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Based on observation, interview, and review of the Rules for Critical Access Hospitals and Related Institutions in Arkansas 2021, it was determined the facility failed to provide the required temperature in one (Endoscopy Room) of two procedure rooms (Endoscopy Room, General Operating Room). The failed practice had the likelihood to affect all patients undergoing procedures in this space in that a clean environment was not ensured and an elevated risk of infection was present. Findings follow:

A. Review of the Rules for Critical Access Hospitals and Related Institutions in Arkansas 2021 Section 70:D.1 showed air conditioning, heating, and ventilation (HVAC) systems shall provide the dry bulb temperatures noted in Table 3. Further review of the Rules for Critical Access Hospitals and Related Institutions in Arkansas 2021: Table 3 showed Endoscopy Rooms shall be maintained in the range of 68 to 73 degrees Fahrenheit.

B. Observation on 8/23/22 at 2:00 PM of the Endoscopy Room showed the room had a thermostat on the wall which read "61 degrees Fahrenheit". This finding was verified with the Director of Maintenance in an interview on 8/24/22 at 9:00 AM, during which he also verified that the Endoscopy Room was consistently kept below 68 degrees Fahrenheit.

Based on observation, interview, and review of the Rules for Critical Access Hospitals and Related Institutions in Arkansas 2021, it was determined the facility failed to provide a visual mechanism for monitoring the air pressure of the room at two of two (Patient Room 130, Patient Room 131) airborne infectious isolation rooms. The failed practice had the likelihood to affect all patients and staff in that an incorrect air pressure of either isolation room would not be detected, allowing an infectious disease to be transmitted through the air going out of the room. Findings follow:

A. Review of the Rules for Critical Access Hospitals and Related Institutions in Arkansas 2021 Section 44:C.7 showed each airborne infection isolation room shall have a permanently installed visual mechanism for monitoring the pressure status of the room when occupied by patients with an airborne infectious disease.

B. Observation of Patient Rooms 130 and 131 on 8/25/22 at 10:45 AM showed both rooms were airborne infection isolation rooms and were not provided with any mechanism for monitoring the pressure of either room while occupied. This finding was verified with the Maintenance Technician at the time of observation.

Based on observation, interview, and review of the Rules for Critical Access Hospitals and Related Institutions in Arkansas 2021, it was determined the facility failed to maintain an air filter change out log for the heating, ventilation, and air-conditioning (HVAC) system. The failed practice had the likelihood to affect all patients, staff, and visitors in that there was no process in place to ensure HVAC air filters were replaced frequently enough to prevent contaminated air from flowing through the facility and infecting a vulnerable person. Findings follow:

A. Review of the Rules for Critical Access Hospitals and Related Institutions in Arkansas 2021 Section 42:A.9 showed an HVAC air filter change out log shall be maintained.

B. In an interview with the Director of Maintenance on 8/23/22 at 1:00 PM it was verified that the facility did not maintain an HVAC air filter change out log.

Based on observation, interview, and review of the facility's Hot Water Temperature Log and the Rules for Critical Access Hospitals and Related Institutions in Arkansas 2021, it was determined the facility failed to maintain a weekly hot water temperature log. The failed practice had the likelihood to affect all patients relying on hot water in that there was no process in place to ensure the hot water being provided for patient use each week was sufficiently hot for clinical use. Findings follow:

A. Review of the Rules for Critical Access Hospitals and Related Institutions in Arkansas 2021 Section 42:A.8 showed a weekly hot water temperature log shall be maintained for hot water intended for patient use.

B. Review on 8/22/22 at 1:30 PM of the facility's Hot Water Temperature Log showed temperatures of hot water intended for patient use were being recorded monthly. This finding was verified with the Director of Maintenance in an interview on 8/23/22 at 1:00 PM.

