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Based on interview and record review, the facility's Governing Body failed to ensure that the contracted services for the Medical Director of Laboratory Services was in substantial compliance. This failure had the potential to cause inadequate laboratory services oversight that could lead to poor patient outcomes. The facility census was 14.

Findings included:
Review of the facility's document titled, "Professional Services Agreement," dated 12/05/15, showed that the facility entered into an independent contractor relationship agreement with Staff FF, for the services of Laboratory Services Medical Director.

Review of the facility's undated document titled, "Laboratory Director Job Description," showed that the Laboratory Director responsibilities included:
- Provided in-service educational programs for laboratory personnel.
- Medical staff functions.
- Laboratory Quality Assurance Program.
- Participated in committees that reviewed tissue, infection control, and blood usage.
- Reported monthly evaluation and recommendations of laboratory services to facility administration.
- Supervised all laboratory staff.

During an interview on 04/22/19 at 5:00 PM, Staff A, Laboratory Manager, stated that Staff FF was the facility's contracted Laboratory Services Medical Director.

During an interview on 04/22/19 at approximately 6:00 PM, Staff EE, Interim Chief Executive Officer (CEO), stated that Staff FF was the contracted Laboratory Services Medical Director; however, "he would have to be replaced".

Review of facility-provided documents dated 02/22/19, 02/26/19, and 03/25/19, showed copies of emails exchanged between Staff A, Laboratory Manager, and an account executive (Person #1) with a laboratory services company (Company #1). In response to Staff A, Person #1 indicated that Company #1 was interested to provide medical directorship services for the facility's laboratory, the approximate monthly cost for services to be provided, and that the facility "would have support and a monthly visit" included in the monthly cost.

Although requested from the facility, specific information that included employment status at the time of survey entrance, the number of hours worked onsite the previous three months, if the required duties of the agreement were fulfilled, and the most recent dates that each of the required services were provided to the facility by Staff FF, per the Professional Services Agreement, no information was provided by the facility.

Based on interview, record review and policy review, the facility failed to ensure that staff provided the initial Important Message from Medicare (IM, information about a patient's right to appeal discharge) and ensure it was signed, dated, and placed in the patient's medical record upon admission, but not longer than two calendar days after admission, for two patients (#11 and #12) of three current Medicare patients' medical records reviewed. This failed practice had the potential to affect all Medicare eligible patients' ability to be informed of their right to appeal discharge. The facility census was 14.

Findings included:

1. Review of the facility's policy titled, "Medicare Important Message, Medicare Beneficiary Notification of Discharge Appeal Rights," reviewed 10/23/14, showed that:
- Inpatient Medicare beneficiaries (patients) had a statutory right to appeal when a hospital, with physician concurrence, determined that inpatient care was no longer necessary.
- Hospitals must use the Important Message from Medicare (IM) to explain the inpatient Medicare beneficiary's rights, including discharge appeal rights.
- The beneficiary or their representative must sign the IM and a copy must be provided.
- The Registration Department would issue the IM upon admission, but not later than two calendar days from admission.
- A copy of the signed notice would be placed in the patient's medical record.

A concurrent review of Patient #11 and #12's medical records on 04/23/19 at 10:00 AM, showed:
- Both patients were Medicare beneficiaries;
- The patients were admitted to the facility on 04/19/19 and 04/16/19, respectively; and,
- There was no evidence that an initial IM was provided to either patient or their representative(s) upon admission or within two calendar days.

During an interview and concurrent record review of Patient #11 and #12's medical records on 04/23/19 at 10:05 AM, Staff H, Registered Nurse (RN), stated the IMs were not present in either medical record. Staff H contacted Staff J, Utilization Review, and requested the patients' medical records be reviewed. Staff H verbally confirmed to Staff J that the IMs were not present in the medical records.

During an interview and concurrent record review of Patient #1 and, #12's medical records on 04/23/19 at 10:07 AM, Staff J, Utilization Review, stated that IMs are completed by the Registration Department upon admission and by the Utilization Review Department two days prior to discharge. Staff J confirmed the IMs were not present in the medical records.

During an interview and concurrent record review of Patient #11 and #12's medical records on 04/23/19 at 10:25 AM, Staff K, Registration Supervisor, stated the IMs were not present in the medical records as they should have been upon admission.

Based on observation, interview, and policy review, the facility failed to ensure that patient privacy and confidential health information was protected when Staff L, Certified Nurse Assistant (CNA), informed the visitor of one patient (#11) of a third person's previous inpatient admission to the facility, and a computer terminal was not logged off allowing full access to patient information. These failed practices had the potential to affect all patients admitted to the facility by revealing personal patient information to the public. The facility census was 14.

Findings included:

1. Review of the facility's policy titled, "Privacy Policy," dated 04/14/03, showed that:
- The purpose of the policy was to ensure that personal health information was protected.
- All employees and persons associated with the facility were responsible to protect all personal health information that was obtained, handled, learned, heard, or viewed in the course of his/her work or association with the facility.
- Use and disclosure of personal health information was acceptable only in the discharge of one's responsibilities and duties and based on the need to know.

Observation on 04/23/19 at 11:05 AM, showed Staff L, CNA, and Patient #11's visitor, engaged in a personal conversation near the nurses' station in the Intensive Care Unit. Over the course of the conversation, Staff L stated to the visitor that a third person had previously been a patient at the facility.

During an interview on 04/25/19 at 1:05 PM, Staff L, CNA, stated that staff were not to disclose who (patients or visitors) came in and out of the facility. Staff L stated if asked or called, staff were never to disclose if someone was a patient, and stated the requestor should be referred to the charge nurse or the house supervisor. Staff L further stated that staff and/or the facility could be fined if they violated the Health Information Portability and Accountability Act of 1996 (HIPAA, a law designed to provide privacy standards to protect patients' medical records and other health information provided to health plans, doctors, hospitals, and other health care providers).

During an interview on 04/25/19 at 1:12 PM, Staff CC, Registered Nurse (RN), Assistant Chief Nursing Officer (ACNO), stated the expectation was that patient information would not be given out inappropriately and that discussions would only occur if appropriate and on a "need to know basis."

