical Doctor (MD) #20 and MD #17. Per the letter, PA #18's privileges would expire on 05/14/2026. Per the letter, "The granting and continuation of these privileges are conditioned upon your acceptance and compliance with all of the conditions and responsibilities specified within the Medical Staff Bylaws Rules and Regulations and Medical Center policies."

The facility "Medical Staff Bylaws," revised 09/20/2024, indicated "Section 3. Initial Appointment Procedure 3.1 Completion of Application 3.1.1 All requests for applications for appointment to the medical staff and request for clinical privileges will be forwarded to the medical staff office. Upon receipt of the request, the medical staff office will provide the applicant an application package which will include a complete set of the medical staff bylaws." Per the Medical Staff Bylaws, a completed application included, at a minimum: "i. Three current (dated within six months of application) references from peers knowledgeable about the applicant's experience, ability and current competency to perform the privileges being requested."

A reveal of PA #18's credential file, revealed no evidence of three peer review performed.

During an interview on 10/15/2024 at 9:30 AM, the Administrative Services Coordinator stated there were no peer reviews conducted for PA #18.

Based on interview, medical staff bylaws, and facility policy review, the facility failed to ensure policies were reviewed biennially (something that occurred every two years) for 6 of 11 sampled policies reviewed. The failure had the likelihood to cause the facility to not maintain best and most current practices.

Findings included:

The facility "Medical Staff Bylaws," revised 09/20/2024, indicated, "Section 9. Review, Revision, Adoption, and Amendment 9.1 Medical Staff Responsibility 9.1.1 The medical staff shall have the responsibility to formulate, review at least biennially, and recommend to the Board any medical staff bylaws, rules, regulations, policies, procedures, and amendments as needed."

A facility policy titled, "Discharge from PACU [post-anesthesia care unit]" revealed the policy was last revised 06/10/2009.

A facility policy titled, "Inventory Outdated Supplies/Medication Procedure," revealed the policy had a last revised date of 10/2009 and an adopted by date of 11/10/2009.

A facility policy titled, "Dishwashing Temperature" revealed the policy had an origination date of 07/26/2021 and an approved date of 07/31/2021.

A facility policy titled, "Food Safety Requirements" revealed the policy had an origination date of 07/26/2021 and an approved date of 07/31/2021.

A facility policy titled, "Monitoring of Cooler/Freezer Temperature," revealed the policy had an origination date of 07/28/2021 and an approved date of 07/31/2021.

A facility policy titled, "Record of Food Temperature," revealed the policy had an approved date of 07/31/2021 and an origination date of 08/02/2021.

During an interview on 10/17/2024 at 4:56 PM, the Chief Nursing Officer (CNO) stated the facility was currently working to update the Inventory Outdated Supplies/Medication Procedure policy and since it was a multidisciplinary policy, it took a while to get everyone to review it. The CNO confirmed the most recent approved version of the policy was in 2009. The CNO stated the most current date for the dietary policies was in 2021 and the Discharge from PACU policy was most current as of 2009. The CNO stated she did not believe policy review frequency was outlined in the bylaws.

Based on interview, record review, and facility policy review, the facility failed to ensure there was documentation of a patient's discharge criteria in the patient's medical record for 5 (Patients #51, #55, #57, #58, and #60) of 10 surgical records reviewed. The facility further failed to ensure staff documented in a patient's medical record that advance directive notice was given and if the patient had executed an advance directive for 10 of 10 outpatient medical records reviewed. These failures had the likelihood to result in patients not being properly discharged from the post-anesthesia care unit (PACU) and not having their advanced directives respected.

Findings included:

1. A facility policy titled, "Discharge from PACU [post-anesthesia care unit]," with a last revised date of 06/10/2009, indicated, "1. Purpose: To ensure that patients are appropriately and adequately recovered from effects of anesthesia prior to discharge." Per the policy, "6. Procedure: 6.1 Patients are discharged from the PACU by order of the anesthesia provider or surgeon. The order may be written in the Physician's Order sheet or on the Post Anesthesia Evaluation where TIME for discharge is indicated and signature of anesthesia provider is present. 6.2 Patients are discharged from the PACU when they have achieved a score of eight (8) or greater on the Aldrete Post Anesthesia Recovery Score for Discharge Criteria."

A patient demographic record revealed the facility admitted Patient #51 on 04/16/2024, for an examination under anesthesia for a possible anorectal advanced flap fistulotomy. The "Discharge Documentation," revealed the patient discharged on 04/16/2024; however, there was no evidence to indicate Patient #51's Aldrete Post Anesthesia Recovery Score for Discharge Criteria.

A patient demographic record revealed the facility admitted Patient #55 on 07/08/2024 for a laparoscopy cholecystectomy. Per the patient demographic record, Patient #55 discharged on 07/08/2024. Patient #55's "Surgical Documentation," dated 07/08/2024, indicated the procedure was performed under general anesthesia. Patient #55's medical record revealed no evidence to indicate the patient's Aldrete Post Anesthesia Recovery Score for Discharge Criteria.

A patient demographic record revealed the facility admitted Patient #57 on 07/08/2024 for a umbilical hernia repair. Per the patient demographic record, Patient #57 discharged on 07/08/2024. Patient #57's "Surgical Documentation," dated 07/08/2024, indicated the procedure was performed under general anesthesia. Patient #57's medical record revealed no evidence to indicate the patient's Aldrete Post Anesthesia Recovery Score for Discharge Criteria.