Based on observation, interview, and review of the Rules for Critical Access Hospitals and Related Institutions in Arkansas 2021, it was determined the facility failed to maintain the Generator Room in that combustible items were stored in the room. The failed practice had the likelihood to affect all patients, staff, and visitors in that the presence of combustible items near a gas fired machine created a fire hazard in the building. Findings follow:

A. Review of the Rules for Critical Access Hospitals and Related Institutions in Arkansas 2021 Section 42:A.3 showed rooms for gas fired equipment shall not be used for storage except for noncombustible materials.

B. Observation on 8/25/22 at 11:00 AM of the Generator Room showed two portable air conditioning units, an unused extension cord, a portable battery charger, and an upholstered stool were stored in the room with the gas fired generator. This finding was verified with the Maintenance Technician at the time of observation.

Based on observation, interview, and review of the Rules for Critical Access Hospitals and Related Institutions in Arkansas 2021, it was determined the facility failed to store food containers in a manner that protected the contents in that 4 of 4 cardboard boxes of vegetable oil were stored on the kitchen floor. The failed practice had the likelihood to affect all patients and visitors in that the containers could have become contaminated and caused illness in the people consuming the food prepared with it. Findings follow:

A. Review of the Rules for Critical Access Hospitals and Related Institutions in Arkansas 2021 Section 17:B.10 showed all storage containers/foodstuffs shall be stored at least 6 inches above the floor in a manner that protects the food.

B. Observation of the Kitchen on 8/24/22 at 10:20 AM showed 4 cardboard boxes containing vegetable oil were stored on the floor of the Kitchen. This finding was verified with the Dietary Director at the time of observation.

Based on observation, interview, and review of the Rules for Critical Access Hospitals and Related Institutions in Arkansas 2021, it was determined the facility failed to maintain the premises in a state of good repair in that there were stained ceiling tiles present in various patient care areas, a missing ceiling tile in one patient care area, ceiling lights that were not functional, and automatic doors that were not functional. The failed practice had the likelihood to affect all patients and visitors in that the stained ceiling tiles presented a risk of contamination in patient care areas, the defective ceiling lights presented a hazard of tripping or falling in dimly lit areas, and the defective automatic doors presented an obstacle to emergency medical technicians trying to enter the facility quickly to provide emergency care. Findings follow:

A. Review of the Rules for Critical Access Hospitals and Related Institutions in Arkansas 2021 Section 42:A.1 showed the building and equipment shall be maintained in a state of good repair.

B. Observation on 8/23/22 at 2:00 PM of the Waiting Area showed the automatic door serving as the main entrance was stuck in the open position and was not functioning and 2 ceiling lights were unlit.

C. Observation on 8/23/22 at 2:30 PM of the Emergency Department showed the automatic door serving as the entrance from the ambulance bay was in the closed position and was not functioning, requiring manual force to slide it open.

D. Observation on 8/23/22 from 2:35 PM to 2:50 PM of the Medical-Surgical Department showed 2 ceiling tiles were stained in the Employee Nourishment room, 1 ceiling tile was stained and partially sliding out of the ceiling grid in Patient Room 146, and 1 ceiling tile was missing from the ceiling grid exposing insulation next to the Nurse Station.

E. Observation on 8/25/22 at 8:45 AM of Respiratory Storage showed 1 stained ceiling tile was present and the light switch on the wall did not turn on the ceiling lights.

F. Observation of the Kitchen on 8/24/22 at 10:15 AM showed one ceiling light was flickering off and on in the Walk-In Refrigerator near the rear exit.

G. Observation on 8/22/22 at 12:00 PM of the Conference Room showed 2 ceiling lights were unlit and did not turn on when the light switch on the wall was toggled.

H. Observation on 8/22/22 at 3:00 PM of the Administration Corridor showed 1 ceiling light was unlit in the Employee Nourishment room and did not turn on when the light switch on the wall was toggled.

