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Based on a review of facility documentation and staff interview (EMP), it was determined that the facility failed to conform to all applicable federal, state, and local laws.

A review of Pennsylvania Code 49, Chapter 21 §21.45 revealed "(a) The LPN is prepared to function as a member of the health care team ... (1) An LPN shall communicate with a licensed professional nurse and the patient's health care team members to seek guidance when: ... "

Review of the Pennsylvania Department of Health, School Health, School Health Staff, Licensed Practical Nurses (LPN) revealed "The LPN regulations require that they function as a member of the healthcare team. In the school setting, they serve as Supplemental Staff under the Certified School Nurse (CSN)."

Based upon observation, staff interview, and review of facility documents, it was determined the facility failed to comply with 49 PA Code, Chapter 21 State Board of Nursing, Subchapter B.

Findings Include:

On May 24, 2023, at 11:50pm, a tour of the Penn Highlands Connellsville Regional Center for Autism which is licensed under the hospital as Branch 7659536 occurred. On May 24, 2023 at 12:00pm, EMP21 revealed the school was also licensed by the Pennsylvania Department of Education.

On May 24, 2023, at 12:05pm, during a review of school medication administration records, revealed the school nurse was a licensed practical nurse (LPN).

On May 24, 2023, at 12:06pm, EMP22 confirmed they did not hold a Pennsylvania School Nurse Certificate. EMP22 stated their "coverage" was obtained by the Certified School Nurse at Connellsville Area School District. EMP22 stated their backup coverage was the Employee Health Nurse at Penn Highlands Connellsville Hospital.

On May 24, 2023, at 1:10pm, a contract between Penn Highlands Connellsville Hospital and Connellsville Area School District for coverage of the LPN was requested. No contract for coverage was presented.

On May 24, 2023, EMP3 indicated they did not possess a Pennsylvania School Nurse Certificate to act as "back up" coverage to EMP22.

On May 24, 2023, at 2:30pm, PF11 was reviewed. There was no Pennsylvania School Nurse Certificate within the file.

On May 24, 2023, at 3:30pm, the above findings were confirmed with EMP1.

Based on a review of facility documents and employee interview (EMP) it was determined that the governing body failed to operate effectively as evidenced by the operationally integrated management functions of separately licensed and certified hospitals (PA Hospital License-037301 and PA Hospital License-137001).

Findings include:

1. On May 22, 2023, a review of the Penn Highlands Healthcare organizational chart (v4) for the Southwestern Region (Effective: 4/13/2023) revealed "Blue boxes represent shared functions that are dually managed with corporate counterparts." The following departments were recognized on the organizational chart as dually managed between Penn Highlands Mon Valley (PHMV) and Penn Highlands Connellsville Hospital (PHCV): Medical Staff, Budget, General Accounting, Coding, Patient Accounting, Health Information Management, Case Management/Social Work, Purchasing, Information Systems, Plant Operations, Bio Med, Pharmacy, Cardiology Services, Behavioral Health, Detox Unit, Human Resources, Imaging/Interventional Radiology, Lab, Occupational Therapy, Physical Therapy. Speech Therapy, Monongahela Blood Draw, Respiratory Therapy/Sleep Lab, and Cardiopulmonary Rehab.

On May 22, 2023, EMP1 confirmed they reported to OTH2 at PHMV.

On May 22, 2023, EMP4 confirmed they reported to OTH3 at PHMV.

On May 23, 2023, EMP14 confirmed the Penn Highlands Mon Valley and Penn Highlands Connellsville Hospital were separately licensed and certified. EMP14 confirmed there was not a contract between the two hospitals for the management oversight.

On May 24, 2023, at 10:03am, EMP15 confirmed the organizational chart represented an integration of functions in the absence of a single license/certification.

2. On May 24, 2023, a review of the Scope of Service for "Penn Highlands Connellsville Penn Highlands Diabetes and Nutrition Center," revised date January 2023, revealed "Overview The Penn Highlands Diabetes & Nutrition Center offers both outpatient diabetes education and medical nutrition education based on receipt of physician orders ... Staffing Current staffing for the PHCV Diabetes Center consists of the following: 1 Dietitian Diabetes Educator, 1 Administrative Assistant."

On May 24, 2023, a review of a facility "Employee Lease Agreement," dated August 24, 2021," by and among Monongahela Valley Hospital, Inc. ("MVH") and Highlands Hospital ("Highlands")," revealed "Recitals ... B. Due to shortages in health care employees during a nationwide pandemic, MVH and Highlands each have short-term needs that the other could assist with staffing ... 1.Personnel 1.1. Subject to the terms of this Agreement, MVH agrees to furnish to Highlands, and Highlands agrees to engage from MVH, such employees as may be necessary to conduct hospital operations on the premises of Highlands or for the benefit of hospital operations on the Highlands premises (such employees, the "MVH Assigned Employees)."