2. Review of the facility's undated policy titled, "Administrative Safeguards - Risk Analysis," showed the facility will conduct an annual assessment to identify the threats to the confidentiality, integrity and availability of electronic protected health information within the facility.

Observation on 04/23/19 at 9:00 AM, on the Medical/Surgical Unit, showed a computer terminal located in the main hallway across from the nurse's desk. A nurse documented patient care in the electronic medical record at the computer terminal, with the screen clearly visible. The nurse left the computer terminal area, and did not log out of the computer.

During an interview on 04/23/19 at 9:00 AM Staff R, Compliance Officer, stated that the nurse should have logged out before she walked away from the terminal.

Based on interview and record review, the facility failed to ensure the Medical Staff conducted periodic appraisals, re-appraisals and peer review for nine staff physicians (FF, GG, HH, II, JJ, KK, LL, MM, and NN) and failed to ensure documentation of continuing education for four staff physicians (GG, HH, LL, and MM) of nine physician credentialing files reviewed for credentialing/recredentialing. This deficient practice had the potential to allow physicians to provide patient care outside of acceptable professional standards as determined by the Medical Staff. The facility census was 14.

Findings included:

1. Record review of credentialing files (files used in the process to verify qualifications, and ensure current competence) for Staff FF, GG, HH, II, JJ, KK, LL, MM, and NN, Physicians, showed none of the nine had documented periodic Medical Staff appraisal of the patient care each had provided, and Staff GG, HH, LL, and MM did not have continuing education documentation.

During an interview on 04/24/19 at 10:00 AM, Staff PP, Medical Staff Coordinator, and Staff OO, Chief Executive Officer (CEO) confirmed the following:
- That the facility did not have policies and procedures that directed the credentialing process (process used to request and grant clinical privileges);
- None of the current members of the Medical Staff had documented, periodic appraisals of the patient care each had provided.
- Continuing education is part of the credentialing process and copies of that education should be in all the physician files.
- The facility does not have a Peer Review (the evaluation of work by one or more people with similar competences as the producer of the work) Process for Medical Staff.

Based on observation, interview, record review and policy review, the facility failed to:
- Ensure nursing staff consistently identified, treated, and documented skin and wound care for one current patient (#11) of one current patient with wounds reviewed;
-Provide an Interdisciplinary Plan of Care (care plan) for three current patients (#13, #15, #21) of eight current patients reviewed;
- Provide an updated individualized care plan for five current patients (#1, #3, #6, #11, and #12), of eight current patients reviewed;
- Obtain physician orders for wound care for one current patient (#11) of one current patient reviewed;
- Obtain physician orders for restraints for three discharged patients (#25, #26, and #27) of five discharged patients reviewed.
These failures had the potential to lead to negative outcomes for patients through the development of wounds or deterioration of existing wounds and patients with restraints, and could affect all patients in the facility.
The facility census was 14.

The severity and cumulative effect of these systemic failures resulted in non-compliance with 42 CFR 482.23 Condition of Participation: Nursing Services.

Refer to 2567 for details.


39841




39563

Based on observation, interview, record review and policy review, the facility failed to ensure nursing staff consistently identified, treated, and documented skin and wound care, and failed to obtain a physician order for wound care for one current patient (#11) of one current patient with wounds reviewed. These failures had the potential to lead to negative outcomes for patients through the development of wounds or deterioration of existing wounds and could affect all patients in the facility. The facility census was 14.

Findings included:

1. Review of the facility's policy titled, "Documentation of Daily Skin Assessment, Impaired Skin Integrity (injured skin), and Pressure Ulcers (pressure injury, injury to the skin and/or underlying tissue, usually over a bony area)," revised 02/2014, showed the following directives:
- It is the responsibility of all licensed nursing staff to document a daily skin assessment on all patients;
- Describe in detail the location, size, stage (numerical number directly related to the depth and involvement of the wound), color, drainage, odor, and any other distinguishing factors;
- Describe the precise location of the wound in anatomical terms; and
- Measure the wound daily, or with dressing changes; be sure to include width, length, and depth and include shape of the wound.

Review of the facility's policy titled, "Verbal and/or Telephone Physician Orders," revised 11/2013, showed that the individual accepting the verbal order must record and then read back the order in it's entirety to the prescribing physician at the time the order is given, documenting that the order was received and read back.

Observation on 04/23/19 at 1:30 PM showed Patient #11's right foot covered with a foam dressing and secured with an elastic wrap.

Review of Patient #11's medical record on 04/23/19 at 4:05 PM, showed on 04/20/19, a pressure injury was identified on her right outer foot near the bunion area (a bony bump on the joint at the base of the big toe). A dressing was applied, but there was no documentation of physician notification, no treatment orders written and no documented assessment of the wound.

During an interview on 04/23/19 at 1:45 PM, Staff AA, RN, stated that she had discovered the wound when removing the patient's sock, but had failed to complete an assessment on the area. She stated that she called the physician on 04/20/19, received a phone order for a foam dressing, but had failed to write the order.





















39563

Based on observation, interview, record review and policy review, the facility failed to develop comprehensive, individualized care plans based on the assessment of patient needs for five current patients (#11, #12, #13, #15 and #21) of eight current patients reviewed and failed to provide an updated individualized care plan for three current patients (#1, #3, and #6) of eight current patients reviewed. This failed practice had the potential to affect all patients admitted to the facility by not meeting individual needs of the patient. The facility census was 14.

Findings included:

1. Review of the facility's policy titled, "Patient Plan of Care," revised 11/2014 showed:
- It was the responsibility of all nursing personnel to participate in the development and implementation of the patient plan of care (care plan).
- Nursing personnel would utilize the nursing process to develop the multi-disciplinary plan of care for each patient admitted to the facility.
- Nursing personnel would initiate the plan of care at the completion of the admission assessment as a measurable, outcome-based, collaborative effort with the medical staff and other health team members.
- A patient's plan of care would be initiated within 12 hours of admission.
- Nursing personnel would update the plan of care as necessary during the course of the hospital stay.