I. The above findings were verified at the time of observatin with the Director of Maintance at the time of observation

Based on policy review, observation, and interview, it was determined the sterile supplies were not maintained in a safe and secure environment to protect the integrity of sterile supplies for patient use in that sterile supplies were stored below wound care solutions and expired sterile supplies were available for use. The failed practice had the likelihood for the spread of infection. The failed practice had the likelihood to affect all patients receiving treatment in the Emergency Department (ED). The findings follow:

A. Review of Policy on 08/24/22, titled "Storage of Sterile Supplies" not dated, showed the following:
1) All sterile supplies shall be stored in a secure location that was clean, dry, and protected from moisture.
2) Sterile stock should be checked monthly to verify not outdated stock.
3) All sterile stock was to be clearly labeled with the name of item, date of processing, sterile expiration date, lot/load stamp, and initials of Central Sterile employee.
4) Sterile supplies shall be separated from clean supplies.
5) Items were to be stored with same size and shape items, neatly stacked and the identification plainly visible.
6) Storage of sterile supplies shall be done to protect the integrity of the packaging.

B. Observation on 08/23/22 at 2:35 PM of the ED area showed the following:
1) The supply closet with sterile instrument packs on a shelf packed tightly in bins
2) The sterile instrument packs were on a shelf under the wound care solution shelf which could potentially leak onto the sterile packs.
3) There were expired instrument packs with the following examples:
a) Forceps dated 07/7/16
b) Hemostat dated10/26/16
c) Curved scissors dated 02/27/18
d) Suture pack dated 07/25/19
e) Nasal speculum dated 11/4/19
f) C (Cesarean) section pack had no date

C. During an interview on 08/24/22 at 2:45 PM, the Chief Nursing Officer confirmed the findings in A and B.

Based on review of the Rules for Critical Access Hospitals and Related Institutions in Arkansas 2021, National Fire Protection Association (NFPA) 101 2012 Edition, NFPA 99 2012 Edition, and NFPA 110 2010 Edition, interview, and observation, it was determined the facility failed to maintain a physical environment safe for patient care in that:

A. The facility failed to install two of two alcohol-based hand-rub dispensers a safe distance from hazardous locations in accordance with NFPA 101 standards to prevent fire hazards from being present. See K-325
B. The facility failed to conduct fire drills on one (2nd shift) of two shifts (1st shift, 2nd shift) once per shift per quarter in accordance with NFPA 101 standards to ensure staff were able to take necessary life-saving actions in the event of a fire. See K-712
D. The facility failed to provide visual mechanisms for monitoring the air pressure of two of two (Patient Room 130, Patient Room 131) infectious airborne isolation rooms as required by the Rules for Critical Access Hospitals and Related Institutions in Arkansas 2021. See A-812
C. The facility failed to maintain the Endoscopy Room within the required temperature range to ensure a clean environment was present to prevent an elevated risk of infection. See A-812
E. The facility failed to maintain a filter change out log of the heating, ventilation, and air conditioning (HVAC) system to ensure clean air was provided throughout patient care areas. See A-812
F. The facility failed to maintain a weekly temperature log of the hot water intended for patient use to ensure the water was hot enough for clinical use. See A-812
G. The facility failed to maintain the Generator Room free of combustible items to prevent a fire hazard from being present. See A-812
H. The facility failed to store food containers in a manner that protected the containers from contamination. See A-812
I. The facility failed to maintain the premises in a state of good repair by failing to repair ceiling lights, ceiling tiles, and automatic doors, which presented trip hazards, contamination risks, and impediments to emergency procedures. See A-812
J. The facility failed to inspect the emergency generators weekly or test them under load monthly or annually in accordance with NFPA 101 and NFPA 110 standards to ensure functionality in the event of an emergency. See K-918
K. The facility failed to maintain the medical gas central supply system, vacuum piped system, and related alarm systems in accordance with NFPA 99 standards to ensure functionality in the event of an emergency. See K-924

Based on policy and procedure review and refrigerator temperature log review for 01/01/22 through 08/22/22, it was determined the facility failed to ensure that employees followed its policy in that one of one refrigerator temperatures (South wing patient care unit refrigerator) were documented out of the acceptable range without corrective action. Failure to ensure refrigerator temperatures were within acceptable ranges did not ensure that patient food and beverages were kept at safe temperatures to prevent food borne contamination. Findings follow.

