HospitalInspections.org

Based on observation, interview, record review and policy review, the hospital's Governing Body failed to ensure that:
- The Chief Executive Officer (CEO) effectively managed the hospital in order to meet applicable regulatory requirements. (A-0057)
- All contracted services were included in the Quality Assurance Performance Improvement (QAPI, process for reporting and/or identifying adverse events, near misses or review of high risk problem prone areas for patient safety) Program in order to measure the effectiveness and safety of services. (A-0084)
- The results of all psychiatric and/or social services consultative evaluations of the patient and appropriate findings by clinical staff involved with the care of the patient was promptly filed and documented in the medical record for nine discharged patients (#42, #51, #52, #55, #56, #57, #58, #59 and #60) of 15 discharged medical records reviewed with a psychiatric or social services consult or evaluation. (A-0464)
- The hospital had an effective hospital-wide infection control program using accepted infection prevention standards. (A-0749)
- One Emergency Department physician (Staff NNN) of two ED physician medical staff personnel records reviewed, had current required advanced life support certifications. (A-1112)

These failures had the potential to adversely affect the quality of care and safety of all patients in the hospital.

The severity and cumulative effect of these systemic practices resulted in the hospital's non-compliance with 42 CFR 482.12 Condition of Participation: Governing Body and resulted in the hospital's failure to ensure quality health care and safety.

The hospital census was 46.

Based on observation, interview, record review, and policy review, the Governing Body failed to ensure the Chief Executive Officer (CEO) was responsible for management of the entire hospital including accountability for the effective oversight of staff to comply with the requirements under 42 CFR 482.42 Condition of Participation (COP): Infection Prevention and Control and Antibiotic Stewardship Programs, 42 CFR 482.24 COP: Medical Record Services and 42 CFR 482.12 COP: Governing Body. This failure had the potential to affect the quality of care and safety of all patients. The hospital census was 46.

Findings included:

1. Review of the hospital's document titled, "Missouri Delta Medical Center Bylaws," dated 01/12/21, showed that the President shall be the Chief Executive Officer and in this capacity shall have the authority to direct and administer all the activities and departments of the Hospital.

The CEO failed to ensure compliance with the COP of Governing Body as evidenced by failure to effectively manage the hospital in order to meet applicable regulatory requirements (A-0057) and that contracted services were evaluated for quality and provided in a safe and effective manner. (A-0084)

The CEO failed to ensure compliance with the COP of Infection Prevention and Control and Antibiotic Stewardship Programs, as evidenced by failure of the hospital to ensure staff followed infection control practices and infection prevention standards. (A-0749)

The CEO failed to ensure compliance with the COP of Medical Record Services as evidenced by failure to ensure the results of all psychiatric and/or social services consultative evaluations of the patient and appropriate findings by clinical staff involved with the care of the patient was promptly filed and documented in the medical record. (A-0464)

The CEO failed to ensure compliance with a standard level deficiency in Emergency Services as evidenced by failure to ensure one Emergency Department (ED) physician (Staff NNN) of two ED physician personnel records reviewed, had current advanced life support certifications. (A-1112)

During an interview on 11/4/21 at 10:20 AM, Staff ZZZ, President/CEO, stated that he was responsible for the entire hospital and for the oversight/management of Infection Prevention, Medical Records and Governing Body.



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Based on interview, record review and policy review, the hospital's Governing Body failed to ensure that all contracted services were included in the Quality Assurance Performance Improvement (QAPI, process for reporting and/or identifying adverse events, near misses or review of high risk problem prone areas for patient safety) Program in order to measure the effectiveness and safety of services. This had the potential to put all patients at risk for substandard quality care and compromise their health and safety. The hospital census was 46.

Findings included:

1. Review of the hospital's document titled, "Missouri Delta Medical Center Bylaws," dated 01/12/21, showed that a duty of the board of directors was to monitor and evaluate the quality of patient care rendered by the hospital.

Review of the hospital's document titled, "Quality & Performance Improvement Plan," dated 02/2021, showed that:
- The objectives of the Quality and Performance Improvement Process was to organize improvement activities around the flow of patient care services with special attention to customer and supplier relationships.
- To ensure compliance with all relevant policies, standards, regulations and laws set forth by accreditation, licensing and regulatory agencies.
- The function for leadership was to review service contracts.
- A function of the Quality and Performance Improvement Plan was to improve organizational performance by assessment of care or services provided to high-risk populations (example - suicide (to cause one's own death) prone).

Review of the hospital provided list of contracted services showed 10 clinical contracted services and 122 hospital wide contracted services. The list of clinical and hospital wide contracted services did not include the nearby counseling service that provided staff for psychiatric evaluations in the Emergency Department (ED) through Missouri Crisis Access Response System (MOCARS, Crisis counselors that were available 24/7 to assist with psychiatric consultations).

During an interview on 11/04/21 at 10:00 AM, Staff M, Quality Director, stated that no contracted services were integrated into QAPI at this time.