On May 24, 2023, at 1:20 PM, a tour of the off-site facility diabetes clinic was conducted. During an interview at that time, EMP17 revealed the only diabetes educator was OTH1. EMP17 revealed OTH1 was at the clinic Thursdays and occasionally an hour or so on other days because OTH1 was the Director of the Diabetes Department at Penn Highlands Mon Valley Hospital.

On May 24, 2023, at 3:15 PM, the personnel file for OTH1 was requested from EMP4. EMP4 stated the facility didn't keep an employee file for OTH1 because she was an employee of Penn Mon Valley Hospital, not this facility.

Based on review of facility policy, review of medical records (MR), and interview with facility staff (EMP), it was determined that the facility failed to ensure that patients were made aware of their rights prior to providing services for four of four surgical medical records reviewed (MR7, MR8, MR9, and MR10).

Findings include:

On May 24, 2023, review of facility policy titled "Patient Rights and Responsibilities" last dated 8/26/22, revealed "... The purpose of this policy is to provide patients with an outline of their rights and responsibilities...". The policy did not address how patients will be made aware of their rights.

On May 24, 2023, review of MR7, date of service 5/12/23, did not reveal evidence the patient received their rights.

On May 24, 2023, review of MR8, date of service 5/3/23, did not reveal evidence the patient received their rights.

On May 24, 2023, review of MR9, date of service 3/22/23, did not reveal evidence the patient received their rights.

On May 24, 2023, review of MR10, date of service 3/17/23, did not reveal evidence the patient received their rights.

On May 24, 2023, at 5:00 pm, EMP8 confirmed the above findings.

Based on review of facility policy, tour of the facility, and interview with facility staff (EMP), it was determined that the facility failed to ensure the Purell hand sanitizer was appropriately stored in Operating Rooms (OR) 1 and 2.

Findings include:

On May 23, 2023, review of facility document titled "... FIRE SAFETY... Dept: Operating Room ... Revision Dates: 2/23..." revealed "... Surgical team members will: Survey the flammable materials that may be on or around the patient, including: Liquids (e.g., alcohol-based skin antiseptic), ...".

Tour of OR1 on May 22, 2023, at approximately 12:00 pm revealed a 12-ounce bottle of Purell alcohol-based hand sanitizer on the anesthesia cart. EMP8 confirmed the presence of the sanitizer at the time of the tour and confirmed this should not be located on the anesthesia cart.

Tour of OR2 on May 22, 2023, at approximately 12:05 pm, revealed a 12-ounce bottle of Purell alcohol-based hand sanitizer on the anesthesia cart. EMP8 confirmed the presence of the sanitizer at the time of the tour and confirmed this should not be located on the anesthesia cart.

Based on review of facility policies, medical records (MR), and interview with facility staff (EMP), it was determined that the facility failed to ensure the use of restraint or seclusion was incorporated in the patient's plan of care for two or two seclusion medical records reviewed (MR17 and MR18).

Findings include:

On May 24, 2023, review of facility policy titled "MULTIDISCIPLINARY TREATMENT PLAN AND REVIEW," last dated 1/24/23, revealed "... Any time a patient is placed in 'Restraints or Seclusion', the patient's treatment plan must be updated at that time to indicate the use of restraints on the patient and to document describing the clinical justification for each episode or [sic] restraints, the patient's response to interventions and the criteria for termination of restraint use. If a patient needs to be placed in restraints or Seclusion [sic] on more than one occasion, the treatment plan will need updated with each occurrence...".

Review of MR17 on May 24, 2023, revealed the patient was admitted on 2/9/23. MR17 was in seclusion on 2/9/23, 2/10/23, 2/11/23, and 2/13/23. There was no documentation in the patient's treatment plan for the use of seclusion.

Review of MR18 on May 24, 2023, revealed the patient was admitted on 4/17/23. MR18 was in seclusion on 4/23/23 and 4/24/23. There was no documentation in the patient's treatment plan for the use of seclusion.

On May 24, 2023, at 2:30pm, EMP19 confirmed the above findings.

Based on review of facility policies, medical records (MR), and interview with facility staff (EMP), it was determined the facility failed to ensure the use of restraints or seclusion was in accordance with the appropriate order of a physician or other licensed practitioner for two of two seclusion medical records reviewed (MR17 and MR18).