Review of Patient #1's medical record on 04/23/19 at 10:00 AM, showed the patient was a 73 year old female admitted to the facility on 04/18/19 at 4:10 PM, with a diagnosis of hypokalemia (a low level of potassium [a mineral that helps regulate fluid balance, muscle contractions and nerve signals] in the blood). A care plan had been initiated for Patient #1 which only addressed the risk of falls. The care plan had not been updated since 04/19/19 at 4:46 AM and the diagnosis of hypokalemia had not been addressed.

Review of Patient #3's medical record on 04/23/19 at 9:30 AM, showed the patient was a 72 year old female admitted to the facility on 04/16/19, and had a diagnosis of congestive heart failure (CHF, where the heart muscle doesn't pump blood as well as it should), and lower left leg cellulitis (an infection of the skin). A care plan was not initiated for Patient #3 until 04/19/19 at 8:59 AM for the problem of "Ineffective Airway Clearance". The care plan had not been updated since 04/19/19 and the issue of cellulitis had not been addressed.

Review of Patient # 6's medical record on 04/24/19 at 10:30 AM, showed the patient was a 63 year old male admitted to the facility on 04/15/19 at 4:05 PM, and had a diagnosis of respiratory failure (RF, a condition in which not enough oxygen passes from the lungs into the blood). A care plan had been initiated on 04/16/19 at 4:49 AM, but had not been updated since 04/16/19 and only addressed Ineffective Airway Clearance.

Review of Patient #11's medical record on 04/23/19 at 4:05 PM, showed the patient was admitted to the facility on 04/19/19, and had diagnoses of bradycardia (abnormally slow heart rate), beta blocker (a type of drug used to treat high blood pressure) toxicity (overdose), and a gastrointestinal bleed (all forms of bleeding in the gastrointestinal tract, from the mouth to the rectum), which required a blood transfusion (to administer blood into a vein) on the morning of 04/23/19. Patient #11 was ordered a mechanical soft diet (food that requires little to no chewing), she had wound dressings to her left and right heels and right forearm, she had sutures (thread-like material used to sew tissue together) to her right hand, both hands were wrapped in gauze. She was ordered nebulizer (a device that turns liquid medication into a mist for inhalation into the lungs) treatments three times daily, and she was ordered blood glucose (blood sugar) testing every four hours. On 04/20/19, a day after her admission, when removing her sock, a pressure injury (injury to the skin and/or underlying tissue, usually over a bony area) was identified on her right outer foot near the bunion area (a bony bump on the joint at the base of the big toe) and a dressing was applied. A care plan was not initiated until 04/23/19 at 12:06 PM, and the wound was not addressed in the care plan. The care plan also indicated that a specific foam dressing used to absorb wound drainage should be applied to the patient's heels, but there were no wounds on the patient's heels.

Review of Patient #12's medical record on 04/23/19 at 4:07 PM, showed the patient was admitted to the facility on 04/16/19, and had a diagnosis of gastrointestinal bleed. Patient #12 had a nasogastric tube (soft, flexible tube inserted through the nostril and into the stomach to remove contents, or instill fluids, liquid nutrition, or medication) that was discontinued on 04/17/19. She had an intravenous (IV, in the vein) catheter (small, flexible tube inserted into a vein through the skin to deliver medications or fluids into the bloodstream) and was ordered a blood transfusion on 04/17/19 and 04/22/19 in the morning, and again on 04/22/19 in the evening, and was ordered IV antibiotic (a drug used to treat bacterial infections) therapy (treatment). Patient #12's care plan was not initiated until 04/23/19 at 12:09 PM, and only addressed the potential for injury related to falls and restraints.

Review of Patient #13's medical record on 04/23/19 at 4:05 PM, showed the patient was admitted to the facility on 04/21/19, and had a diagnosis of muscle weakness and metabolic syndrome (a group of risk factors that raises the risk of heart disease and other health problems, such as diabetes and stroke). Patient #13 had an IV catheter, and was ordered an IV antibiotic (a drug used to treat bacterial infections) therapy (treatment) and blood glucose (blood sugar) testing. Patient #13 was developmentally delayed (failure to meet certain developmental milestones) and unable to follow simple commands. A care plan had not been initiated for Patient #13.

Review of Patient #15's medical record on 04/23/19 at 10:00 AM, showed the patient was a 57 year old male admitted to the facility on 04/21/19, and had a diagnosis of pneumonia. A care plan had not been initiated for Patient #15.

Review of Patient # 21's medical record on 04/24/19 at 10:15 AM, showed the patient was a 55 year old female admitted to the facility on 04/22/19 at 7:30 AM, and had a diagnosis of GI bleed. A care plan had not been initiated for Patient #21.

During an interview on 04/24/19 at 4:30 PM Staff CC, Intensive Care Director, Medical/Surgical Director, and Assistant Chief Nursing Officer (CNO) stated that the care plan should be initiated on admission and updated with any changes. The care plan should address all areas of the patient's care.



39089




39563

Based on record review, and policy review, the facility failed to ensure staff followed facility policy when they failed to ensure verbal and telephone orders were signed by the prescribing practitioner within 48 hours as evidenced by lack of documentation for two current patients (#11 and #12) and one discharged patient (#29) of three patients' records reviewed on the Intensive Care Unit (ICU, a unit where the more critically ill patient is cared for). This failed practice had the potential to affect all patients admitted to the facility and placed them at risk for miscommunicated orders which could ultimately result in medication and/or medical errors. The facility census was 14.

Findings included:

Review of the facility's policy titled, "Verbal and/or Telephone Physician Orders," revised 11/2013, showed that verbal and telephone orders should be signed by the prescribing practitioner within 48 hours.

Review of Patient #11's medical record on 04/25/19 at 1:30 PM, showed the following orders were not signed by the prescribing practitioner:
- Verbal order dated 04/22/19 at 7:00 AM;
- Telephone order dated 04/22/19 at 8:45 AM;
- Telephone order dated 04/22/19 at 2:10 PM; and,
- Telephone order dated 04/22/19 at 6:30 PM.

