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Based on observation, interview, and record review, the facility failed to establish, implement, and follow a policy and procedure for ensuring all essential mechanical, electrical, and patient-care equipment were identified and included on an inventory list which included a record of maintenance activities; failed to ensure all equipment was inspected and tested for performance and safety before initial use; and failed to ensure all essential medical equipment was maintained through a facility established maintenance strategy. The accumulative effect of this deficiency had the potential to affect all patients provided care services utilizing the identified equipment. Findings include:

A review of the facility's policy and procedure titled, Maintenance, with a revision date of 4/1/23, failed to include procedures for the initial inspection and testing for performance safety of essential patient care equipment.

1. During an observation and record review on 1/3/24 at 2:00 p.m., the following emergency room based medical equipment was identified as not having a facility established maintenance sticker, did not have an initial safety evaluation, and was not listed on the facility's established equipment maintenance list:

- A McGrath (Covidien) Video Laryngoscope.
- A Butterfly Ultrasound Machine.

During an interview on 1/3/24 at 4:00 p.m., staff member B stated she had checked with staff member D and they did not have the video laryngoscope or the ultrasound device identified on their facility's periodic maintenance log. Staff member B stated these two machines had not had an initial evaluation prior to their use in the emergency department.

2. During an observation and record review on 1/3/24 at 2:00 p.m., the following glucose machines were identified as not having a facility established maintenance sticker, did not have an initial safety evaluation, and were not listed on the facility's established equipment maintenance list:

- Xpress glucometer with a label marked: 5/467
- Xpress glucometer with a label marked: 6/468

During an interview on 1/3/24 at 4:00 p.m., staff member B stated she had checked with staff member D and they did not have the two glucometers identified on their facility's periodic maintenance log. Staff member B stated these two machines had not had an initial evaluation prior to their use in the emergency department. Staff member B stated she did check with staff member E, and the lab did perform an initial glucose control to test the high and low readings prior to them being utilized on the unit; however, the glucometers were not identified in the facility's periodic maintenance list.

Based on interview and record review, the facility failed to follow their established policies and procedures to ensure all radiologic technologists were up to date on their CPR certifications. This deficient practice had the potential to affect any direct-care patients in need of emergent basic life support in the radiology department. Findings include:

Review of the facility's policy and procedure titled, Basic Life Support Certification, last reviewed on 12/27/23, showed:

- "Policy:
- Improve patient safety by ensuring that personnel are properly trained in the basic techniques of Cardiopulmonary Resuscitation.
- Procedure:
- All employees involved in direct patient care must be CPR certified ...
- It shall be the employee's responsibility to attend refresher courses so that the BLS certification card does not expire.
- Proof of renewed certification must be presented to the department manager. ..."

Review of the facility's job description for a Registered Radiologic Technologist, last revised 3/2/22, showed:

- ... "Minimum Requirements
- ... CPR Certification. ..."

Review of the facility's personnel files, on 1/4/24, showed staff member R's BLS certification was expired.

During an interview on 1/4/24 at 10:38 a.m., staff member A stated according to the records from the radiology department, staff member R's BLS certification had expired. He stated staff member R had worked after the expiration of the certification.

Based on interview and record review, the facility failed to ensure the developed plan of care for therapy services included the frequency and duration of the physical and occupation therapy services for 2 (#s 2 and 18) of 20 sampled patients. This deficient practice had the potential to affect all patients receiving therapy services. Findings include:

During an interview on 1/3/24 at 10:30 a.m., staff member N stated the frequency and duration of recommended therapy services should be included in each patient's therapy plan of care.

1. A review of patient #2's medical record showed a physician order, dated 12/27/23, for PT evaluate and treat.

Review of patient's #2's PT Acute Evaluation and PT Care Plan, completed on 12/28/23, failed to include the prescribed frequency and duration of the therapy services to be provided.

2. A review of patient #18's medical record showed a physician order, dated 10/18/23, for PT/OT evaluate and treat.

A review of patient #18's PT and OT established plan of cares failed to include the prescribed frequency and duration of those therapy services to be provided.

During an interview on 1/4/24 at 11:06 a.m., staff member B stated she had spoken with staff member N regarding patient #'s 2 and 18's therapy plan of cares and the recommended frequency and duration were not included in their plan of cares.

Based on interview and record review, the facility failed to ensure a medical doctor co-signed and assumed full responsibility for the H&P, when a patient was admitted by a mid-level practitioner for 2 (#s 4 and 8) of 5 sampled patients. Findings include:

1. Review of patient #4's medical record showed an admission date and H&P completed on 11/10/23, by staff member W. The H&P was not co-signed for approval and the responsibility of the patient care was not assumed by the MD/DO.

2. Review of patient #8's medical record showed an admission date and H&P completed on 9/10/23, by staff member Z. The H&P was not co-signed for approval and the responsibility of the patient care was not assumed by the MD/DO.

During an interview on 1/4/24 at 8:35 a.m., staff member G stated 100 percent of mid-level providers' patient charts were reviewed by an MD.

During an interview on 1/4/24 at 8:43 a.m., staff member G stated mid-level providers had admitting privileges and were required to notify an MD of an admission. She stated all mid-level providers' H&P's were co-signed by the MD.

Based on interview and record review, the facility failed to ensure their organ, tissue, and eye donation program (OPO) was integrated into their facility's Quality Assurance and Performance Improvement Program (QAPI). This deficient practice had the potential to affect all patients with a requested organ donor and imminent death. Findings include:

During an interview and record review on 1/3/24 at 1:00 p.m., staff member B stated the facility currently did not include their OPO program into their QAPI. She stated there was currently no documentation from their QAPI meeting minutes which would include the OPO program since it currently was not included in their QAPI.

Based on interview and record review, the facility failed to follow their established policies and procedures to provide on-going training to their employees on the prohibition and prevention of patient abuse. Findings include:

Review of the facility's policy and procedure titled, Mistreatment, Abuse, and Neglect, last reviewed on 11/1/22, showed:

- ... "Annual education will be provided to hospital staff on how to recognize abuse, preventive measures, how to recognize the elements that may lead to abuse, appropriate interventions to deal with alleged abuse situations, reporting, the investigation processes and possible outcomes of alleged abuse situations. ..."

Review of the facility's employee personnel files for staff members B, C, I, J, L, O, R, and Y showed no evidence of annual or additional sessions on abuse training.

During an interview on 1/4/24 at 10:51 a.m., staff member A stated the last abuse training was in March of 2022. He stated there had not been additional training since then unless the employee was newly hired.