Findings include:

On May 24, 2023, review of facility policy titled "Restraints, Non-Behavioral, Behavioral, and Seclusion Policy", last dated 01/2023, revealed "... I. SECLUSION OR RESTRAINT DOCUMENTATION 1. A written physician order is obtained including: a) Reason for restraint b) Clinical Justification for use of device c) Type of restraint maximum time limit not to exceed 4 hours (adult), 2 hours (ages 9-17) and 1 hour (under 9) d) Observation Status e) Less restrictive alternatives attempted...".

On May 24, 2023, review of MR17, date of admission, 2/9/23, revealed an order for seclusion on 2/9/23 at 1410. The order did not include the maximum time limit or the least restrictive alternatives attempted. There was an order for seclusion on 2/10/23 at 1028 that did not include the maximum time limit or least restrictive alternatives attempted. There was an order for seclusion on 2/11/23 at 0935. The order did not include the maximum time limit. There was an order for seclusion on 2/13/23 at 1219. The order did not include maximum time limit.

On May 24, 2023, review of MR18, date of admission, 4/17/23, revealed an order an order for seclusion on 4/23/23 at 1440. The order did not include the maximum time limit, the reason for the restraint, or the least restrictive alternatives attempted. There was an order for locked seclusion on 4/23/23 at 2240. The order did not include the maximum time limit, the reason for the restraint, or the least restrictive alternatives attempted. There was an order for locked seclusion on 4/24/23 at 0240. The order did not include the maximum time limit, the reason for the restraint, or the least restrictive alternatives attempted. There was an order for locked seclusion on 4/24/23 at 0640. The order did not include the maximum time limit, the reason for the restraint, or the least restrictive alternatives attempted. Nursing documentation revealed the patient was in seclusion on 4/23/23 at 1840-2240. There was no order.

On May 24, 2023, at 2:30pm, EMP19 confirmed the above findings.

Based on review of facility policies, medical records (MR), and interview with facility staff (EMP), it was determined that the facility failed to ensure the condition of the patient who was in seclusion was monitored at the interval determined by the hospital policy for two of two seclusion medical records reviewed (MR17 and MR18).

Findings include:

On May 24, 2023, review of the facility policy titled "Restraints, Non-Behavioral, Behavioral, and Seclusion Policy," last dated 01/2023, revealed "... I. SECLUSION OR RESTRAINT DOCUMENTATION ... 2. The Behavioral Health Seclusion and Restraint Record includes ... 7. RN performs and documents flow sheet every 2 hours... 8. While in seclusion or restraints, the patient is in constant observation status ... will observe and document every 15 minutes including the behavior of the patient...".

On May 24, 2023, review of MR17, date of admission, 2/9/23, revealed there was no 15-minute documentation for the seclusion orders on 2/9/23 at 1410, 2/10/23 at 1028, 2/12/23 at 1300, and 2/12/23 at 1700. Further review revealed there was a Behavioral Health Seclusion and Restraint Record missing for the seclusion order on 2/13/23 at 1219.

On May 24, 2023, review of MR18, date of admission, 4/17/23, revealed there were no Behavioral Health Seclusion and Restraint Records for the seclusion orders on 4/23/23 at 1440, 4/23/23 at 2240, 4/24/23 at 0240, or 4/24/23 at 0640.

On May 24, 2023, at 2:30pm, EMP19 confirmed the above findings.

Based upon a review of facility documents, credential files (CF) and staff interview (EMP), it was determined that the medical staff failed to thoroughly review the credentials prior to making recommendations to the governing body for appointment for six of ten credential files (CF3, CF4, CF5, CF8, CF9, and CF10).

Findings included:

Review on May 23, 2023, of the Credentialing Procedures Manual (Last Reviewed- January 25, 2023) revealed "Part Three: Systems and Procedures for Delineating Clinical Privileges: 3.1 Division and Section Responsibilities- It shall be the responsibility of the division or section to formulate and recommend to the MEC and, subsequently, to the Board, through the Professional Affairs Committee, the privilege delineation mechanism to be used and the qualifications of members holding privileges. 3.2 Procedure for Delineating Privileges- 3.2.1 Requests: Every initial application for staff appointment as well as applications for reappointment ..., shall contain a request for specific clinical privileges desired by the applicant ... "

1. On May 23, 2023, a review of CF 5 (Credential Term: 9/14/2022 to 6/30/2024) revealed the delineation of privileges was approved on 3/11/2021. There was no delineation of privileges associated with the current credential term of 9/14/2022.

On May 23, 2023, a review of CF10 (Credential Term: 12/30/2022 to 12/1/2024) revealed the delineation of privileges was signed/approved on 2/7/2023 for the credential term beginning 12/30/2022.