Review of Patient #12's medical record on 04/25/19 at 1:30 PM, showed the following orders were not signed by the prescribing practitioner:
- Telephone order dated 04/17/19 at 2:20 PM;
- Verbal order dated 04/22/19 at 8:20 AM;
- Telephone order dated 04/22/19 at 5:30 PM;
- Verbal order dated 04/22/19 at 5:30 PM; and,
- Telephone order dated 04/23/19 at 7:00 AM.

Review of Patient #29's medical record on 04/25/19 at 1:30 PM, showed two telephone orders that were not signed by the prescribing practitioner, dated 03/25/19 and 03/28/19.

Based on observation, interview, and policy review, the facility failed to ensure medications were kept locked and secured to prevent access by unauthorized persons in the Operating Room (OR). The facility census was 14.

Findings included:

1. Record review of the facility's policy titled "Pharmaceuticals: Storage and Handling" revised on 05/2014, showed that anesthesiology carts located in the OR, or any other anesthesia location, will be kept locked when unattended. The anesthesia provider is responsible for locking the cart.

Observation on 04/24/19 at 10:30 AM of the OR, following a surgical procedure, showed an unlocked anesthesia cart which was left unattended while the room was cleaned. The cart contained numerous medications such as antibiotics, antihypertensive medications (medication to lower blood pressure), intravenous (IV, in the vein) fluids, paralytics (medications that prevent voluntary movement), anesthesia agents (medications used to induce sleep during surgery), and analgesics (medications that treat minor aches and pains and reduce fever).

Observation on 04/24/19 at 10:45 AM, showed Staff V, Certified Registered Nurse Anesthetist (CRNA) and Staff W, Student Registered Nurse Anesthetist (SRNA), leave the room. When they exited the room, they failed to lock and secure the unsupervised anesthesia cart.

During an interview on 04/24/19 at 10:45 AM, Staff V, CRNA, stated that he usually locked the anesthesia cart when he left it unsupervised between surgical cases.

Based on interview, the facility failed to routinely inspect and properly maintain radiation (the use of energy waves to diagnose or treat disease) shielding (blocking) devices, which included lead apron shields (a protective measure against the harmful effects of radiation exposure), glove shields, and thyroid (a large gland in the neck that secretes hormones that regulate growth and development) shields. This deficient practice had the potential for use of shielding devices that no longer maintained functional integrity (soundness, whole) and subsequent, unintentional radiation exposure. The Radiology Department averaged 224 inpatient procedures and 1,300 outpatient procedures per month. The facility census was 14.

Findings included:

1. Although requested, the facility was unable to provide a log that verified personal shielding devices were properly maintained and routinely inspected.

During an interview on 04/24/19 at 3:10 PM, Staff BB, Radiologic Technologist (RT, medical personnel who perform X-ray and X-ray like examinations and administer specialized cancer therapy treatments), Radiology (a variety of medical imaging/x-ray techniques used to diagnose or treat diseases) Director, stated the following:
- The Radiology Department did not have a schedule that routinely inspected and maintained personal shielding devices.
- The Radiology Department did not have a log that tracked or verified when routine inspections and maintenance of personal shielding devices were completed.
- The facility did not have a written policy or procedure that directed staff to routinely test shielding devices.

Based on observation, interview, record review and policy review, the facility failed to ensure that staff:
- Maintained a clean and safe environment in the Emergency Department (ED), the Medical/Surgical (Med/Surg) Unit, the Intensive Care Unit (ICU), and the Dietary Department by failing to make necessary repairs to equipment, walls, ceilings, floors, doors and trim to reduce hazards and ensure that the condition of the overall hospital environment was maintained in a manner to ensure the safety and well-being of patients.
- Maintained or replaced ceiling tiles that were soiled/stained throughout those units observed with missing ceiling tiles, large holes in the ceiling tiles, and soiled/stained ceiling tiles.
- Performed the necessary environmental repairs throughout those units observed for holes in walls, paint chippings, stains on walls that were not painted, baseboards along floor that were separated from the wall's edges, and dirty areas along the floor edges.
- Performed the necessary cleaning for dead bugs that were lying in the floor of the cabinet located on the Med/Surg unit.
- Performed the necessary cleaning and/or replacing of intravenous (IV) poles in the ED that had rust at the bottom of the poles.
- Performed the necessary repairs in the ED waiting room observed for holes in the walls, dirty/stained ceiling tiles, stains on the walls that were not painted, and dirty/stained floor.
- Performed the necessray repairs on equipment in the dietary department used to store, prepare, and serve food that was taken out of service and reported to maintenance for repair.

Due to the widespread and cumulative effect of these deficient practices, and without necessary repairs to the physical environment that directly affected the safety and well-being of patients, staff and visitors, it was determined that 42 CFR 482.41 Condition of Participation: Physical Environment was out of compliance. The facility census was 14.

Refer to 2567 for details.


39563

Based on observation, interview, record review and policy review, the facility failed to ensure that staff maintained a clean and safe environment in the Emergency Department (ED), the Medical/Surgical (Med/Surg) Unit, the Intensive Care Unit (ICU), and the Dietary Department, by failing to clean and replace or make necessary repairs to equipment, walls, ceilings, floors, doors and trim, to reduce hazards and ensure that the condition of the overall hospital environment was maintained in a manner to ensure the safety and well-being of patients. This deficient practice allowed for unsanitary and potentially hazardous conditions in the hospital, and could affect all patients, visitors and staff. The facility census was 14.

Findings included:

1. Review of the undated "Purpose Page" for the Infection Control program showed that:
- The purpose of an organized Infection Control Program is to ensure the well-being of patients, visitors, and staff.
- All levels of hospital management and employees have a primary responsibility for the health and well-being of all patients, visitors, and staff.
- The Infection Control Nurse and the Infection Control Committee will consistently enforce all rules and regulations, and be alert for unhealthy conditions and take appropriate actions to correct the problem.