A. Review of undated policy titled "Infection Control; Dietary Services" on 08/23/22 showed refrigerator storage temperature range of 34 degrees to 41 degrees Fahrenheit.

B. Review of undated policy and procedure titled "Infection Control: Nutritional Services", on 08/23/22, showed out-of-range temperatures were to be reported to the maintenance department and notification documented on the temperature log.

C. Review of refrigerator temperature logs for 01/01/22 through 08/22/22 revealed that temperatures were out of range for 234 of 234 days with no corrective action. For example:
1) On 01/01/22 the temperature was documented as 30 degrees Fahrenheit.
2) On 06/01/22 the temperature was documented as 30 degrees Fahrenheit.
3) On 08/01/22 the temperature was documented as 30 degrees Fahrenheit.

D. The above findings in A, B, and C were verified with the Chief Nursing Officer on 08/22/22 at 2:50 PM.

Based on review of monthly medication storage area inspections, review of policy, review of Pharmacist Job Description and interview, it was determined pharmacy failed to inspect medications in patient care areas monthly in four (Scope Room, South Wing, East Wing and Radiology) of five (Emergency Department (ED), Scope Room, South Wing, East Wing and Radiology) areas toured, per policy. By not inspecting medications in patient care areas monthly, the facility could not assure medications were properly stored to maintain their integrity, stability, and efficacy. The failed practice had the likelihood to affect all patients who received medication from these areas. Findings follow:

A. Record review of facility policy titled, "Drugs Returned to Pharmacy," showed the Director of Pharmacy or his/her designee should make monthly checks of all medication storage areas.
B. Record review of the Pharmacist Job Description showed the pharmacist was responsible for the procurement, storage, preparation, dispensing, recording and control of all drugs used in the hospital.
C. Review of monthly medication storage area inspections on 08/24/22 for the previous 12 months (August '21 through July '22) showed the following missing inspections:
1) South Wing was missing March, April and May of '22;
2) Scope Room was missing all 12 months;
3) East Wing was missing September, October, November, December of '21, January, February June and July '22;
4) Radiology was missing all 12 months.
D. During an interview on 08/24/22 at 8:45 AM, the Director of Pharmacy verified the missing inspections listed in findings C.

Based on review of policy, review of Computerized Axial Tomography (CT) Room emergency medicine kit check sheets and interview, it was determined the facility failed to ensure the contents of emergency medication kit were secured (by a breakaway seal) at the beginning of each shift (per policy) in one (Computerized Axial Tomography (CT) Room) of one area surveyed in Radiology. The potential exists for the emergency medication kit not to have medications present for patient emergencies. The failed practice had the likelihood to affect all patients who needed medications in an emergency. Findings follow:

A. Record review of the facility's policy titled "Checking Crash Carts," showed the contents of emergency medication kits were to be checked at the beginning of each shift. "Crash Cart" is a general term that includes all carts/kits that contain emergency medications in them.
B. During a tour of the CT Room on 08/22/22 from 2:15 PM until 2:25 PM the CT emergency medication kit check sheets were reviewed. From 07/07/21 through 08/03/22, the sheets showed the kit was being checked once a month.
C. During an interview on 08/22/22 at 2:18 PM, Radiology Technician #1 verified the emergency medication kits were checked monthly instead of daily.


Based on review of policy, observation, and interview, it was determined the facility failed to ensure outdated medications were not available for patient use in one (adult) of two (adult and pediatric) emergency crash carts surveyed in the Emergency Department. By not disposing of medications once they expire, the facility could not assure their safety or efficacy. The failed practice had the likelihood to affect all patients who received medications at the facility. Findings follow:

A. Record review of the facility's policy titled, "Drugs Returned to Pharmacy" showed the Director of Pharmacy or his/her designee should make monthly checks of all patient care areas and remove outdated drugs.
B. During a tour of the Emergency Department on 08/22/22 from 2:20 PM to 2:42 PM, the following expired medications were observed in the adult emergency crash cart:
1) #3- Amiodarone 150 mg(milligram)/ 3 ml(milliliter) single dose vial expired 04/22;
2) #1- Adenosine 6mg/ 2ml single dose vial expired 05/22; and
3) #1- Verapamil 5mg/ 2ml single dose vial expired 07/22.
C. During an interview on 08/22/22 at 2:33 PM the Chief Nursing Officer verified the expired medications stored in the adult crash cart.