2. On May 23, 2023, a review of the Credentialing Procedures Manual (Last Reviewed- January 25, 2023) revealed " Part Two: Reappointment Process 2.1.3 Internal Information to be Considered: The chief executive officer shall be responsible for collecting information from sources within the Hospital with respect to the following: c) Cooperation with peers and hospital personnel ... h) Clinical competence ... "

On May 23, 2023, a review of CF9 (Credential Term: 12/30/2022 to 12/1/2024) and CF10 (Credential Term: 12/30/2022 to 12/1/2024) revealed no peer references for the current credential term.

3. On May 23, 2023, the Bylaws of the Highlands Hospital Medical Staff (Undated) were reviewed and revealed " Article IV: Membership Categories and Health Professional Affiliates: 4.1 Categories: The medical staff shall be divided into Active, Associate, Courtesy ER Courtesy, Consulting, Honorary and Affiliate categories."

On May 23, 2023, a review of CF10 revealed the practitioner was assigned Health Plan Administrator as the category of medical staff. This was not a recognized category of staff under the current bylaws of the facility.

4. On May 23, 2023, a review of CF4 (Credential Term: 12/30/2022 to 12/1/2024) revealed that CF4 failed to request credentials to Penn Highlands Connellsville Hospital (PHCV). Credentials requested were for Penn Highlands Mon Valley Hospital (PHMV). Privileges were granted to PHCH via the governing body on 12/30/2022.

5. On May 23, 2023, a review of CF3 (Credential Term: 7/1/2021 to 6/30/2023) revealed the following documents were executed after the credential term had commenced on 7/1/2021: NPDB was completed 8/27/2021 and the delineation of privileges was signed on 9/28/2021. The notification to the practitioner by the governing body was dated 11/3/2021.

6. On May 23, 2023, a review of CF5 (Credential Term: 9/14/2022 to 6/30/2024) revealed that CF5 failed to request credentials to Penn Highlands Connellsville Hospital (PHCV). Credentials requested were for Penn Highlands Mon Valley Hospital (PHMV). Privileges were granted to PHCH via the governing body on 9/14/2022.

7. On May 23, 2023, a review of CF 4, and CF7, and CF8 revealed the Authorization and Release from Liability signed by the practitioner did not include PHCH.

All of the above findings were confirmed during an interview with EMP12 and EMP 13 on May 23, 2023, from 12: 30pm to 1:00pm.

Based on a review of facility documentation, observations, and interview (EMP), it was determined the facility failed to ensure the crash cart was properly stocked, in good working order, and easily accessible.

Findings include:

On May 24, 2023, a review of the facility policy, "Crash Cart," dated April 26, 2023, revealed "Objective: To have all Crash Carts uniformly stocked for the convenience of personnel responding to a Code Blue on any unit. This will ensure consistent restocking of drugs and supplies used during a Code Blue. ... Nursing personnel will check Crash Cart/defibrillator and document daily (on the daylight shift). ... Carts will be checked daily for the following by Nursing Personnel. Cart number. Defibrillator performed its daily quality control. Defibrillator Pad expiration date. Pharmacy drawers secured with green lock. Other drawers secured with yellow lock."

1. On May 22, 2023, at 10:30 AM, a tour of the 3rd floor medical/surgical unit was conducted. The crash cart log was noted to be blank for having been checked by the nursing care staff on May 21, 2023.

During an interview on May 22, 2023, at 11:00 AM, EMP3 and EMP5 confirmed the above observation.

2. On May 24, 2023, at 10:15am, a tour of Outpatient Physical Therapy, located on the second floor revealed the crash cart was in a staff kitchen and was obstructed by a dining table and chairs.

During an interview on May 24, 2023, at 10:17am, EMP2 and EMP23 confirmed the above observation.

Based on review of facility policies, review of medical records (MR), and interview with facility staff (EMP), it was determined that the facility failed to ensure that the appropriate findings by the clinical staff were incorporated in the patient's record for one of four inpatient medical records reviewed (MR13).

Findings include:

On May 24, 2023, a policy or medical staff bylaws pertaining to the time frame for providers to read/review diagnostic tests were requested. No policy or medical staff bylaw was provided.

On May 24, 2023, review of MR 13, admission date 4/10/23, revealed an echocardiogram was completed on 4/10/23. The echocardiogram was read by the physician 4/12/23. It was signed by the physician on 4/18/23.


On May 24, 2023, at 12:45 pm EMP18 confirmed the above findings.

Based on review of facility policies, medical records (MR), and interview with facility staff (EMP), it was determined that the facility failed to ensure properly executed consents to treat for two of sixteen medical records reviewed (MR5 and MR15).

Findings include:

On May 24, 2023, review of facility policy titled "Patient Consent," last revised 07/2006, revealed "... B. The form 'Authorization and consent [sic] to Treatment' must be obtained prior to any examination, procedure, or treatment...".