Review of the facility's policy titled, "Emergency Room (ER, also known as ED) Infection Control," revised 05/2014, showed that:
- The ER constitutes an area where patients with undiscovered infections arrive and are examined.
- It is the responsibility of all nursing personnel assigned to the ER to abide by these infection control guidelines.
- All equipment should be cleaned after each patient use.
- ER personnel shall comply with the infection control program.

Review of the facility's policy titled, "Instructions for Cleaning Pumps and Poles," revised 11/2010, showed that:
- Housekeeping or nursing can clean poles.
- Housekeeping will clean the poles with a damp cloth daily.
- If the base of the poles are rusty, send them to maintenance to have rust removed.

Review of an undated policy titled, "10-5 Rule," showed that cleanliness is everyone's job and that holes in walls, cracked tiles, stained ceilings, and rusted fixtures should be reported to maintenance.

Review of the facility's policy titled, "Housekeeping Infection Control," revised 04/2015, showed:
- The housekeeping department is responsible for providing a clean, sanitary environment for the patients and employees throughout the institution.
- To thoroughly clean all areas of traffic, including patient areas and corridors.
- Utility rooms, nourishment stations, treatment rooms, service areas, medicine rooms, diet kitchens, and pantries should be cleaned.
- To clean sinks, hoppers, cabinets, cupboards, ice makers, and refrigerators.
- Corridors, lobbies, and waiting rooms should be thoroughly cleaned.
- ER should be cleaned seven days per week.
- To clean walls and ceilings throughout the facility.

Review of the facility's policy titled, "Maintenance Infection Control," revised 05/2015, showed that:
- The maintenance department shall make every effort to provide a clean and safe environment for patients, visitors, and employees.
- The maintenance department will maintain all walls and ceilings needing repair.
- Ceiling panels will be replaced as needed and peeling wall surfaces will be repaired to provide a sanitary environment.

Observation on 04/22/19 at 3:15 PM in the ED, showed IV poles stored in a patient area with brown rust on bottom of poles, discolored and broken ceiling tiles throughout the ED area, and walls with unpainted areas. The waiting area for the ED had dirty,stained floors, broken dirty ceiling tiles, holes in the walls, and unpainted areas on the walls.

Observation on 04/23/19 at 1:30 PM, in patient room number 216, showed holes in the walls, broken and stained ceiling tiles and a dirty floor.

Observation on 04/23/19 at 1:45 PM, in hallways and common areas of the med/surg unit showed multiple ceiling tiles were discolored and some were broken. Walls had unfinished areas of repair and unfinished painted areas, and the floors were discolored and dirty, especially around the baseboards.

2. Review of the undated facility's infection control policy titled, "Dietary Department", showed the dietary department personnel will clean and monitor all equipment and items used in meal production and service to ensure sanitary and safe conditions for all served in the facility. All coolers and freezers will be monitored daily and temperatures recorded. If temperatures are out of range, maintenance will be notified to inspect and make repairs or schedule service as needed.

Observation on 04/22/19 at 3:30 PM in the Dietary Department coolers showed:
- The cooling unit fans were covered in dirt and blew dirt over the food.
- The doors to the coolers did not close all the way.
- The steamer door did not close all the way and would not get hot enough to steam the food.

Observation and concurrent record review on 04/22/19 at 3:45 PM in the Dietary Department freezers showed:
- Frozen meat was not labeled and no dates were on the packages.
- The cooling unit fans were covered in dirt and blew dirt over the food.
- On the ceiling of the freezers there were areas that had thawed, dripped water and refroze.
- Food stored in the original card board boxes they were shipped in, and had been wet from the water that had dripped from the ceiling and refroze.
- The staff documented temperatures did not show any temperatures above zero, and there was no documentation that there had been a problem with the freezers' temperatures.
- The door to the freezers did not close all the way and one did not latch at all.

Observation on 04/22/19 at 4:15 PM in the Dietary Department showed:
- The patient ice machine had black debris inside and had not been cleaned since January 2019.
- The staff and visitors ice machine had black debris inside and had not been cleaned since September 2018.
- The double fryer had leaked oil onto the floor and staff had placed a folded cardboard box on the spill to keep anyone from walking in it.
- The steamer door did not close all the way and would not get hot enough to steam the food.

During an interview on 04/22/19 at 4:00 PM, Staff EE, Dietary Manager, stated that:
- She knew the coolers and freezers did not close tight and she had put in a request to maintenance to get them fixed.
- She did not know when the freezers had thawed but sometimes they got warm when staff went in and out of them during the day.
- She was not aware they should have documented problems with the coolers and freezer temperatures.
- She had called maintenance concerning the issues with the deep fryer and the steamer, but had not gotten a response from them, and could not remember when she had called them.

Observation on 04/23/19 at 8:45 AM on the Med/Surg Unit showed the following:
- In the Nourishment Room there were dead bugs on the shelf under the sink.
- In the Clean Utility Room there were cardboard boxes stored under the sink and they had been wet.
- All of the storage areas under the sinks on the unit were soiled, had boxes stored under them and those boxes were soiled from being wet.

During an interview on 04/25/19 at 3:50 PM, Staff DD, RN, Infection Control, stated her expectations would be that:
- Ceiling tiles would be replaced when stained or broken.
- Walls would be cleaned, repaired and painted.
- Floors would be cleaned.
- Cabinets would be cleaned with no dead bugs found in them.
- Dietary would clean dirty carts, dirty blinds, greasy equipment, and dirty floors.
Staff DD also stated that physical environment and infection control concerns related to paint chips, dirty baseboards, holes in the walls, and stained and broken ceiling tiles had been discussed in the Quality Assurance and Performance Improvement (QAPI) meetings in the past. She also stated, "The Quality Nurse and I performed walk-throughs in dietary and made large amount of notes concerning dirty carts, dirty blinds, greasy filthy equipment, nasty floors, and open food items not dated and discussed it with the dietary manager approximately two months ago." She stated the facility often had problems with bed bugs and roaches and they called pest control, but she would expect the dead bugs to be cleaned from cabinets.