During an interview on 11/04/21 at 10:15 AM, Staff ZZZ, President and Chief Executive Officer, stated that the clinical care contracts were reviewed annually by the Governing Body but none of the clinical care contracts or hospital wide contracts were incorporated into QAPI.

Based on observation, interview, record review and policy review, the hospital failed to ensure that results of all psychiatric and/or social services consultative evaluations of the patient and appropriate findings by clinical staff involved with the care of the patient was documented in the medical record for nine discharged patients (#42, #51, #52, #55, #56, #57, #58, #59 and #60) of 15 discharged medical records reviewed with a psychiatric or social services consult.

The cumulative effect of this systemic practice resulted in the hospital's inability to ensure the completeness and accuracy of all patient medical records and resulted in the hospital being out of compliance with 42 CFR 482.24 Condition of Participation (COP): Medical Record Services.

Based on observation, interview, record review and policy review, the hospital failed to ensure that the results of all psychiatric (relating to mental illness) and/or social services consultative evaluations of the patient and appropriate findings by clinical staff involved with the care of the patient was promptly filed and documented in the medical record for nine discharged patients (#42, #51, #52, #55, #56, #57, #58, #59 and #60) of 15 discharged medical records reviewed with a psychiatric or social services consult or evaluation. This failure had the potential to negatively affect the patient when consultative information was not available to the physician or other care providers to use in making assessments of the patient's condition, to justify treatment or continued hospitalization and to support or revise the patient's diagnosis or plan of care. The hospital census was 46.

Findings included:

1. Review of the hospital's document titled, "Medical Staff - Rules and Regulations," revised 08/2020, showed the following:
- Consultation by appropriately credentialed staff members is encouraged on all seriously ill patients, on all patients in whom the diagnosis is obscure or in whom there is doubt as to the best therapeutic measures to be utilized.
- A consultation includes examination of the patient and the record.
- A written opinion signed by the consultant must be included in the medical record and verbal communication is encouraged in certain situations.
- Consultation reports shall include documentation of the examination of the patient, a report of the consultant's findings, opinions, recommendations and documented within 24 hours.
- The attending physician is responsible for a complete medical record for each patient.
- This record shall include special reports and consultations.

Review of Patient #42's medical record showed the following:
- She was a 44 year old female that presented to the Emergency Department (ED) on 09/10/21 at 2:53 PM with suicidal ideations (SI, thoughts of causing one's own death), homicidal ideations (HI, thoughts or attempts to cause anther's death) and hallucinations (seeing or hearing things which are not there).
- An order for consult to Social Services was entered on 09/10/21 at 3:48 PM.
- The initial plan for the patient was admission to a mental health facility.
- On 09/11/21 at 10:21 AM, the patient stated to the ED nurse that she was not suicidal or homicidal and wanted to be discharged home. The nurse notified the ED physician and the physician ordered a Missouri Crisis Access Response System (MOCARS, Crisis counselors that are available 24/7 to assist with psychiatric consultations) reevaluation. (There was no initial evaluation by a MOCARS or social services staff member documented in the medical record)
- On 09/11/21 at 11:36 AM, MOCARS crisis staff member was at the patient's bedside, talking with the patient.
- 0n 09/11/21 at 12:29 PM, MOCARS crisis staff member stated that she had reevaluated the patient and believed she was ok to be discharged home, that she had been provided with resources. The ED nurse notified the ED physician.

There was no signed documentation by a MOCARS staff member in Patient #42's medical record that included an examination of the patient, a report of the consultant's findings, opinions and recommendations.

Review of Patient #51's medical record showed the following:
- He was a 48 year old male that presented to the ED on 07/19/21 at 4:46 PM with SI, depression (extreme sadness that doesn't go away) and alcohol intoxication (to be affected by alcohol or drugs where physical and mental control is markedly diminished).
- An order for consult to Social Services was entered on 07/19/21 at 4:56 PM.
- On 07/20/21 at 9:19 AM, MOCARS crisis line was contacted.
- On 07/19/21 at 10:16 AM, the patient spoke with a MOCARS staff member on the phone.
- The patient was discharged home on 07/22/21 at 10:50 AM.
- Patient #51 presented to the ED a second time on 08/14/21 at 4:54 PM with alcohol intoxication and depression. The plan was to consult psychiatry for admission.
- On 08/15/21 at 10:12 AM, MOCARS was contacted.
- A one page email document from a MOCARS staff member that stated a crisis evaluation was conducted by phone on Patient #51 on 08/15/21. The staff member determined that Patient #51 could be released from the ED and recommended referral to an in or outpatient rehab facility.

There was no signed documentation by a MOCARS staff member in Patient #51's medical record on the 07/19/21 and 08/14/21 ED encounters that included any mental status assessment/exam, presenting problems/behaviors or diagnostic impression of the patient.