The policy does not address the need for dating the signature.

On May 24, 2023, review of MR5, date of service 4/13/23, revealed a consent to treat was signed by the patient and witness. The consent was not dated. It was unable to be determined if the consent was completed prior to examination, procedure, or treatment.

On May 24, 2023, review of MR15, date of service 5/5/23, revealed a consent to treat was signed by the patient and witness. The consent was not dated. It was unable to be determined if the consent was completed prior to examination, procedure, or treatment.

On May 24, 2023, at 12:45 pm EMP18 confirmed the above findings.

Based on review of facility materials, medical records (MR), and interview with facility staff (EMP), it was determined that the facility failed to ensure the completion of medical records within 30 days of discharge for one of four surgical medical records reviewed (MR9).

Findings include:

On May 24, 2023, review of facility material titled "Highlands Hospital Medical Staff Rules and Regulations," last dated 01/25/23, revealed "... 22. Medical records must be completed within thirty (30) days of the patient's discharge from the facility...".

On May 24, 2023, review of MR9, date of service 3/22/23, revealed the operative note was dictated on 3/22/23 and transcribed on 3/23/23. The physician signed the operative note on 5/17/23.

On May 24, 2023, at 5:00 pm, EMP8 confirmed the above findings.

Based on a review of facility documents, observations, and staff interviews (EMP), it was determined the facility failed to ensure that drugs were kept in a secure area in the operating suite (OR).

Findings include:

Review of facility's "SPACE, EQUIPMENT, AND SUPPLIES" policy, last reviewed 1/25/2023, revealed "... OBJECTIVE: To promote patient safety through the proper storage, preparation, dispensing and administration of drugs. ... Drugs are stored under the proper conditions of sanitation, temperature, light, moisture, ... and security. ..."

During a tour of the OR suite with EMP8 on May 22, 2023, at approximately 12:05 PM, the back hallway entrance to the OR suite was observed to be unlocked. There was no mechanism in place to restrict entry by unauthorized persons. This door opened to the a back hallway into the medical/surgical unit - an unrestricted area where the public may travel.

During a tour with EMP8 on May 22, 2023, at approximately 12:20 PM, a refrigerator in the OR corridor, used to store Succinylcholine (used to cause short-term paralysis as part of general anesthesia), Rocuronium (a muscle relaxant), and Duovisc (an ophthalmologic solution) was observed to be unlocked.

Given that the doorway to the OR suite was unlocked, and the refrigerator in the OR corridor was unlocked, the above medications were not stored in a secure area per facility policy.

During the tour of the OR suite on May 22, 2023, at approximately 12:05 PM, EMP8 confirmed the back hallway door to the OR suite remained unlocked when the OR was being used.

During an interview with EMP11 on May 24, 2023, at 9:05 AM, EMP11 confirmed that while the above medications were not controlled medications, they should be kept secured.

Based on review of facility documents, facility policy, and staff interviews (EMP), it was determined the facility failed to make available to all medical, nursing, and food service personnel a current therapeutic diet manual approved by the dietitian and medical staff.

Findings include:

Review of facility "Policy #: DC 101," last revised 12/14, revealed "Subject: Diet Manual ... POLICY: To provide a diet manual which meets the recommended dietary intake for optimal nutrition. The diet manual will be approved by the department director, and medical staff. This manual will be available to all clinical areas of the hospital that provide nutrition. ..."

During an interview on May 22, 2023, at 1:40 PM, OTH1 stated they did not have a therapeutic diet manual.

During an interview with EMP7 on May 24, 2023, at approximately 8:30 AM, EMP7 clarified that the facility has access to a therapeutic diet manual. EMP7 stated the therapeutic diet manual had not yet been approved by the medical staff nor made readily available to all medical, nursing and food service personnel.

Based on a review of facility policies, observation, and interview with facility staff (EMP), it was determined that the facility failed to ensure that it followed proper routine storage of trash on the third floor medical surgical unit and the 1 West BH Unit.

Findings include:

Review of the facility policy "Handling/Disposing of General Solid Waste", last dated 3/6/23, revealed "... solid waste is then collected by the housekeepers and carried to the storage utility room for temporary storage and covered garbage containers...".

On May 22, 2023, at 11:10 am, tour of the third-floor medical surgical unit ' s biohazard room, trash was piled above the trash cans, above the one biohazard container, and a bag of trash was noted on the floor, blocking the ability to walk into the room.

On May 22, 2023, at 11:10 am, EMP1 and EMP3 confirmed the above findings.

On May 22, 2023, at 1:05 pm, a tour of 1 West BH Unit "Tranquility" was conducted with EMP1. The unit is a 17-bed unit. The following finding was observed. The soiled utility room 117 contained multiple bags of garbage, some overflowing and some sitting on the floor.

