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Based on observation of the Psychiatric Unit and interview, it was determined the facility failed to maintain the building for a ligature free environment. The failed practices promoted self-harm to patients and had he likelihood to affect all patients admitted to psychiatric unit. Finding follow:

A. Observation of the Psychiatric Unit on 03/07/2024 at 8:36 AM showed the following:
1) Non- ligature free door hinges being used in patient rooms
2) Vertical bars presenting ligature risk on the front of patient room doors
3) Non-ligature free toilets being used in patient rooms

B. The findings of A were verified with the Director of Nursing on 03/07/2024 at 8:45 AM

Based on observation of the Medicine Room, Sub Sterile Equipment Room, and Emergency Department and interview, it was determined the facility failed to maintain the building physical structure, safety, environment, and equipment in a state of good repair. The failed practices promoted the spread of infection and had he likelihood to affect all patients, staff and visitors, Findings follow:

A. Observation of the Medicine room on the Medical Surgical hall on 03/04/2024 from 1:55 PM to 2:00 PM showed to the following :
1) Plastic piping under the sink instead of metal piping
2) Multiple wall penetrations

B. The findings in A were verified with the Supervisor of Maintenance on 03/04/2024 at 2:05 PM

C. Observation of the Central Sterile Room on 03/04/2024 from 2:01 PM to 2:09 PM showed the following:
1) Cracked floor tiles
2) A large wall penetration behind the equipment
3) Damaged cabinets that need to be resurfaced, exposed wood on cabinets that could not be disinfected

D. The finding in C were verified with the Supervisor of Maintenance on 03/04/2024 at 2:20 PM

E. Observation of the Emergency Department on 03/04/2024 from 2:12 PM to 2:45 PM showed the following:
1) Stained ceiling tiles
2) Bugs in the light fixtures in Emergency Room 5
3) Damaged cabinets in Emergency Room 3 that needed to be resurfaced
4) Dragging door in observation room causing damaged floors
5) Peeling wallpaper around automatic ER doors near nurses station
6) Damaged Cabinets and Sink in Emergency Department medicine room
7) Damaged floors and desks in Emergency Department Check-in
8) Damaged floor in PAC-U area in Emergency Department

F. The findings in E were verified with the Supervisor of Maintenance on 03/04/2024 at 2:57 PM.

Based on observation, review of National Fire Protection Association (NFPA) 101 standards and interview, it was determined the facility failed to ensure that the Generator was maintained and that an emergency stop switch was not installed on the generator. The generator did not have the sufficient amount of fuel required, and there was no battery powered emergency light installed on the generator. The failed practice did not ensure smoke and fire did not spread and had the likelihood to affect all patients, visitors and staff in the facility. Findings follow:

A. On 03/04/2024 at 3:05 PM observation of the emergency generator showed there was no covered emergency stop switch installed 10 to 15 feet away from the generator.

B. On 03/04/2024 at 3:10 PM, observation of the emergency generator showed there was no battery powered emergency light installed on the generator.

C. On 03/04/2024 at 3:13 PM observation of the emergency generator showed to not have a sufficient amount of fuel. The generator only had 12 hours of fuel instead of the required 48 hours as stated in NFPA 110.

D. On 3/4/2024 at 4:20 PM observation of kitchen showed to have a food warmer with a temperature exceeding 140 degrees as required by by NFPA standards.

E. The Findings A-D were verified with the Supervisor of Maintenance on 03/04/2024 at 4:00 PM

Based on observation, review of National Fire Protection Association (NFPA) 101 standards and interview, it was determined the facility failed to ensure that the central receiving area had a sufficient amount of space between sprinkler head and materials. The failed practice did not ensure smoke and fire did not spread and had the likelihood to affect all patients, visitors and staff in the facility. Findings follow:

A. Review of NFPA 101 Standards showed that a minimum of 18 inches needs to be kept between stored materials and the head of sprinklers.

B. On 03/04/2023 1:57 PM observation of the central receiving area showed to have boxes stored on top of a shelf exceeding an 18 inch gap between material and the sprinkler head.