Review of Patient #52's medical record showed the following:
- She was a 34 year old female that presented to the ED on 07/01/21 at 10:25 PM with Suicidal Ideation and depression.
- On 07/02/21 at 4:13 AM, the patient completed a psychiatric evaluation by phone with a MOCARS staff member. The MOCARS staff member spoke with the ED RN and received a verbal statement the patient was safe and cleared for discharge to home.

There was no signed documentation by a MOCARS staff member in Patient #52's medical record that included an examination of the patient, a report of the consultant's findings, opinions and recommendations.

2. Review of the following six medical records were from a list of patient names (#55, #56, #57, #58, #59 and #60) with date of service, sent to the state agency from Executive Director RRR of a nearby counseling service, whose staff performed the crisis evaluations for MOCARS. These patients were evaluated by a MOCARS staff member.

Review of Patient #55's medical record showed the following:
- He was a 33 year old male that presented to the ED on 07/25/21 at 8:36 PM with SI, suicide attempt by hanging and depression.
- An order for MOCARS to see patient was entered on 07/25/21 at 9:30 PM.
- On 07/26/21 at 12:08 AM, the ED physician reported the patient was seen by mental health and cleared to be discharged home.

There was no signed documentation by a MOCARS staff member in Patient #55's medical record that included an examination of the patient, a report of the consultant's findings, opinions and recommendations.

Review of Patient #56's medical record showed the following:
- She was a 12 year old female that presented to the ED on 09/18/21 at 2:00 AM with SI, depression and self harm (behavior that is harmful or potentially harmful to oneself).
- An order for consult to Social Services was entered on 09/18/21 at 2:21 AM.
- The patient was discharged home on 09/18/21 at 5:10 AM.

There was no signed documentation by a MOCARS staff member in Patient #56's medical record that included an examination of the patient, a report of the consultant's findings, opinions and recommendations.

Review of Patient #57's medical record showed the following:
- He was a 10 year old male that presented to the ED on 09/19/21 at 10:15 AM with assaultive behavior (potential to become violent with others) and oppositional defiant behavior (a behavior where a person displays a pattern of angry and/or cranky mood or combative behavior).
- On 09/19/21 at 12:05 PM, MOCARS contacted.
- No order for a social services consult or MOCARS consult.
- On 09/19/21 at 1:40 PM, MOCARS staff member in patient's room.
- On 09/19/21 at 2:22 PM, ED nurse documented that a safety plan was set up with MOCARS. The counselor went over techniques with the patient on anger management, gave the family phone numbers for the crisis line. The ED nurse notified the ED physician.
- The patient was discharged home on 09/19/21 at 2:40 PM.

There was no signed documentation by a MOCARS staff member in Patient #57's medical record that included an examination of the patient, a report of the consultant's findings, opinions and recommendations.

Review of Patient #58's medical record showed the following:
- He was an 11 year old male that presented to the ED on 10/07/21 at 3:08 PM with aggressive (behavior that is intended to harm another individual) behavior.
- On 10/09/21 at 7:15 AM, ED physician requested repeat assessment of patient by mental health professional to determine if inpatient care was appropriate at this time. MOCARS was contacted.
- No order for a social services consult or MOCARS consult.
- On 10/09/21 at 8:03 AM, MOCARS staff member in patient room.
- On 10/09/21 at 8:36 AM, MOCARS staff member reported to ED RN that the patient can go home while we work on bed placement for inpatient psychiatric hospitalization.
- The patient was discharged home on 10/09/21 at 9:10 AM.

There was no signed documentation by a MOCARS staff member in Patient #58's medical record that included an examination of the patient, a report of the consultant's findings, opinions and recommendations.

Review of Patient #59's medical record showed the following:
- She was a 47 year old female that presented to the ED on 10/16/21 at 2:15 PM after getting angry with her mother and saying she was going to kill herself. The patient denied SI or HI. The patient had schizophrenia (serious mental disorder that affects a person's ability to think, feel and behave clearly).
- On 10/16/21 at 5:36 PM, the ED physician reported that MOCARS staff evaluated the patient.
- No order for a social services consult or MOCARS consult.
- The patient was discharged home on 10/16/21 at 6:10 PM.

There was no signed documentation by a MOCARS staff member in Patient #59's medical record that included an examination of the patient, a report of the consultant's findings, opinions and recommendations.

Review of Patient #60's medical record showed the following:
- She was a 17 year old female that presented to the ED on 10/31/21 at 7:24 PM with SI and depression.
- An order for consult to Social Services was entered on 10/31/21 at 8:03 PM.
- The patient was admitted to the hospital's adolescent behavioral health unit.

There was no signed documentation by a MOCARS staff member in Patient #60's medical records that included an examination of the patient, a report of the consultant's findings, opinions and recommendations.