The above was confirmed by EMP1 at the time of this observation.

Based on a review of facility policies, tour of the facility, and interview with facility staff (EMP), it was determined that the facility failed to ensure that the overall hospital environment was maintained in such a manner that the safety and well-being of patients are assured.

Findings include:

On May 23, 2023, review of the following facility policies occurred:

"Cleaning Public Areas," last dated 3/6/23, revealed "... All public areas are cleaned daily... Remove all trash and damp wipe the trash cans with a disinfectant and reline. High dust area, focusing on TV, pictures, door frames, hinges, and window frames...".

"Cleaning of Public Restrooms," last dated 3/6/23, revealed "... Place toilet bowl cleaner in the toilet. ... With disinfectant damp wipe and buff were necessary sinks, Chrome fixtures, paper towel holders, door handles and light switches. ... Flush the toilet. ...".

"Dry Mopping," last dated 3/6/23, revealed "... To remove loose soil and dust accumulation and prepare the floor for damp mopping..."

"Cleaning of Discharge Bathrooms," last dated 3/6/23, revealed "... High dust over the door frame and sink. ... Damp wipe all metal hand rails and wall fixtures. If shower is in the room clean the walls and shower fixtures..."

"Cleaning a Discharge Room," last dated 3/6/23, revealed "... high dust the following: top of cabinets, overhead lights, television and door frame. ... windowsill... Clean the bathroom ..."

"Pest Control," last dated 3/6/23, revealed "... The environmental services department is responsible for the control and elimination of pests anywhere on hospital grounds. ... environmental services department shall maintain a contract with a competent pest control service for the purpose of providing a monthly treatment of potential problem areas. ..."

"Handling/Disposing of General Solid Waste," last dated 3/6/23, revealed "... solid waste is then collected by the housekeepers and carried to the storage utility room for temporary storage and covered garbage containers ...."

"Crash Cart," last dated 4/26/23, revealed "... Nursing personnel will check Crash Cart/defibrillator and document daily (on the daylight shift). ..."

1. On May 22, 2023, a tour of the third-floor medical surgical unit was conducted. The unit has 17 beds, with a census of four patients at the time of the tour. The following findings were observed at the following times:

10:30 am hallway: eight stained ceiling tiles were observed outside of the fire door. The windowsill had cobwebs and a dead bug. Six stained ceiling tiles were observed outside of the elevator.

10:37 am room 307: seven stained ceiling tiles were observed in the room, bubbling paint was noted by the windowsill, and dust and debris were noted on the air conditioning unit below the window. In the bathroom, a ceiling tile was noted to be falling, five ceiling tiles were stained, and the floor tiles were raised in a manner that created a tripping hazard.

10:40 am room 309: five stained ceiling tiles were observed in the room. Also observed in the room was an intravenous supply cart, that included needles, that was not locked or secured.

10:43 am room 304: two stained ceiling tiles were observed in the room. Clumps of dust were noted on the windowsill, and there was a sharp metal object being stored on the windowsill. In the bathroom there were cobwebs observed by the window with dust and dirt and a displaced ceiling tile.

10:46 am room 302: four stained ceiling tiles observed in the room.

10:50 am room 312: eight stained ceiling tiles were observed in the room. There was an open, screenless window. EMP1 and EMP3 confirmed the window was not supposed to be open. Chunks of dust were noted on windowsill. The bathroom had one floor tile, raised in a manner that created a tripping hazard.

10:52 am in the shower room closest to blanket warmer: there was a blind replacement hanging on the hook inside the door. The light was hanging from the shower ceiling. There was one brown dead bug, approximately 2.5-3 inches in size, on the shower floor. There were two small bugs on the window. The shower was not marked as closed or as having work done.

10:55 am in the shower room closest to the crash cart: there were two small dead bugs on the shower floor.

11:00 am the blanket warmer temperature log was not filled out for May 21, 2023. EMP3 stated the entire staff know how to do the log. EMP3 noted the employee that takes the most responsibility has been off. At this time, it was also noted that the crash cart had not been checked on May 21, 2023, or for May 22, 2023. EMP5 stated that it is not one person's specific job to check the cart. Night shift takes responsibility usually. Each shift does not check it themselves.

11:05 am in the room labeled Evacuation Chair: the door to this room was found to be unlocked. Three cases of HaloMist, a disinfecting agent, were found on the floor. EMP3 stated the HaloMist was supposed to be in the storeroom in the basement.

11:10 am in the biohazard room: trash was observed piled above the trash cans, above the one biohazard container, and a bag of trash was noted on the floor, blocking the ability to walk into the room. There was one stained ceiling tile in the hallway outside of this room.