C. The findings of B was verified by the Supervisor of Maintenance on 03/04/2024 at 2:24 PM.

Based on review of policy, observation, and interview, it was determined the facility failed to keep hand washing sinks and sink areas clean, per policy, in two of two (Medical/Surgical and Emergency Department) Medication Rooms toured. By not keeping the medication preparation areas clean, the facility could not assure the medications prepared in these areas weren't contaminated. This failed practice had the likelihood to affect all patients receiving medications in these two areas. Findings follow:
A. Record review of the facility's policy titled, "Medication Room Cleaning," showed medication rooms should be kept clean and the following tasks should be completed: Sinks and counter tops should be cleaned and disinfected daily.
B. During a tour of the facility on 03/04/2024 from 12:50 PM to 2:08 PM, observation showed the following:
1) Medical / Surgical Floor's Medication Room: The hand-washing sink was visibly dirty, with a dark grimy substance accumulated around the entire sink's edges and the back splash where it attached to the counter. Substances were dried out and not cleaned up from around the hot/cold handles. The ice machine was directly next to the handwashing sink and its fan was blowing directly into the handwashing sink and was only 6-8 inches from the sink.
2) Emergency Department's Medication Room: The hand-washing sink was visibly dirty, with a dark grimy substance accumulated around the entire sink's edges and the back splash where it attached to the counter. The backsplash was pulling apart from the counter and wall and had a dark grimy substance accumulated where the caulk was missing and along the caulk. The ice machine was directly next to the handwashing sink and its fan was blowing directly into the handwashing sink and was only 6-8 inches from the sink.
C. The findings were verified at the time of observation by Registered Nurse #1.

Based on review of policy, review of Arkansas Department of Health - Pharmacy Services and Drug Control Branch Rules and Regulations Pertaining to Controlled Substances [12/01/2014] and interview, it was determined the facility failed to follow accepted professional principles in that they wasted pharmaceutical narcotics in the sharps container instead of into a receptacle that would render them non-retrievable in two of two (Room #1 & #2) Operating Rooms and two of two (Medical Surgical and Emergency) Medication Rooms toured. By not wasting the narcotics according to accepted professional principles, the facility was not in compliance with Arkansas Department of Health's Pharmacy Services and Drug Control Branch's Rules and Regulations Pertaining to Controlled Substances. The failed practice had the likelihood to affect all medications wasted in the facility. Finding follow:
A. Record review of the facility's policy "Automated Dispensing Machines - Controlled Substances," showed disposing of the Controlled Substances in a sharps container was an acceptable method of wastage.
B. Record review of Arkansas Department of Health Pharmacy Services and Drug Control Branch Rules and Regulations Pertaining to Controlled Substances 12/01/2014 showed Controlled Substance waste should have been disposed of in a receptacle that would render it non-retrievable.
C. During an interview on 03/04/24 at 1:00 PM, while touring Operating Room #1, the Certified Registered Nurse Anesthetist was asked where the staff dispose of their narcotic waste and she replied they dispose of it in the Sharps container.
D. During an interview on 03/04/24 at 1:08 PM, while touring Operating Room #2, the Certified Registered Nurse Anesthetist was asked where the staff dispose of their narcotic waste and she replied they dispose of it in the Sharps container.
E. During an interview on 03/04/24 at 2:00 PM, while touring Medical / Surgical Unit, Registered Nurse #1 was asked where the staff dispose of their narcotic waste and she replied they dispose of it in the Sharps container.
F. During an interview on 03/04/24 at 2:10 PM, while touring the Emergency Department, Registered Nurse #1 was asked where the staff dispose of their narcotic waste and she replied they dispose of it in the Sharps container.

Based on review of policy, review of Physical Therapist Assistant's (PTA) personnel files, review of timecards, and interview, it was determined one (PTA #6) of six (PTA #1 - #6) therapists did not have evidence of current CPR (Cardio-Pulmonary Resuscitation) certification, per policy. By not having evidence of this qualification, the facility could not assure services provided to patients would be given by a qualified therapist. The failed practice had the likelihood to affect all patients that receive Rehabilitation Services. Findings follow:

A. Record review of facility policy titled "CPR Training," revised 06/03/2023, showed all PTAs shall maintain competency in CPR.
B. Review of PTA #6's personnel file showed PTA #6's CPR certification expired 10/02/2022.
C. Review of PTA #6's timecards showed he treated patients on the following days:
1) 2022: 10/17, 10/18, 10/19, 10/20, 11/02, 11/03, 11/07, 11/08, 11/14, 11/21, 11/24, 12/03, 12/04, 12/12, 12/13, 12/14, 12/15, 12/17, 12/18, 12/19, 12/20, 12/21, 12/22, 12/27, 12/28 and 12/29.
2) 2023: 01/03, 01/04, 01/07, 01/08, 03/04, 03/25, 03/26, 04/08, 04,09, 05/27, 05/28, 12/24, 12/25, 12/30 and 12/31.
3) 2024: 1/1/24.
D. During an interview on 03/06/2023 at 1:10 PM, the Inpatient Rehabilitation Director verified PTA #6's CPR had been expired since 10/02/2022 and has treated patients on the above listed dates.