During an interview on 04/25/19 at 4:30 PM, Staff EE, Interim Chief Executive Officer (CEO), shook her head in agreement when the physical environment and infection control concerns were discussed, and stated that she knew there were were environmental issues and needed repairs. She was not aware of the dead bugs in the cabinet.







39563

Based on observation, interview, and policy review, the facility failed to ensure staff removed outdated or expired supplies in the Intensive Care Unit (ICU, a unit where the more critically ill patient is cared for) and in the Laboratory. This failed practice had the potential to cause ineffective supplies to be used for patient care or to produce inaccurate test results. The facility census was 14.

Findings included:

Review of the facility's policy titled, "Accu-Check Inform II," reviewed 10/03/18, showed:
- Glucose control solutions, level 1 (low) and level 2 (high), were stable for three months from the opened date or until the manufacturer expiration date, whichever came first.
- The directive for facility staff to label the vial with the three-month expiration date (90 days from the date opened) or the vial's manufacturer expiration date, whichever came first.

Observation with concurrent interview in the Intensive Care Unit (ICU) on 04/23/19 at 9:35 AM, showed two glucose control solution vials (one low level and one high level) and one vial of test strips opened and without expiration dates written on the vials. Staff I, Registered Nurse (RN), Charge Nurse, confirmed expiration dates were not written on the vials.

Review of a facility-provided document titled, "Daily Chemistry MT/MLT Duties," dated 02/2009, showed it was the responsibility of the Med Tech (MT) or Med Lab Tech (MLT) to check all reagent volumes and replace reagents that would expire within 12-hours after the end of their shift.

Observation on 04/22/19 at 5:30 PM in the Laboratory, showed an expired multi-use vial of Enzyme Diluent, in the refrigerator available for use, with an open date of 03/05/19.

Observation on 04/22/19 at 5:35 PM in the Laboratory, showed two boxes of Flex Reagent Cartridge Gentamycin, with 20 cartridges each (40 cartridges total), in the refrigerator available for use, that expired 02/18/19.

During an interview on 04/22/19 at 5:35 PM, Staff A, Laboratory Manager, stated that part of the daily Med Tech or Med Lab Tech duties was to check for expiration dates and items were to be replaced that would expire within 12-hours. Staff A confirmed the supplies were expired.

Based on observation, interview, record review and policy review, the facility failed to ensure staff followed infection control policies and infection prevention standards when they failed to:
- Maintain a clean and safe environment in the Emergency Department (ED), the Medical/Surgical (Med/Surg) Unit, the Intensive Care Unit (ICU), and the Dietary Department.
- Perform environmental repairs throughout those units observing for holes in walls, chipping paint, stains on walls that were not painted, baseboards along floor that were separated from the wall's edges, dirty areas along the floor edges, missing ceiling tiles, large holes in the ceiling tiles, and soiled/stained ceiling tiles, dirty curtains that were broken and hanging from the curtain rods.
- Ensure that refrigerated and frozen food storage temperatures remained at a safe level.
- Ensure the dietary department, refrigeration and freezer air handlers were free of dust and debris.
- Ensure food items are stored in a manner to decrease the risk of cross contamination.
- Dispose of outdated foods and label open food containers in the kitchen coolers and freezers with date opened and beyond use date.
- Perform the necessary cleaning for dead bugs that were lying in the floor of the cabinet located on the Med/Surg unit.
- Perform the necessary cleaning and/or replacing of intravenous (IV, in the vein) poles in the ED that had rust at the bottom of the poles, and the Med/Surg Unit where was unknown fluid and dust on the pole and the stand.
- Follow the hand hygiene policy policy when administering an IV medication to one patient (#13) of one patient observed during IV medication administration.
- Ensure the ICU medication refrigerator was clean and free of debris.

The cumulative effect of these systemic failures resulted in the facility's non-compliance with 42 CFR 482.42 Condition of Participation: Infection Control and resulted in the facility's failure to ensure safe infection control practices to prevent infections and communicable disease. The facility census was 14.

Please refer to A-0749 for additional information.




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Based on observation, interview, record review and policy review, the facility failed to ensure staff followed infection control policies and infection prevention standards when they failed to:
- Maintain a clean and safe environment in the Emergency Department (ED), the Medical/Surgical (Med/Surg) Unit, the Intensive Care Unit (ICU), and the Dietary Department.
- Perform environmental repairs throughout those units observing for holes in walls, chipping paint, stains on walls that were not painted, baseboards along floor that were separated from the wall's edges, dirty areas along the floor edges, missing ceiling tiles, large holes in the ceiling tiles, and soiled/stained ceiling tiles, dirty curtains that were broken and hanging from the curtain rods.
- Ensure that refrigerated and frozen food storage temperatures remained at a safe level.
- Ensure the dietary department, refrigeration and freezer air handlers were free of dust and debris.
- Ensure food items are stored in a manner to decrease the risk of cross contamination.
- Dispose of outdated foods and label open food containers in the kitchen coolers and freezers with date opened and beyond use date.
- Perform the necessary cleaning for dead bugs that were lying in the floor of the cabinet located on the Med/Surg unit.
- Perform the necessary cleaning and/or replacing of intravenous (IV, in the vein) poles in the ED that had rust at the bottom of the poles, and the Med/Surg Unit where was unknown fluid and dust on the pole and the stand.
- Follow the hand hygiene policy policy when administering an IV medication to one patient (#13) of one patient observed during IV medication administration.
- Ensure the ICU medication refrigerator was clean and free of debris.
These failures had the potential to lead to negative outcomes for patients through the increased risk of cross contamination that placed all patients, visitors and staff at risk for infection. The facility census was 14.

Findings included:

1. Review of the facility's undated policy titled, "Dietary Infection Control", showed:
- Dish washing machine should be cleaned daily.
- Cooling and freezing units will be checked daily
- Floors, ceilings, and walls are the responsibility of the Housekeeping Department.
- Ceilings and walls will be cleaned bi-annually by the House keeping Department
- Spills and leaks will be the responsibility of the Housekeeping Department
- All ice machines are cleaned thoroughly on a quarterly basis.