11:15 am restroom across from nurse's station: one dead bug was observed in the ceiling light and there was a ceiling vent covered in what appeared to be dust.

11:20 am room labeled Full Cylinder Storage: the door to this room was found to be unlocked. The entrance to the room was blocked by what appeared to be a delivery of clean supplies that included a mixture of shower caps, bedpans, and cups. The room stored clean and sterile supplies, oxygen cylinders, cleaning agents, intravenous fluids, and clean linen. There were cobwebs and dust noted in the room. There were what appeared to be sterilely packaged colostomy bags and wafers. These were not dated and appeared to have crumb-like materials in the package and a broken rubber band. The cleaning agents were stored above clean supplies and included hydrogen peroxide and germicidal wipes. Supplies were not stored off the floor in a manner that would allow for cleaning of the floor. Temperature and humidity were not monitored for this room. Clean linens were noted to be uncovered.

At the time of the observations, EMP1 and EMP3 confirmed the above findings.

2. On May 22, 2023, at 11:40 am, a tour of the Out-Patient area was conducted with EMP9. The following findings were observed:

In the 1st floor outpatient lounge, there was an open screenless window. The windowsill had a gritty black substance. There was a table with a gritty black substance. The wall in the corner of this room had bubbling plaster and paint.

In the 2nd floor outpatient lounge, the wallpaper was stained around window frame. The windowsill had a gritty black substance. The table had a visible dust accumulation on hand swipe.

The above was confirmed at the time of the observation by EMP9.

3. At 11:55 am a tour of the Chapel revealed black chunks on all the chairs and floor, appearing to be coming from the air conditioner.

EMP9 confirmed this at the time of the observation.

4. On May 22, 2023, at 1:05 pm, a tour of 1 West BH Unit " Tranquility" was conducted with EMP1. The unit is a 17-bed unit. The following findings were observed:

The IT room had visible clumps of dust and coins lying on the floor.

The men's bathroom off the corridor revealed a toilet with visible residual brown substance, and there was no available toilet paper.

The soiled utility room 117 contained multiple bags of garbage, some overflowing, some sitting on the floor.

The above was confirmed by EMP1 at the time of this observation.

5. On May 22, 2023, at approximately 12:20 PM - 1:15 PM, a tour of the Emergency Department with EMP1, EMP2, EMP3 and EMP10 revealed the following:

The hallway walls in the Emergency Department had visible dirt and chipped paint. The handrails in the hall had dust and the floors had dirt and dark colored smudge marks. The garbage can in the patient bathroom had overflowing paper towels. There was trash in the can overflowing onto the bathroom floor.

The entrance to the Emergency Department from within the hospital had an exposed doorway ledge, approximately one inch in height, on the floor adjacent to a black mat.

At the time of observation EMP1, EMP2, EMP3, and EMP10, confirmed the above findings.

Based on a review of facility policies, tour of the facility, and interview with facility staff (EMP), it was determined the facility failed to ensure that proper temperature was maintained in the Full Cylinder Storage where sterile supplies were stored; failed to ensure proper temperature controls for refrigerated medications in the OR suite in accordance with hospital policy; and failed to ensure that ventilation systems were routinely assessed for the operating suite and associated areas.

Findings include:

1. On May 23, 2023, review of facility policy titled "Monitoring Temperature and Humidity," last dated 1/2023, revealed "... The policy is compliant with Guidelines for Design and Construction of Health Care Facilities (2010) and the National Fire Protection Agency (NFPA) 99 Standards for Healthcare Facilities. ... To provide a stable environment for the storage of sterile supplies ... Temperature and humidity will be monitored daily. ...".

The policy did not address what temperature and humidity for storing sterile supplies.

On May 22, 2023, at 11:20am, a room labeled "Full Cylinder Storage" was inspected on the third-floor medical surgical unit. Upon inspection, the room was found to store sterile supplies.

On May 22, 2023, at 11:20am, EMP1 and EMP3 confirmed that the room was not monitored for temperature and humidity.

At the time of the observations, EMP1 and EMP3 confirmed the above findings.

2. Review on May 23, 2023, at 10:00 AM, of the facility's "DRUG STORAGE AREA INSPECTIONS" policy, last reviewed 1/25/2023, revealed "... Policy... 9. ... Departments that are not opened on a seven day work schedule that have refrigerators, freezers, and warmers (if applicable) where medications are stored throughout the hospital shall have the temperatures checked every day that the department is opened. The temperature of the medication refrigerators, freezers, and warmers (if applicable) in these departments shall be monitored by a digital thermometer with the capability of holding the past temperature in memory. On the first day these departments reopen, the temperature that is stored in the memory will be checked and recorded...".