During an interview on 11/02/21 at 3:30 PM, Staff A, ED Nursing Director, stated that:
- MOCARS was supposed to document an assessment in the medical record.
- It depended on which staff member from MOCARS did the assessment, whether it was documented or not.
- MOCARS did the ED psychiatric evaluations Monday through Friday from 4:30 PM to 8:00 AM and 24/7 on the weekends, starting at 4:30 PM on Friday.
- He noticed that MOCARS had not put evaluations in the chart since covid started and evaluations have been done over the phone.

During an interview on 11/03/21 at 8:30 AM, Staff NNN, ED Medical Director, stated that:
- The ED physicians use MOCARS for psychiatric evaluations.
- He does not actually write an order for a psychiatric evaluation or consult; he lets the nurse know and she contacted MOCARS.
- Since covid, MOCARS had been doing phone consults with patients.
- After MOCARS staff member evaluated the patient, the staff member would talk to the ED nurse and relay the recommendations for the patient. The nurse then relayed information to the physician.
- He was not aware that MOCARS was not providing documentation of patient evaluations in the medical record and that would be ideal to have a report in the chart.

During an interview on 11/03/21 at 8:50 AM, Staff FFF, Health Information Management (HIM) Director stated that:
- She was not aware that MOCARS psychiatric evaluations were not being placed in the patient's medical records.
- All patient evaluations and consultations should be documented in the patient's medical record.
- HIM staff review ED medical records for consults. If there was not a specific order for a MOCARS consult or Social Services consult, the staff do not know to make sure to look that an evaluation was in the patient's medical record.
- She was instructed by administration on 11/02/21 to look for MOCARS orders or MOCARS consults in ED medical records going forward.

During an interview on 11/03/21 at 10:25 AM, Staff BBBB, Social Services Director, stated that:
- She did psychiatric evaluations for the ED Monday through Friday from 8:00 to 4:30 PM.
- ED staff contact MOCARS to do psychiatric consults and evaluations after hours and on weekends.
- A psychiatric evaluation must be scanned into the patient's medical record.
- It had been an ongoing problem that MOCARS does not document an evaluation in the medical record.

During an interview on 11/03/21 at 11:00 AM, Staff PPP, Chief Medical Officer, stated that:
- She was not aware that psychiatric evaluations/consultations from MOCARS staff was not documented in the patient's medical record.
- Anything a clinical staff member does for a patient, such as an evaluation or a safety plan should be documented for patient safety and staff knowledge of the patient's mental status.
- She was not aware that ED physicians were not writing orders for consults.

During an interview on 11/02/21 at 4:00 PM, Staff ZZZ, Chief Executive Officer, stated that:
- The hospital does not have a contract or agreement with MOCARS.
- They were a branch of a nearby counseling service that the hospital used for inpatient mental health evaluations.
- All MOCARS staff were privileged and credentialed at the hospital.
- The ED staff document that MOCARS did an evaluation; MOCARS staff had not documented psychiatric evaluations since 2020, when covid started.

During an interview on 11/03/21 at 10:45 AM, Executive Director RRR of nearby counseling service, stated that:
- MOCARS was part of the state of Missouri Crisis Response System.
- The counseling service he directed was the administrative agent for MOCARS in the surrounding counties.
- The psychiatric evaluations were documented by the MOCARS staff and filed in our office.
- This was a service we were providing to the hospital and considered the evaluations our documentation, not the hospital's.
- We verbally report our findings to the ED staff.
- There should probably be documentation in the patient's medical record from the MOCARS staff.

Based on observation, interview, record review and policy review, the hospital failed to have systemic practices in place that:
- Ensured negative pressure (air pressure inside the room was lower than the air pressure outside
the room to help with spread of viruses) fans that were seated in plywood, and secured with
masking tape, could be properly cleaned and disinfected.
- Ensured staff followed the hospital's hand hygiene policy when caring for patients on seven of nine patient areas observed for hand hygiene.
- Ensured staff followed the hospital's protocol for wearing masks in patient care areas.
- Ensured laryngoscope (used for visualization of the vocal cords to place a tube in the windpipe to assist patient with breathing) handles were packaged and properly stored.
- Ensured disposable plastic oropharyngeal airways (a medical device use to maintain or open a
patient's airway) were packaged and properly stored.
- Ensured the instrument used for covid (highly contagious and sometimes fatal, virus) testing in the Emergency Department (ED) was cleaned as directed in the user's manual.
- Identified and removed outdated blood glucose (sugar that circulates in the blood and when too high or too low can be detrimental to a person's health) test meter control solution vials (a solution that lets the user know the meter was working).
- Discarded saline fluid (salt water solution) 1000 ml (a measurement of liquid) intravenous bag with uncapped and unlabeled tubing from one patient care unit of four patient care units observed with patients that had IV tubing.
- Ensured intravenous (IV, in the vein) site dressings were labeled with date, IV size, and nurse initials on five IV site dressings of six IV site dressings observed.
- Ensured ice dispenser exterior was clean and free of white buildup on two patient care areas of five patient care areas observed.
- Ensured bleach solutions were properly mixed and labeled.
- Identified and removed outdated fluids from patient care units.
- Ensured expired patient care items were removed from one patient care unit of five patient care units observed.
- Ensured food without expiration dates were properly stored and labeled in two patient refreshment areas of two patient refreshment areas observed.
- Ensured kitchen ovens were free of gummy and baked on residue.
- Ensured plastic cups were not reused between patients on the adolescent psychiatric unit.
- Ensured medication vials were disinfected before withdrawing medication on three patients (#11, #12 and #13) of four patients observed.