Review of the facility's policy titled, "Departmental Personnel", dated 10/88, showed:
- In the first days of employment each new employee will be involved in the Dietary Orientation Program.
- Each employee is expected to participate in scheduled in-service programs.
- Each new employee is required to complete the new employee orientation on Infection Control and Fire safety within 30 days of employment.
- Each employee is required to complete the annual Infection Control and Fire Safety in-service.

Review of the undated facility's infection control policy titled, "Dietary Department", showed: The Dietary Department personnel will clean and monitor all equipment and items used in meal production and service to ensure sanitary and safe conditions for all served in the facility. All coolers and freezers will be monitored daily and temperatures recorded. If temperatures are out of range, Maintenance will be notified to inspect and make repairs or schedule service as needed.

Review of the facility's policy titled, "Housekeeping Infection Control", dated 05/2014 shows that the Housekeeping Department will clean the kitchen and kitchen storeroom seven days a week. They will dry mop and wet clean floors daily and clean walls and exterior of vents once per month.

Observation on 04/22/19 at 3:30 PM in the Dietary Department coolers showed:
- Expired Turkey and Ham slices for sandwiches;
- A container of cottage cheese labeled with three different dates (4/8, 4/19, and 4/22);
- A 25 pound container of boiled eggs that had been opened and had a use by date of 04/06/19;
- Shredded cheese with a use by date of 04/19;
- Large container of drink mix that had been reconstituted on 04/09/19;
- Food stored in the cooler in original cardboard boxes;
- The cooling unit fans were covered in dirt and blew dirt over the food; and
- The doors to the coolers did not close all the way.

Observation on 04/22/19 at 3:45 PM in the Dietary Department freezers showed:
- Frozen meat was not labeled and there were no dates on the packages.
- The cooling unit fans were covered in dirt and blew dirt over the food.
- On the ceiling of the freezers, there were areas that had thawed, dripped and refroze.
- Food stored in original card board boxes they were shipped in, had been wet from the water that had dripped from the ceiling and refroze.
- The staff documented temperatures did not show any temperatures above zero and staff did not document that there had been a problem with the freezers temperatures.
- The door to the freezers did not close all the way and one did not latch at all.

Observation on 04/22/19 at 4:15 PM in the Dietary Department showed:
- The patient ice machine had black debris inside and had not been cleaned since January 2019.
- Staff and visitors ice machine had black debris inside and had not been cleaned since September 2018.
- The double fryer had leaked oil onto the floor and staff had placed a folded cardboard box on the spill to prevent anyone from walking in it.
- The steamer door did not close all the way and would not get hot enough to steam the food.
- A cooler located in the area for staff and visitors, had food without labels, and a bottle of medication used to treat upset stomach that belonged to staff.
- Boxes of cooking oil were stored on the floor behind the serving line (area where prepared food is assembled on plates or trays, and served to patient's, visitors and staff).
- The handwashing sink cabinet behind the serving line was made of wood and no longer had a smooth cleanable surface due to water saturated wood.
- The outside of the dishwasher had debris caked around the seal of the door.

During an interview on 04/22/19 at 4:00 PM, Staff EE, Dietary Manager, stated that:
- She knew the coolers and freezers did not close tight and she had put in a request to maintenance to get them fixed.
- The food in the coolers and freezers were to be labeled with the open date and an expiration or a use by date.
- She did not know when the freezers had thawed but knew they got warm when staff went in and out of them during the day.
- She was not aware they should document problems with the coolers and freezer temperatures, but added that they had called someone to fix them.
- She had called maintenance concerning the issues with the deep fryer and the steamer, but had not received a response from them, and could not remember when she had called them.

2. Observation on 04/23/19 at 10:00 AM in the Med/Surg Unit, Staff B, Registered Nurse (RN) went to find an IV pole to hang bag of blood on. The pole was dirty. There was dried fluid of unknown origin that had run down the pole and splashed on the base. Dust had also settled on the base.

During an interview on 04/23/19 at 10:15 AM Staff B, RN, stated that housekeeping cleaned all of the IV poles and equipment used on the Med/Surg Unit. She also stated if something was visibly soiled, she would clean it before taking into another room.

3. Observation on 04/23/19 at 8:45 AM on the Med/Surg Unit showed the following:
- In the Nourishment Room there were dead bugs on the shelf under the sink.
- In the Clean Utility Room there were cardboard boxes stored under the sink that had been wet.
- The Clean Utility Room was being used as a coffee room for patients and visitors. There were coffee supplies mixed in with patient care supplies, nutrition supplies and supplies for the respiratory department.
- All of the storage areas under the sinks on the unit were dirty, with boxes stored in them that were soiled from being wet.

During interview on 04/23/19 at 9:00 AM, Staff CC, Intensive Care Unit (ICU) and Med/Surg Director, and Assistant Chief Nursing Officer, stated that housekeeping cleaned all the equipment in the patient room upon a patient's discharge, and left it in the cleaned room. Staff CC added that staff would know that if the room was clean, then the equipment was also clean. She also stated that nothing should be stored under the sinks and she did not know the cabinets were dirty.

4. Review of the undated "Purpose Page" for the Infection Control program showed that:
- The purpose of an organized Infection Control Program is to ensure the well-being of patients, visitors, and staff;
- All levels of hospital management and employees have a primary responsibility for the health and well-being of all patients, visitors, and staff;
- The Infection Control Nurse and the Infection Control Committee will consistently enforce all rules and regulations, and be alert for unhealthy conditions and take appropriate actions to correct the problem.

Review of the facility's policy titled, "Emergency Room (ER, also known as ED) Infection Control," revised 05/2014, showed that:
- The ER constitutes an area where patients with undiscovered infections arrive and are examined;
- It is the responsibility of all Nursing Personnel assigned to the ER to abide by these Infection Control guidelines;
- All equipment should be cleaned after each patient use;
- Any suspected infection on an IV device will be reported to the Infection Control Nurse;
- ER personnel shall comply with the Infection Control program.