During a tour of the OR suite on May 22, 2023, at approximately 12:20 PM, the medication refrigerator located in the corridor of the OR Suite was observed to contain the following medications: Succinylcholine, Rocuronium, and Duovisc (an ophthalmologic solution which is used for eye surgeries). A "MEDICAL TEMPERATURE RECORD" was secured to the refrigerator.

Review of the Medical Temperature Record revealed "... UNIT/LOCATION Operating Room MONTH/YEAR May 2023. ...1. Check thermometer each day, Graph temperature, Record Time and Initials 2. Record Action taken to correct & Temperature variations outside appropriate ranges. 3. Return this completed monthly record to Pharmacy for reporting to QA. ...".

On May 22, 2023, at approximately 12:22 PM, the Medical Temperature Record was reviewed with EMP8 who confirmed there were no temperature recordings documented on the following weekend days during May 2023: May 6, 2023, May 7, 2023, May 13, 2023, May 14, 2023, May 20, 2023, and May 21, 2023. When asked why temperature recordings were not documented on the above dates, EMP8 explained there is no OR staff present on weekends.

On May 23, 2023, at approximately 11:00 AM, EMP11 also confirmed there were no temperature readings recorded on the above weekend days.

3. Review of facility policy "Monitoring Temperature and Humidity ... Dept: Operating Room ... Date: 1/24/2023...," revealed "... PURPOSE: ... The policy is compliant with guidelines for Design and Construction of Healthcare Facilities (2010) ...".

When asked for most recent ventilation survey reports for the operating suite and its associated areas, EMP6 provided Test and Balance Reports dated March 5, 2020, and October 5, 2020.

During an interview with EMP6 on May 24, 2023, at approximately 8:40 AM, EMP6 confirmed the building HVAC systems should be assessed annually, and the last assessments were conducted on March, 2020 and October, 2020.

Based on a review of facility documents, credential files (CF) and staff interview (EMP), it was determined the facility failed to properly credential surgical staff responsible for the oversight of Certified Registered Nurse Anesthetists (CRNA) in 3 of 3 credential files (CF1, CF3, and CF9).

Findings include:

On May 24, 2023, a review of the Highlands Hospital-Surgical Division of the Medical Staff, Rules and Regulations (Adopted: January 25, 2023) revealed " ... 40. A certified Registered Nurse Anesthetist (CRNA) administering general, regional, spinal and monitored anesthesia must be supervised either by the operating practitioner who is performing the procedure, or by an anesthesiologist who is immediately available. 41. The operating practitioner may supervise a CRNA under the following criteria: Bullet One- The operating practitioner is granted privileges for the case he/she is supervising. Bullet Two- The operating practitioner may supervise the following type of anesthesia: General, Regional, Spinal, and Monitored Anesthesia Care. 42. The responsibility of supervising, operating practitioner included the following: Bullet One: Determine that the patient is an appropriate candidate to undergo the planned procedure and anesthesia based on the Certified Registered Nurse Anesthetist (CRNA) pre anesthesia evaluation and the patient's medical record. Bullet Two: Remain physically available in the Operating Room suite, room, or corridor for the immediate diagnosis and treatment of emergencies. Bullet Three: Determine that the patient can be discharged from the PACU following the procedure with appropriate post-op anesthesia evaluation. "

On May 23, 2023, a review of the delineation of privileges for CF1, CF3, and CF9, revealed there was no delineation of privileges related anesthesia care or the oversight of the CRNA for general anesthesia, regional anesthesia, spinal anesthesia or monitored anesthesia care.

There is no anesthesiologist on staff. Thus, supervsion and oversight of the CRNA is the responsibility of the operating surgeon.

The above findings were confirmed during an interview with EMP12 and EMP 13 on May 23, 2023, from 12: 30pm to 1:00pm.

Based on review of facility policies, medical records (MR), and interview with facility staff (EMP), it was determined the facility failed to ensure post anesthesia evaluations were completed by an individual qualified to administer anesthesia for two of four surgical medical records reviewed (MR7 and MR10).

Findings include:

On May 24, 2023, review of the facility policy "PATIENT POST ANESTHESIA CARE," last dated 06/2017, revealed "... 2. Postoperative Evaluation: All postoperative patients will receive a post-anesthesia evaluation...".

On May 24, 2023, review of MR7, date of service 5/12/23, revealed the "Post Anesthesia Evaluation" was not completed.

On May 24, 2023, review of MR10, date of service 3/17/23, revealed the "Post Anesthesia Evaluation" was not completed.

On May 24, 2023, at 5:00 pm, EMP8 confirmed that section was to be completed by the anesthesia provider. At this time, EMP8 also confirmed the above findings.