Based on observation, policy and procedure review, and interview, it was determined that the facility failed to perform the daily maintenance procedures, the daily safety checklist and the monthly reservoir cleaning for the whirlpool tub used for the patients on the medical surgical floor for wound care and/or patient bathing, per the facilities established policy. The failed practice promoted the spread of infection and had the likelihood to affect all patients using the tub. Findings follow:

A. Observation during a tour of the Medical Surgical floor on 03/11/24 at 1:40 PM showed a whirlpool bathtub that did not have a daily cleaning log and/or patient log, or a monthly cleaning log. The Chief Executive Office and the Director of Engineering on 03/11/24 at 1:45 PM.

B. Review of the Penner Spas Aqua-Aire Sit Bath System 6900 manufacturer's instructions showed:
1) Clean and disinfect the tub after every bath with Penner Cleaner/Disinfectant.
2) Reservoir cleaning at least once per month or more often if needed.
3) Daily Maintenance Procedures
4) Daily Safety Checklist
a. Safety checks for the Cascade Tub
b. Safety checks for the Cascade Reservoir

C. Review of the policy and procedure "Whirlpool, Cleaning and Disinfecting Whirlpool and the Whirlpool Cleaning Log," revised on 06/16/05 showed that the facility policy did not conform to the manufacturer's instructions for use for the daily cleaning, reservoir cleaning, daily maintenance, and the daily safety checklist. The "Whirlpool Cleaning Log" showed what date the whirlpool tub was cleaned, what it was cleaned with, and who cleaned the tub. There was no evidence of a log with the daily maintenance or daily safety checklist.

D. Interviews with Facility Representatives:
1) During an interview with the Director of Engineering on 03/05/24 at 10:32 AM, he stated that they did not have a monthly cleaning log for the whirlpool tub.
2) During an interview with the Infection Control Preventionist on 03/06/24 at 2:10 PM, she stated that the current policy for "Whirlpool" and "Cleaning and Disinfecting Whirlpool" did not conform to the manufacturer's instructions for use.



Based on observation and interview, it was determined that the nurse's station in the Operating Room had an opening in the ceiling and wood surfaces exposed. The failed practice allowed objects to fall from the ceiling and the exposed wooden surfaces could not be disinfected. The failed practice promoted the spread of infection and had the likelihood to affect all patients undergoing a procedure. Findings follow:

A.Observation during a tour of the operating room on 03/04/24 at 12:53 PM showed:
1) The cabinet in the surgical services foyer had exposed particle board showing. The ceiling above the cabinet was missing.
2) There were two holes in the sheetrock under the fallen cabinet. Underneath the cabinet and the wall adjacent to the cabinet, there were sheets of hanging wallpaper, approximately eight inches for both openings.

B. The findings in A were verified by Director of Surgical Services at the time of the observation.




Based on observation, policy and procedure review, and interview, it was determined that the facility failed to accurately check the Negative Pressure/Airflow Rooms per the facilities established policy for two of two Negative Pressure/Airflow Rooms. The failed practice placed the patients at risk of infection and had the likelihood to affect all patients admitted to the rooms and hospital staff. Findings follow:

A. Review of the policy "Bradley County Medical Center Tuberculosis (TB) Control Plan Attachment" reviewed on 06/04/23 showed the Emergency Department nursing floor was to be checked every day, twice a day, once on the day shift and once on the evening shift. The negative air pressure units would be turned on and let run for 10 - 15 minutes. Then a ribbon would be placed on the floor outside the door (with the door closed tight). The ribbon should be sucked up under the door, indicating the door was creating negative pressure.

B. In an interview with the Emergency Room (ER) Registered Nurse (Nurse #2) on 03/06/24 at 1:15 PM, she stated she turns on the valve, shuts the door and records the time without patients in Rooms #4 and #5.

C. In an interview with Infection Control Preventionist on 03/06/24 at 1:20 PM, she agreed with the ER Registered Nurse (Nurse #2) regarding the process for the negative pressure rooms. Surveyor requested a policy regarding testing of negative pressure rooms.

D. In an interview with Infection Control Preventionist on 03/06/24 at 2:30 PM, she stated that she could not find a policy for the Negative Pressure/Airflow room, however, she gave the policy "Bradley County Medical Center Tuberculosis Control Plan Attachment" with procedure of how to test for the negative air pressure. She stated that "There is a ribbon to use for the negative pressure test and that they are doing it correctly despite how the emergency room RN stated the process."