Review of the facility's policy titled, "Instructions for Cleaning Pumps and Poles," revised 11/2010, showed that:
- Housekeeping or nursing can clean poles;
- Housekeeping will clean the poles with a damp cloth daily;
- If the base of the poles are rusty, send them to maintenance to have rust removed

Review of an undated policy titled, "10-5 Rule," showed that cleanliness is everyone's job and that holes in walls, cracked tiles, stained ceilings, and rusted fixtures should be reported to maintenance.

Review of the facility's policy titled, "Housekeeping Infection Control," revised 04/2015, showed that:
- The housekeeping department is responsible for providing a clean, sanitary environment for the patients and employees throughout the institution;
- Thoroughly clean all areas of traffic, including patient areas and corridors;
- Utility rooms, nourishment stations, treatment rooms, service areas, medicine rooms, diet kitchens, and pantries should be cleaned;
- Clean sinks, hoppers, cabinets, cupboards, ice makers, and refrigerators;
- Corridors, lobbies, and waiting rooms should be thoroughly cleaned;
- ER should be cleaned seven days per week;
- Take down and re-hang draperies and cubicle curtains when soiled;
- Clean walls and ceilings throughout the facility;
- Cleaning procedures and schedules shall be reviewed by the Infection Control Committee on an annual basis.

Review of the facility's policy titled, "Maintenance Infection Control," revised 05/2015, showed that:
- The maintenance department shall make every effort to provide a clean and safe environment for patients, visitors, and employees.
- The maintenance department will maintain all walls and ceilings needing repair;
- Ceiling panels will be replaced as needed and peeling wall surfaces will be repaired to provide a sanitary environment.

5. Observation on 04/22/19 at 3:15 PM, in the ED showed IV poles stored in a patient area with brown rust on the bottom of poles, discolored and broken ceiling tiles throughout the ER area, and walls with unpainted areas. The waiting area for ED had dirty/stained floors, broken dirty ceiling tiles, holes in the walls, and unpainted areas on the walls.

6. Observation on 04/23/19 at 1:30 PM, in patient room number 216, showed holes in the walls, ceiling tiles broken and stained, and floor dirty.

7. Observation in hallways and common areas of the med/surg unit showed multiple ceiling tiles discolored and some broken. Walls had unfinished areas of repair and unfinished painted areas. The floors were discolored and dirty, especially around the baseboards.

During an interview on 04/25/19 at 3:50 PM, Staff DD, RN, Infection Control, stated her expectations would be that:
- Ceiling tiles would be replaced when stained or broken;
- Walls would be cleaned, repaired and painted;
- Floors would be cleaned;
- Cabinets would be cleaned with no dead bugs found in them;
- Dietary would clean dirty carts, dirty blinds, greasy equipment, and dirty floors.
Staff DD stated that the physical environment and infection control concerns related to paint chips, dirty baseboards, holes in the walls, and stained and broken ceiling tiles had been discussed in the Quality Assurance and Performance Improvement (QAPI) meetings in the past. She also stated, "The Quality Nurse and I performed walk-throughs in dietary and made large amount of notes concerning dirty carts, dirty blinds, greasy filthy equipment, nasty floors, and open food items not dated and discussed it with the dietary manager approximately two months ago." She stated the facility often had problems with bed bugs and roaches and they called pest control, but would expect the dead bugs to be cleaned from cabinets.

During an interview on 04/25/19 at 4:30 PM, Staff EE, Interim Chief Executive Officer (CEO), shook her head in agreement as the physical environment and infection control concerns were discussed, and stated that she knew there were issues with the environment, and that repairs needed to be made. She was not aware of the dead bugs in the cabinet.

8. Review of the facility's policy titled, "Handwashing," revised 05/2014, showed that in the absence of a true emergency, personnel should always wash their hands after they had direct contact with patients, even if gloves were used, and after contact with inanimate objects (a thing that is not alive, such as a computer, a bed or other objects that may not be clean) in the immediate vicinity of the patient.

Observation on 04/23/19 at 10:30 AM, showed Staff I, RN, Charge Nurse, prepared to administer an IV antibiotic (a drug used to treat bacterial infections) to Patient #13 in the ICU. Staff I gathered the medication and supplies, laid them on top of the patient's contaminated bed linens while the patient lied in bed, and used the bed area as a work surface. Staff I performed hand hygiene, donned (put on) clean gloves, opened a package of IV tubing obtained from the patient's bed, attached the tubing to the medication, and filled the IV tubing with the medication while she wore the contaminated gloves. Staff I then touched the patient's arm to position it for administration, opened an alcohol prep pad package she obtained from the patient's bed, touched the patient's arm while she wore the same gloves and subsequently brushed the patient's arm with the exposed alcohol pad. Staff I then wiped the patient's IV access port (area when the IV tubing is connect to the IV), connected the IV tubing to the patient's IV access port, and began the medication infusion. Staff I wore the same contaminated gloves throughout the procedure after she touched contaminated items and surfaces in the immediate vicinity of the patient.

During an interview on 04/25/19 at 1:12 PM, Staff CC, Intensive Care Unit (ICU) and Med/Surg Director, and Assistant Chief Nursing Officer (CNO), stated the expectation was that nursing staff would not place supplies and medications on patients' beds, and that they followed infection control guidelines when medication administration was performed.

9. Review of the facility's undated policy titled, "Unit Inspection," showed that all drug storage areas within the facility would be inspected at least monthly to ensure proper storage of medications.

Observation on 04/23/19 at 10:45 AM, showed visible dust, and debris in the clear storage bins located within the secured (locked) refrigerated electronic medication dispensing system on the Intensive Care Unit (ICU). The storage bins were used to separate and store different types of bagged fluids and medications within the refrigerated system.

During an interview on 04/23/19 at 10:45 AM, in the ICU, Staff I, RN, Charge Nurse, stated that the pharmacy department was responsible for all contents within the locked refrigerated medication system.




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