The severity and cumulative effects of these systemic practices resulted in the hospital's non-compliance with 42 CFR 482.42 Condition of Participation: Infection Prevention and Control and Antibiotic Stewardship Programs and resulted in the hospital's failure to ensure quality health care and safety.

The hospital census was 46.

Based on observation, interview, record review, and policy review, the hospital failed to ensure staff followed infection control practices and infection prevention standards when they failed to:
- Ensure negative pressure fans that were seated in plywood, and secured with masking tape, could be properly cleaned and disinfected.
- Ensure staff followed the hospital's hand hygiene policy when caring for patients on seven of nine patient areas observed for hand hygiene.
- Ensure staff followed the hospital's protocol for wearing masks in patient care areas.
- Ensure laryngoscope handles were packaged and properly stored.
- Ensure disposable plastic oropharyngeal airways were packaged and properly stored.
- Ensure the instrument used for covid testing in the ED was cleaned as directed in the user's manual.
- Identify and remove outdated blood glucose test meter control solution vials.
- Discard saline fluid 1000 ml intravenous bag with uncapped and unlabeled tubing from one patient care unit of four patient care units observed with patients that had IV tubing.
- Ensure IV site dressings were labeled with date, IV size, and nurse initials on five IV site dressings of six IV site dressings observed.
- Ensure ice dispenser exterior was clean and free of white buildup on two patient care areas of five patient care areas observed.
- Ensure bleach solutions were properly mixed and labeled.
- Identify and remove outdated fluids from patient care units.
- Ensure expired patient care items were removed from one patient care unit of five patient care units observed.
- Ensure food without expiration dates were properly stored and labeled in two patient refreshment areas of two patient refreshment areas observed.
- Ensure kitchen ovens were free of gummy and baked on residue.
- Ensure plastic cups were not reused between patients on the adolescent psychiatric unit.
- Ensure medication vials were disinfected before withdrawing medication on three patients (#11, #12 and #13) of four patients observed.

These failures had the potential to cause harmful cross contamination of pathogens (a bacteria, virus, or other microorganism that can cause disease) to patients and negatively affect the quality of care and safety of all patients. The hospital census was 46.

Findings included:

1. Even though requested, the hospital failed to provide a policy on cleaning of window fans, which were installed to create a negative pressure environment for covid positive patients.

Observation on 10/26/21 at 10:05 AM, on the Obstetric (OB, the branch of medical science concerned with childbirth and caring for and treating women in or in connection with childbirth) Unit, showed two patient rooms with fans installed in the window using a plywood frame and masking tape. The fans had visible dust on the rim and fan blades.

During an interview on 10/26/21 at 10:30 AM, Staff H, Housekeeper, stated she used a checklist guide when cleaning OB patient rooms. She stated she had not been trained on cleaning the fan, plywood, or masking tape and the fans were not on her cleaning guide checklist.

During an interview on 10/26/2021 at 10:05 AM, Staff G, RN OB Manager, stated that:
- She had requested Plant Operations (maintains hospital buildings and equipment, construction and the maintenance of hospital grounds) Staff to install fans in two OB patient rooms in case the unit received covid patients.
- She thought the fans would help create a negative pressure environment, which would help stop the spread of the covid virus.
- She was not trained on how to properly clean or disinfect the plywood, masking tape, or fans.

Observation on 10/26/21 at 12:30 PM, on the Telemetry (remote observation of a person's heart rhythm, using signals that are transmitted from the patient to a computer screen) Unit showed 18 patient rooms with window fans in plywood casing with masking tape around window edges.

During an interview on 10/26/21 at 12:30 PM, Staff J, Telemetry Unit Registered Nurse (RN), stated she did not receive training on how to clean the plywood or fans that had been installed in the windows to create a negative pressure environment for covid positive patients.

During an interview on 10/26/21 at 12:55 PM, with Staff I, Director of Plant Operations, stated that:
- A request was received from hospital administration to make inpatient rooms on the second floor negative pressure.
- He had read online instructions through various sites how to make a room negative pressure.
- In March 2020, 30 fans were installed in various patient rooms on the second floor.
- Porous plywood and masking tape were used to place the fans in the windows.
- He was aware that plywood and masking tape would be hard to disinfect or clean.
- He did consult with Infection Control (IC) Prevention Nurse on the design of the fans but he had no documentation to reflect that consultation.