Based on review of manufacturer's recommendations, observation and interview, it was determined the facility failed to adhere to accepted professional standards in that they did not follow manufacturer's recommendations for length of storage for IV (Intravenous) solutions and contrast mediums in two (South Wing and Radiology) of two areas toured with fluid warmers. The facility also failed to adhere to accepted professional standards in that they did not follow manufacturer's recommendations for temperature of storage for one (South Wing) of two (South wing and Radiology) areas toured with fluid warmers. By not following manufacturer's recommendations for storage, the facility could not assure the safety and efficacy of the IV solutions and contrast mediums available for patient use. The failed practice had the likelihood to affect all patients that have had procedures in the facility that required IV fluids and contrast mediums. Findings follow:


A. Review of Manufacturer's storage recommendations for Baxter IV solutions showed that the IV solutions could be warmed to temperatures not exceeding 104 degrees Fahrenheit, and for a period of no longer than 14 days.
B. Review of Manufacturer's storage recommendations for Optiray 350 contrast mediums showed it can be stored for one month at 98.6 degrees Fahrenheit.
C. Review of Manufacturer's storage recommendations for Optipaque 350 contrast mediums showed it can be stored for one month at 98.6 degrees Fahrenheit.
D. During a tour of the facility on 08/22/22 from 2:00 PM to 3:00 PM, observation on the South Wing showed #3 Baxter Sodium Chloride 1000 ml (milliliter) IV solutions in a fluid warmer heated to 110 degrees Fahrenheit. None of the products were dated to assure they didn't exceed the Manufacturer's recommendation of length of stay in a warmer. The warmer was also set above the recommended temperature of 104 degrees Fahrenheit.
E. During a tour of the facility on 08/22/22 from 2:00 PM to 3:00 PM, observation in Radiology showed #2 Optiray 350s and #3 Omnipaque 350s in a warmer. None of the products were dated to assure they didn't exceed the Manufacturer's recommendation of length of stay in a warmer.
F. During an interview on 08/22/22 at 2:50 PM, the Chief Nursing Officer verified the findings at D and E.

Based on observation, review of Pharmacist Job description and interview, the facility failed to ensure medications were properly controlled (locked and unavailable to unlicensed personnel)
in one (Computerized Axial Tomography (CT) Room) of two (CT and X-ray) rooms surveyed in Radiology. By not assuring only licensed personnel have access to the medications, the facility could not assure the medications' safety, efficacy, and inventory. The failed practice had the likelihood to affect all patients who receive medications from the facility. Findings follow:

A. Record review of the Pharmacist Job Description showed the pharmacist was responsible for the procurement, storage, preparation, dispensing, recording and control of all drugs used in the hospital.
B. During a tour of the CT Room on 08/22/22 from 2:15 PM until 2:25 PM the following contrast medium solutions were observed in a warming cabinet, that was not able to be locked:
#2 Optiray 350/ 100 milliliters; and
#3 Omnipaque 350/ 100 milliliters. Both are by prescription only.
C. During an interview on 08/22/22 at 2:25 PM, the Radiology Technician #1 verified the findings at B.

Based on observation, review of policy and interview, it was determined that four of four opened bottles of ACCU-CHEK Inform II glucose control solutions were not dated as to when opened to assure they had not expired. The failed practice had the potential to affect the laboratory results and had the potential to affect any patient when a blood glucose was drawn. Findings included:
A. Review of policy titled, " ACCU-CHEK Inform II Blood Glucose Testing," dated 07/22/20, showed:
1) Only trained staff with documented competency may perform this procedure
2) Liquid QC (Quality Control) vials expire three months after opening with documented new expiration date when opened.
B. Review of the competency assessment for use of the ACCU-CHEK Inform II Blood Glucose Testing showed the employee was to write "open date" on the control vial.
C. Observation of 08/24/22 at 12:45 PM of the ACCU-CHEK Inform II Blood Glucose control solutions showed there was no date of opening to determine the expiration date.
D. During an interview on 08/24/22 at 2:00 PM, the Chief Nursing Officer confirmed the findings in A-B.

