HospitalInspections.org

Based on observation and interview, the facility failed to prominently and conspicuously post for display in a public area that is readily visible to patients, residents, volunteers, employees, and visitors a statement of the duty to report abuse and neglect, or illegal, unethical or unprofessional conduct in accordance with HSC, §161.132(e). The statement shall be in English and in a second language appropriate to the demographic makeup of the community served and contain the number of the department's patient information and complaint line at (888) 973-0022.


Findings were:

During a tour, in the afternoon of 8/8/2022 of the facility's main hospital lobby entrance and in the emergency room lobby revealed the failure to include the posting department's patient information and complaint line.

The above finding were acknowledged by Staff #6, Chief Nursing Officer, on the afternoon of 8/8/2022.

During a tour on the morning of 8/10/22 of the facility's main hospital lobby entrance revealed the postings to include the department's patient information and complaint line were still not posted.

During an interview in the hospital entrance waiting room on the morning of 8/10/22 with Staff #3, Chief Executive Officer, revealed he didn't know that they need the complaint number.

Based on record review and interview the facility failed to 1. develop, update, and review an emergency preparedness plan at least every two years. 2. Develop a plan that is based on and includes a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.

Findings include:

1. Review of the facility Emergency Preparedness Plan reflected that it was last revised in 8/2017, 5 years ago.

2. Review of the facility Emergency Preparedness Plan (EPP), last revised 8/2017, revealed no mention of the facility-based and community-based risk assessment was included.

Review of the Emergency Operations Manual did not reflect any Facility Risk Assessment.

No Policy was provided related to the Facility Risk Assessment.

During an interview on the morning of 8/10/22 Staff #3 , CEO, stated that if "it is not in the book we probably didn't do the assessment."

During an interview on the afternoon of 8/10/22 Staff #6 . CNO, stated "I cannot find the assessment."

During an interview on the afternoon of 8/10/22 Staff #21, Safety Officer, stated "I do not know of any facility assessment being done."

During an interview on the afternoon of 9/10/22 Staff #3 , CEO, stated that "it is my responsibility to make sure this was done."

Based on record review and interview the facility failed to furnish care in accordance with appropriate written policies that are consistent with applicable state law.

Findings were:

Review of facility policy "Animal Bites", last revised 4/2018 next review 6/2022, reflected "Patients arriving to the Emergency Department with animal bites will receive the following care: ...Report all animal bites to the Police Department..."

Review of Patient #7's medical record reflected he was admitted to the Emergency Department (ED) on 12/28/21 with chief complaint of a cat bite. The patient was treated and discharged. The medical record did not reflect the notification of the police department.

Review of Patient #9's medical record reflected she was admitted to the ED on 5/3/22 with chief complaint of "...left middle finger pain and swelling after being bit by her cat this morning. Cat's immunizations are not up to date..." The patient was treated and discharged. The medical record did not reflect the notification of the police department.

During an interview on the afternoon of 8/10/22 Staff #6 stated that there was no record of reporting these to the police. They should have been reported.

Based on record review and interview the facility failed to ensure that an individual, who is qualified through education, training, experience, or certification in infection prevention control, is appointed by the governing body , or responsible individual, and the infection preventionist/infection control professional responsible for the infection prevention and control program. The infection preventionist/infection control professional responsible for the infection prevention and control program has had no training or certification in infection prevention control.

Findings were:

During an interview on the afternoon of 8/9/22 with Staff #6 she stated that she is the infection preventionist. When asked if she had any training in infection prevention she stated that she had none.

Review of the undated Job Description for the Director of Nursing reflected no reference to the infection preventionist, infection control professional responsibilities or required training.

There was no Job Description for the Infection Preventionist provided.

The above was verified by Staff #6 on the afternoon of 8/9/22.

Based on record review and interview the facility failed to develop, update, and review an emergency preparedness plan at least every two years.

Findings include:

Review of the facility Emergency Preparedness Plan reflected that it was last revised in 8/2017, 5 years ago.

During an interview on the afternoon of 9/10/22 Staff #3 , CEO, stated that "it is my responsibility to make sure this was done."

Based on record review and interview the facility failed to develop an emergency preparedness plan that is based on and includes a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.

Findings were:

Review of the facility Emergency Preparedness Plan, last revised 8/2017, no mention of the facility-based and community-based risk assessment was included.

Review of the Emergency Operations Manual did not reflect any Facility Risk Assessment.

No Policy was provided related to the Facility Risk Assessment.

During an interview on the morning of 8/10/22 Staff #3 , CEO, stated that if "it is not in the book we probably didn't do the assessment."

During an interview on the afternoon of 8/10/22 Staff #6 . CNO, stated "I cannot find the assessment."

During an interview on the afternoon of 8/10/22 Staff #21, Safety Officer, stated "I do not know of any facility assessment being done."

During an interview on the afternoon of 9/10/22 Staff #3 , CEO, stated that it is my responsibility to make sure this was done."