During an interview on 10/27/21 at 9:30 AM with Staff E, IC Prevention RN, stated that the Plant Operations Manager consulted with him when the fans were being designed. He stated that hospital staff was not trained on cleaning or disinfecting the fans, plywood, or masking tape that were installed to create a negative pressure environment.

2. Review of the hospital's policy titled, "Hand washing, Hand and Nail Care," revised 12/2017, showed that staff should wash hands:
- Before providing any patient care;
- Between glove changes;
- Between patient contacts;
- When hands are moving from contaminated body sites to clean body sites during patient care;
- After removing gloves;
- After contact with non-intact skin or wound dressings; and
- After hands have been in contact with inanimate objects including medical equipment in the immediate vicinity of the patient.

Observation on 10/25/21 at 3:30 PM in the ED, showed Staff U, RN, entered and exited Patient #1's room without performing hand hygiene. Staff U also adjusted the patient's body position without wearing gloves.

During an interview on 10/25/21 at 3:45 PM, Staff U stated that she should have performed hand hygiene before entering and exiting the patient's room. She stated that gloves should be worn when doing patient care.

Observation on 10/26/21 at 1:35 PM in Patient #5's room, in the Intensive Care Unit (ICU) showed Staff GG, RN, cleansed the left groin wound and applied wet to dry packing with 4 x 4 gauze to cover the wound. Staff GG removed his gloves and applied gloves with no hand hygiene between glove changes.

During an interview on 10/26/21 at 1:45 PM, Staff GG stated that he just forgot to do hand hygiene after removing his gloves.

Observation on 10/26/21 at 3:37 PM on the Medical/Surgical Unit, showed Staff KK, Certified Nursing Assistant (CNA), placed a blood pressure cuff on Patient #4's arm after she dropped it on the floor.

During an interview on 10/26/21 at 3:45 PM, Staff KK stated that she should have cleaned the blood pressure cuff before she placed it on the patient.

Observation on 10/27/21 at 8:30 AM, in the Geri Psych Unit, showed Staff LL, RN, entered and exited Patient #9's room without performing hand hygiene.

Observation on 10/27/21 at 9:15 AM, in the Geri Psych Unit, showed Staff MM, RN, dropped an oral medication on the tray of the rolling cart. She proceeded to crush that medication along with several others and attempted to administer to the patient who refused.

Observation on 10/27/21 at 10:12 AM, showed Staff TT, Patient Dining Associate, used a cup to scoop ice into patient drinking glasses. She removed her gloves and without doing hand hygiene, left the area; returning with a metal ice scoop. She did not perform hand hygiene before putting gloves on.

During an interview on 10:20 AM, Staff TT, stated she should have performed hand hygiene after taking the gloves off and before putting gloves on.

Observation on 11/02/21 at 8:30 AM in the Orthopedic Clinic, showed Staff III, Physician's Assistant, removed steri strips from Patient #28's right shoulder incisions and did not perform hand hygiene after he removed his gloves.

During an interview on 11/02/21 at 8:35 AM, Staff III, stated that he should do hand hygiene after removing his gloves.

Observation on 11/02/21 at 8:40 AM, showed Staff MMM, Medical Doctor (MD), in the Orthopedic Clinic, palpated under Patient #28's right arm and inspected shoulder. He did not wear gloves and did not perform hand hygiene after touching the patient.

During an interview on 11/022/21 at 8:45 AM, Staff MMM, stated that he doesn't wear gloves when touching patients because it was so impersonal. He stated he would wear gloves if it was an open incision.

Observation on 11/02/21 at 8:50 AM in the Wound Clinic, showed Staff JJJ, Licensed Practical Nurse, LPN, did not perform hand hygiene when leaving Patient #26's room.

During an interview on 11/02/21 at 9:18 AM, Staff JJJ, stated that he did not perform hand hygiene when leaving the patients room to get additional supplies for the dressing change.

Observation on 10/27/21 at 10:00 AM on the Telemetry Unit, showed Staff RR, RN, in Patient #13's room. Staff RR touched the patient's lower leg and removed a dressing. Staff RR did not change her gloves and proceeded to administer medication to the patient. Staff RR then looked at the patient's urinary catheter, changed gloves, but did not foam/cleanse hands before putting on new gloves. Staff RR picked an object off the floor and continued to care for Patient #13 without changing her gloves.

During an interview on 10/27/21 at 10:15 AM, Staff RR stated she should have changed her gloves after removing the patient's leg dressing.

3. Review of the hospital's protocol for facial masks, "Isolation Mask Extended Use and Reuse Protocol" dated 09/15/20, showed isolation masks should be worn by staff who are interacting with patients in care areas who are negative for covid or not a patient under investigation (PUI).