Based on review of the Centers for Disease Control and Prevention (CDC) COVID-19 guidelines, review of policy and procedure, observation, and interview, it was determined the facility failed to mitigate the risks of COVID-19 in that the facility failed to provide evidence of screening of visitors, patients, and personnel for signs and symptoms of COVID-19. The failed practice did not allow for tracking of visitors for signs and symptoms of COVID-19 and had the likelihood to affect all patients, staff, and visitors. Findings included:

A. Review of the CDC COVID-19 Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic Infection Control Guidance updated 02/02/22 showed the facility to was establish a process to identify anyone entering the facility regardless of their vaccination status.
B. Review of the CDC COVID-19 Interim Infection Prevention and Control Recommendations Management of Visitors to Healthcare Facilities in the Context of COVID-19, updated Sept. 15, 2020, showed the following:
1. Facilities should designate an entrance that visitors can use to access the healthcare facility.
2. Visual alerts, such as signs and posters, should be placed at facility entrances and other strategic areas instructing visitors not to enter as a visitor if they have fever or respiratory symptoms.
3. Signage should include signs and symptoms of COVID-19 and who to notify if visitors have symptoms.
C. Review of Policy on 08/23/22, titled "Screening for Signs and Symptoms of COVID-19 at Entrance to Facility" not dated, showed the following:
1. Everyone entering the healthcare facility were to be screened and triaged for signs and symptoms of COVID-19.
2. Each person entering the facility were to wait 60 seconds before taking their temperature using a tympanic thermometer
3. Each person entering the facility were to sign the book or tablet at the desk to indicate they had self-screened.
D. Observation upon entering the facility on 08/22/22 through 08/24/22, showed the following:
1. On 08/22/22 and 08/24/22, upon entering the facility, there was no evidence of signage designating location for visitor signs and symptoms of COVID-19 screening.
2. On 08/22/22 and 08/23/22, upon entering the facility, Surveyors four of four (Surveyor #1-#4) were not screened for signs and symptoms of COVID-19.
3. On 08/23/22 two of two visitors stated they had not been screened for signs and symptoms of COVID-19.
4. On 08/24/22, upon entering the facility, Surveyors four of four (Surveyor #1-#4) were not screened for signs and symptoms of COVID-19.
E. On 08/22/22 and 08/24/22, there was no evidence of a screening log for visitors, patients, and personnel used for tracking for signs and symptoms of COVID-19.
F. During the interview on 08/24/22 at 12:15 PM with the Infection Control Nurse, the findings were confirmed for A-E.

Based on observation and interview, it was determined the facility failed to maintain separation of patient supplies, calibration supplies and staff food and drinks in that one of one (Respiratory Department) refrigerator identified as a patient refrigerator contained Arterial Blood gas (ABG) calibration validation product (CVP) and staff food and drinks. The failed practice placed the patient supplies at risk of contamination and had the likelihood to affect all patient receiving respiratory care. The findings were:

A. Observation on 08/23/22 at 1:40 PM showed:
1) The refrigerator located in the Respiratory Department had signage as patient use.
2) The refrigerator in the Respiratory department had CVP in the top door shelf and staff food and drinks in the door and inside shelves.

