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Based on observations and interview, the facility failed to maintain emergency equipment and keep it readily available for treating emergency cases, resulting in the potential for adverse outcomes for all emergency patients.

On 03/02/2022 at 0820, an entrance tour of the Emergency Department (ED) was conducted with ED manager (Staff C). Upon entering the 'Clean Utility' room, an equipment bag was observed hanging on the end of a supply rack. The cloth bag was approximately 12"x36" and was very heavily soiled, with dried mud cracking off and falling to the floor. Staff C was queried as to its purpose, Staff C stated, " That's the bag for our Hare traction splint (immobilization device). That should be in the soiled utility, it shouldn't be in here until after its cleaned. I'll take it there myself." Upon further observation, the Hare traction device was resting against another supply rack. This device has a black foam pad positioned at one end, and upon inspection it was noted that the foam pad had extensive cracks, pits and missing portions. Staff C was again queried, 'Has this device been cleaned prior to entering the 'Clean Utility' room?' Staff C replied, "I'm sure it was." Staff C was then questioned 'if the integrity of foam was an issue with proper cleaning of the device?' Staff C stated, "Yea, that really can't be cleaned like it is. I will get that replaced."

Based on interview and document review, the facility failed to ensure authorization for transfer was adequately completed for 1 (#27) of 36 patients resulting in the potential for less than optimal patient outcomes. Findings include:

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A-2409 Failure to ensure authorization for transfer was adequately completed for 1 (#27) of 36 patient records reviewed, resulting in the potential for adverse outcomes.

Based on record review and interview the facility failed to ensure that the authorization for transfer was adequately completed for 1 (#27) of 36 patient records reviewed, resulting in the potential for adverse outcomes. Findings include:

During record review with Director of Quality (Staff A) on 03/03/2022 at 1420, it was determined that the authorization for transfer for patient #27, lacked signature by the patient or patient's representative, acknowledging the risks and benefits of transfer. "Implied consent" was written into the patient signature space, followed by the signature of the Registered Nurse transferring the patient. Staff A was then questioned why a nurses would sign for consent to transfer. Staff A stated, "That's a mistake. I will re-educate the nurse. Only a patient or designee can consent."


These finding were confirmed with the Chief Nursing Officer on 03/03/2022 during the exit conference.