Observation and concurrent interview on 10/26/21 at 9:20 AM showed Staff X, Director of Laboratory and Staff Y, Pathology Processor/Coordinator, standing approximately one foot from one another with their facial masks pulled down beneath their mouths. Staff X and Staff Y, stated that they should have their masks pulled up to cover their mouth and nose.

Observation and concurrent interview on 10/25/21 at 9:35 AM, showed Staff Z, Medical Technologist and Staff AA, Microbiology Section Leader, standing approximately one foot from one another with facial masks not covering their mouth or nose. Staff S stated that she had medical issues and could not breathe if she wore her mask over her mouth and nose. Staff AA stated that she should have worn her mask over her mouth and nose.

During an interview on 10/26/21 at 3:10 PM, Staff DD, Nurse Manager, stated that she had counseled about 50% of her staff regarding not wearing masks while caring for patients. She stated that she had sent an email the past July to all ICU staff advising them of the need to wear facial masks when caring for patients.

4. Review of the hospital's policy titled, "Cleaning of Laryngoscopes," revised 01/2021, showed that if the laryngoscope handle is to be stored prior to use, transport it to where it is to be stored, using care to prevent re-contamination and damage prior to and during storage. The laryngoscope handle and blade should be stored in a closed carrying case, container, or kit to avoid bacterial colonization.

Observation on 10/25/21 at 4:45 PM, in the ED, showed an unpackaged laryngoscope handle was present in a wire rack on the wall above the patient stretcher.

During an Interview on 10/26/21 at 4:45 PM, Staff D, ED RN, stated that:
- After use, laryngoscope handles were wiped off with a disinfecting wipe and stored unpackaged in a wall rack or in an ED Crash Cart (a cart on wheels that contains emergency medical equipment) drawer.
- She did not know if the unpackaged laryngoscope handle that was stored in the wire rack above the patient stretcher had been cleaned with a disinfecting wipe.
- When laryngoscope handles were stored unpackaged it would be hard to tell if they had been disinfected.

5. Even though requested, the hospital failed to provide a policy on single use item storage.

Observation on 10/27/21 at 9:30 AM in the ED, showed a plastic container labeled Emergency Lifesaver Kit that held 8 sizes of oral airways. The oral airways were lying in a sponge like material to keep them in place inside of a plastic container.

During an interview on 10/27/2021 at 9:30 AM, Staff E, IC Prevention RN, stated that there would be no way to tell if the plastic container of oral airways had been used or contaminated by touch because the oral airways were not individually packaged.

6. Review of the hospital's undated user manual "Maintenance & Cleaning" instructions related to the ID NOW, covid testing instrument, showed that the manufacture recommended the exterior surfaces and the surfaces visible under the open lid be cleaned daily.

Record review of the ID NOW Cleaning Log (the log used to document the cleaning of the instrument used for covid testing) showed no documentation of cleaning done on October 7th and 24th of 2021.

During an interview on 10/25/21 at 3:00 PM, Staff A, stated that the ED techs cleaned the machines each day and were probably not scheduled to work. Staff A stated that he would expect the charge nurse to clean the machine if the tech was not available.

7. Review of the hospital's policy titled, "Laboratory Point of Care Testing," dated 10/2014, showed that new bottles of blood glucose testing controls must be marked with an open date, discard date, and nurse's initials. Opened blood glucose testing control vials are good for three months.

Observation on 10/26/21 at 3:05 PM, on the Adolescent Psychiatric Inpatient Unit (an inpatient unit that provides psychological, behavioral, and/or pharmacological interventions in a safe environment for adolescents' ages 12-17 who are experiencing a mental health crisis) showed that blood glucose testing control vials located with the blood glucose testing meter had expired on 06/10/2021.

During an interview on 10/26/21 at 3:05 PM, Staff L, RN, Manager Adolescent Psychiatric Unit, stated that:
- Blood glucose testing control vials were good for three months after opening.
- After opening the glucose testing control vial it should be marked with open date, discard date, and nurse's initials.
- The control vials that were present with the blood glucose testing meter should have been discarded on 06/10/21.

8. Review of the hospital's policy titled, "Medication Administration IV Therapy, (Peripheral)," revised 07/21, showed that a "wrap around" label should be placed on IV tubing including date, hour, & nurse's initials. The IV site should be labeled with the date, needle gauge and initials of person inserting IV.

Observation on 10/25/21 at 4:30 PM, in the ED, showed a saline (salt water solution) 1000 ml bag of fluid with unlabeled IV tubing attached to the bag and no end cap present, hanging from a hook attached to an ED cart. No patient was present in the ED trauma room (a designated room that is equipped to treat the most high-risk of injuries) #4. The saline bag appeared to contain 1000 ml of fluid.

During an interview on 10/25/21 at 4:30 PM, in the ED, Staff D, ED RN, stated that she did not know who the unlabeled bag of saline fluid belonged to, she stated it could have possibly belonged to a prior patient.

Observation on 10/27/21 at 8:45 AM on the Medical/Surgical Unit, showed Patient #11's IV site dressing was not dated, initialed or needle gauge documented.