B. During an interview on 08/23/22 at 1:40 PM, the Respiratory Supervisor confirmed the findings in A.

Based on policy review, clinical record review, and interview, it was determined the Facility's Interdisciplinary Team (IDT) failed to complete a plan of care (POC) and weekly reassessment after the initial assessment to update the POC for 5 of 5 (#11-#15) swing bed patients. The failed practice had the likelihood to effect continuity of care. The failed practice had the likelihood to affect all patients admitted to the Swing Bed unit. The findings follow:
A. Review of policy titled, " Swing Bed program," dated 02/18/10, showed:
1) The treatment team (IDT) were to review patients' progress weekly and adjust the POC as indicated.
2) Swing bed patients were to be assessed for restorative/rehabilitative nursing care needs after being admitted, discharged from therapies, and when a change in condition occurs.
3) The POC was to be developed for each restorative nursing care and include measurable goals and interventions.
4) Nursing care plans are initiated on all patients.
B. During an interview on 08/25/22 at 8:45 AM., Chief Nursing Officer confirmed the findings in A.
C. Review of clinical record of Patient #11 on 08/25/22, admitted 07/26/22, showed the following:
1) No evidence the nurse initiated the restorative/ rehabilitative plan of care on admission.
2) No evidence the IDT formulated the patient's plan of care.
3) No evidence the IDT completed the weekly assessment in the patient's plan of care.
4) During an interview on 08/25/22 at 10:45 AM., Chief Nursing Officer confirmed the findings in C 1-3.
D. Review of clinical record of Patient #12 on 08/25/22, admitted 07/25/22, showed the following:
1) No evidence the nurse initiated the restorative/ rehabilitative plan of care on admission.
2) No evidence the IDT formulated the patient's plan of care.
3) No evidence the IDT completed the weekly assessment in the patient's plan of care.
4) During an interview on 08/25/22 at 11:00 AM., Chief Nursing Officer confirmed the findings in D 1-3.
E. Review of clinical record of Patient #13 on 08/25/22, admitted 07/30/22, showed the following:
1) No evidence the nurse initiated the restorative/ rehabilitative plan of care on admission.
2) No evidence the IDT formulated the patient's plan of care.
3) No evidence the IDT completed the weekly assessment in the patient's plan of care.
4) During an interview on 08/25/22 at 11:15 AM., Chief Nursing Officer confirmed the findings in E 1-3.
F. Review of clinical record of Patient #14 on 08/25/22, admitted 07/20/22, showed the following:
1) No evidence the nurse initiated the restorative/ rehabilitative plan of care on admission.
2) No evidence the IDT formulated the patient's plan of care.
3) No evidence the IDT completed the weekly assessment in the patient's plan of care.
4) During an interview on 08/25/22 at 11:30 AM., Chief Nursing Officer confirmed the findings in F 1-3.
G. Review of clinical record of Patient #15 on 08/25/22, admitted 07/25/22, showed the following:
1) No evidence the nurse initiated the restorative/ rehabilitative plan of care on admission.
2) No evidence the IDT formulated the patient's plan of care.
3) No evidence the IDT completed the weekly assessment in the patient's plan of care.
4) During an interview on 08/25/22 at 11:45 AM., Chief Nursing Officer confirmed the findings in G 1-3.

Based on review of the facility's Emergency Preparedness Plan and interview, it was determined there was no evidence a facility-based and community-based risk assessment was performed to identify all hazards and strategies for addressing emergency events identified by the risk assessment. The failed practice did not assure the facility identified potential natural disasters (i.e., tornadoes, flooding, etc.) for their geographical region. The failed practice had the likelihood to affect all patients and staff. The findings were:

A. Review on 8/22/22 at 1:00 PM of the Emergency Preparedness Plan showed there was no evidence of a facility-based or community-based all-hazards risk assessment completed.

B. In an interview with the Safety Officer on 8/23/22 at 1:00 PM, he confirmed there was no facility-based or community-based all-hazards risk assessment completed.

Based on review of the Emergency Preparedness binder and interview, it was determined the facility failed to conduct a full-scale test of their emergency program in the 2 years prior to the survey (August 2020 - August 2022). The failed practice had the likelihood to affect all patients and staff in that in the event of a large-scale emergency the staff may not be prepared to respond quickly and effectively to preserve patient safety. Findings follow:

A. Review of the Emergency Preparedness binder showed there was no record of any full-scale community-based or full-scale facility-based exercises conducted.

B. The above finding in A was verified with the Safety Officer on 8/23/22 at 1:00 PM.