Based on observation, policy and procedure review, it was determined that the facility failed to maintain a clean and sanitized negative pressure/airflow room. The failed practice promoted the spread of infection and had the likelihood to affect all immunocompromised patients, existing patients, and hospital staff. Findings follow:

A. Observation during a tour of the Medical Surgical floor on 03/06/24 at 12:06 PM, showed the following:

1) Negative Pressure Room 4105 had rusted Air Conditioning (AC) grill, missing kick plate under AC unit, wallpaper missing, and holes in the walls.
2) Negative Airflow Room 4106 had holes in walls, the Novair 1000 Hepa filter had approximately 3 inches of dust on the filter, and had not been changed since 11/22, porous tape applied to hold the cardboard like material to the window with an Airshield AS900C-NP negative airflow machine.
3) Negative Airflow Room 4107 had black porous wood in the window where Airshield AS900C-NP negative airflow machine, rusted AC grill and porous tape used to hold wood in place.
4) The findings in A were verified by the Director of Engineering and Infection Control Preventionist on 03/06/24 at 12:30 PM.

B. Review of Manufacturer Instructions for use for the "Novair 1000" Hepa filter on 03/07/24 at 11:45 AM, showed that the filters should be checked daily or when the pressure gauge reads 1.6" - 1.8" or when airflow was greatly reduced.

Based on observation and interview, it was determined the facility failed to assure the environment was maintained in a clean and sanitary manner in that in the Magnetic Resonance Imaging (MRI) staging area had four ceiling tiles that were discolored with black/brown stains, and the door to the hallway was worn and unfinished. By failing to maintain this area in a clean manner the facility could not ensure that patients in this area were free from infectious material. This failed practice had the likelihood to affect all patients requiring an MRI. The findings follow:

A. Observation during a tour of the MRI department on 03/06/2024 at 1:00 PM showed four of the ceiling tiles were discolored with brown/black stains and the door to the hallway was worn and unfinished which did not allow for disinfection.
B. The findings in A were confirmed with the Director of Radiology on 03/06/2024 at 1:00 PM.



Based on observation and interview, it was determined that the facility failed to assure the environment was maintained in a clean and sanitary manner in that in the MRI Control room there were four box fans with dirt and debris on all surfaces. By failing to maintain this area in a clean fashion the facility could not ensure that patients in this area were free from infectious material. This failed practice had the likelihood to affect all patients requiring a MRI. The findings follow:

A. Observation during a tour of the MRI department on 03/06/2024 at 1:05 PM showed there were four box fans on shelves with thick dirt and debris across all surfaces of the fans.
B. The findings in A were confirmed with the Director of Radiology on 03/06/2024 at 1:05 PM.



Based on observation and interview, it was determined that the facility failed to assure the environment was maintained in a clean and sanitary manner in that in the Magnetic Resonance Imaging (MRI) Dressing Room a floor tile was not secured to the floor and there were deceased insects in the ceiling light fixture. By failing to maintain this area in a clean fashion the facility could not ensure that patients in this area were free from infectious material. This failed practice had the likelihood to affect all patients needing to use the MRI changing room. The findings follow:

A. Observation during a tour of the MRI department on 03/06/2024 at 1:10 PM showed one of the floor tiles was coming up from the floor causing a gap that could not be kept sanitary and clean and there were four deceased insects in the one ceiling light fixture.
B. The findings in A were verified with the Director of Radiology on 03/06/2024 at 1:10 PM.



Based on observation and interview, it was determined the facility failed to assure that supplies in Emergency Room #5 were kept free from contamination and adulteration in that the supplies, including casting supplies, iv (intravenous) fluids, and assorted patient care supplies, were kept in the room in a open closet with no door. By failing to secure these items the facility was unable to assure that these supplies were free from alteration or contamination. This failed practice had the likelihood to affect all patients requiring supplies from this stock. The findings follow:

A. Observation during a tour of the Emergency Room Department on 03/07/2024 at 8:45 AM showed there was an open closet located in a patient care room (negative pressure capable) that was accessible to unauthorized individuals.
B. The findings in A were verified with the Director of Nursing on 03/07/2024 at 8:45 AM.

Based on review of personnel files and interview, it was determined the facility failed to assure one (Assistant #1) of three (Assistants #1-3) Certified Occupational Therapy Assistants (COTA) were screened to assure no individuals were hired who had been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law. Failure to perform background checks did not assure each patient would be protected from abuse, neglect, exploitation, misappropriation of property, or mistreatment. The failed practice had the likelihood to affect all patients admitted to the facility. Findings follow:

A. Review of personnel file for COTA #1 on 03/07/2024 at 2:00 PM showed a criminal background check (CBC) was not completed.
B. During an interview on 03/07/2024 at 3:04 PM, the Director of Risk Management / Compliance verified COTA #1 has worked at the facility since 05/3/2022 without a background check being completed to verify they had not been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law.