A patient demographic record revealed the facility admitted Patient #58 on 04/18/2024 for a dilation and curettage, hysteroscopy, ablation. Per the patient demographic record, Patient #58 discharged on 04/18/2024. Patient #58's "Surgical Documentation," dated 04/18/2024, indicated the procedure was performed under general anesthesia. Patient #58's medical record revealed no evidence to indicate the patient's Aldrete Post Anesthesia Recovery Score for Discharge Criteria.

A patient demographic record revealed the facility admitted Patient #60 on 06/12/2024 for an inguinal hernia repair. Per the patient demographic record, Patient #60 discharged on 06/12/2024. Patient #60's "Surgical Documentation," dated 06/12/2024, indicated the procedure was performed under general anesthesia. Patient #60's medical record revealed no evidence to indicate the patient's Aldrete Post Anesthesia Recovery Score for Discharge Criteria.

During an interview on 10/17/2024 at 5:07 PM, Registered Nurse (RN) #21 stated she did not see the documented discharge criteria for Patients #51, #55, #57, #58, and #60. Per RN #21, staff were expected to document the discharge criteria.

2. A facility policy titled, "Advanced Directive Policy," revised 07/15/2016, revealed, "4. Every in-patient, and out-patient, as defined in this policy, will receive a notice describing their rights under applicable Federal and State laws to make decisions about their medical care, including their right to accept or refuse treatment and the right to formulate advance directives." The policy specified, "6. Procedures 6.1 During the admission process, [facility name] staff will inquire if the patient has executed advance directives and will provide the Advanced Directive notice to in-patients and applicable out-patients, or their representatives, describing their rights to make medical care decisions. 6.2 [Facility name] staff will document in the patient's medical record that the notice was given and if the patient has executed advance directive documents."

Review of the medical records for Patients (#71, #72, #73, #74, #75, #76, #77, #78, #79, and #80) did not reveal evidence to indicate staff documented in the patient's medical record that the advance directive notice was given or if the patient had executed an advance directive.

During an interview on 10/17/2024 at 3:50 PM, Outpatient Registrar #14 stated advance directives were only given to patients who asked it.

During an interview on 10/17/2024 at 3:59 PM, the Outpatient Registration Manager stated advance directives were given to outpatients only when they requested it.

During an interview on 10/17/2024 at 4:03 PM, Outpatient Registrar #15 stated advance directives were only given to patients who asked it.






45841

Based on observation, interview, and facility policy review, the facility failed to ensure suction cannisters in Trauma One were clean and linen was not stored uncovered in the surgical department. These failure had to potential all patients who received services at the facility as there was a likelihood to result in the transmission of infection.

Findings included:

1. A facility policy titled, "Emergency Room Cleaning," with a last revised date of 04/2023, indicated, "1. Purpose: To assure a clean, safe, and sanitary environment for patients and staff members. 2. Applicability: Housekeeping."

On 10/14/2024 at 11:35 AM, a suction canister, attached to the suction regulator labeled "ICU [intensive care unit] 4" in Trauma One, was observed to have a small amount of a pink-orange tinged fluid.

During an interview on 10/14/2024 at 11:38 AM, Registered Nurse (RN) #3 stated there was something in the bottom of the suction cannister. According to RN #3, when housekeeping cleaned, they were supposed to change the suction cannisters as well, but anyone could change it out if they saw it was dirty.

During an interview on 10/17/2024 at 10:38 AM, the Housekeeping and Laundry Manager (HLM) stated housekeeping was not responsible for the suction cannisters in the patient rooms in the Emergency Department. Per the HLM, the housekeeping staff would notify the nurses or technicians at the nurses' station as they were responsible for changing the canisters out.

2. A facility policy titled, "Handling of Clean Linen," with a last revised date of 05/2023, indicated, "6.2 Linen carts will be covered with cart covers which have been disinfected and laundered daily."

During a concurrent interview and observation of the surgical department n 10/16/2024 at 11:11 AM, with Surgical Technician #8. a gurney was noted in the hallway across from the endoscopy room that contained eight piles of clean linens on it, uncovered. Surgical Technician #8 acknowledged the clean linen was uncovered and stated it stemmed from the surgical department being busy.

During an interview on 10/17/2024 at 10:38 AM, the Housekeeping and Laundry Manager stated that all linens were to be stored covered, and that included in the surgical area.

During an interview on 10/17/2024 at 11:32 AM, Registered Nurse #11 stated clean linen should not be left uncovered, that is should be stored in covered in a cabinet in the supply room.

Based on interview and record review, the facility failed to ensure patients were provided data for post-acute providers that included quality measures and data on resource measures for 1 (Patient #5) of 85 sampled patients. This failure had the likelihood to not allow patients to make a fully informed decision on their post-acute provider options.

Findings included:

Patient #5's "History and Physical Reports," revealed the patient admitted to the facility on 06/03/2024, with a chief complaint of shortness of breath and fluid retention.

Patient #5's "CM [care management] Narrative Note," entered on 06/11/2024, revealed the patient discharged to a facility and was expected to spend 25 to 30 days in a long-term acute care facility.

Patient #5's medical cord revealed no evidence to indicate that the patient was given data for post-acute providers that included quality measures and data on resource measures.

During an interview on 10/17/2024 at 12:07 PM, the Care Management Registered Nurse (CMRN) stated the facility did not provide quality data to patients for post-acute care providers. The CMRN stated the facility did not have a policy to address this and did not provide data to patients for placement options.