Observation on 10/27/21 at 8:55 AM on the Medical/Surgical Unit, showed Patient #4's IV site dressing was not dated, initialed or needle gauge documented.

Observation on 10/27/21 at 3:00 PM on the Medical/Surgical Unit, showed Patient #14's IV site dressing was not dated, initialed or needle gauge documented.

During an interview on 10/27/21 at 9:00 AM, Staff OO, RN, stated that IV dressings should be labeled with date and initials. The labels sometimes fell off of the dressing.

Observation on 10/27/21 at 10:00 AM on the Telemetry Unit, showed Patient #13's three IV site dressings were not dated, initialed or needle gauge documented.

Observation on 10/28/21 at 8:15 AM on the Outpatient Surgery Unit, showed Staff AAA, RN, inserting a peripheral IV in Patient #15's right hand. Staff AAA placed a dressing over the insertion site and did not date, time or document needle gauge on the dressing.

During an interview on 10/28/21 at 8:25 AM, Staff AAA, stated she usually labeled the IV dressing with her initials and date, but forgot to do this. The patients in this department usually go home the same day.

9. Review of the hospital's policy titled, "Environmental Cleaning," dated 04/2020, showed that the patient care environment throughout the facility will be maintained in a state of cleanliness that meets professional standards in order to protect patients and healthcare personnel from potentially infectious micro-organisms. Personnel responsible for cleaning the environment and equipment will receive education and training on proper environmental cleaning and disinfection methods, agent use and selection and safety precautions.

Observation on 10/26/21 at 2:30 PM, on the medical/surgical unit in the patient snack and refreshment area, showed white debris buildup around the ice/water dispenser.

Observation on 10/26/2021 at 3:05 PM, on the adolescent psychiatric unit, showed white debris buildup around the ice/water dispenser.

During an interview on 10/26/2021 at 3:10 PM, Staff L, RN, stated that she did not know who was responsible for cleaning and maintenance of the exterior of the ice machine.

10. Review of the hospital's policy titled, "Mixing Bleach Solution," dated 01/2021, showed directive for staff to mix bleach solution in a 32 ounce bottle:
- Add 3.2 ounces of bleach in empty 32 ounce bottle;
- Add water to bottom of neck;
- Replace push/pull cap; and
- Make sure bottle was properly labeled for bleach solution.

Observation on 10/26/21 at 10:45 AM, showed a 32 ounce bottle of unlabeled cleaner in the soiled utility room cabinet on the OB Unit. Hand written instructions on the bottle showed use one squirt to mix.

During an interview on 10/26/21 at 10:45 AM, Staff G, OB RN, stated that she did not know when the cleaning solution was mixed, where the instructions were located on how to mix, or how long the solution was good after it was mixed. She stated that the OB patient beds were cleaned with a bleach solution.

11. During an interview on 10/26/21 at 4:30 PM, Staff I, Plant Operations Director, stated that part of the daily housekeeping checklist for staff was to wipe down all high touch areas daily. Cleaning of the ice/water dispenser was not specifically on the checklist.

12. Even though requested, the hospital failed to provide a policy on the dating of opened bottles used for patient care.

Observation on 10/26/21 at 1:00 PM, in the Intensive Care Unit (ICU) in Patient #6's room, showed open bottles of Sodium Chloride and Sterile Water with no date when they were opened.

During an interview on 10/26/21 at 1:15 PM, Staff EE, RN, stated that the bottles should have been dated when they were opened and discarded after three days.

Observation on 10/26/21 at 1:25 PM in Patient #5's room, showed open bottles of Sodium Chloride, Sterile Water, Aloe Vesta protective skin ointment, and Aloe Vesta Cleaning Foam with no date when they were opened.

Observation and concurrent interview on 10/26/21 at 3:30 PM in the Dialysis (process that removes excess water and toxins from the blood when the kidneys can no longer perform these functions) Unit, showed opened bottles of Minncare HD Disinfectant (used for disinfection for water purification systems for dialysis) and Aloe Vesta Cleansing Foam with no date of when opened. He stated that he should have dated the bottles when they were opened.

13. Review of the hospital's policy titled, "Expired items, disposal of Assets/Property and Other Items," dated 08/08/19, showed that departments are to assure that no expired items/supplies are in use or available within their departments.

Observation on 10/26/21 at 1:30 PM, on the Medical/Surgical Unit showed a plastic bin labeled stroke box which contained numerous blood collection tubes that had expired between 03/31/21 and 07/31/21. The crash cart contained a bottle of 0.9% Sodium Chloride which expired 10/01/21.

During an interview on 10/26/21 at 1:40 PM, Staff N, RN, Charge Nurse, stated that she had never used the stroke box and was not sure who was supposed to be checking the outdates on the boxes. Pharmacy restocked the crash carts.

14. Review of the hospital's policy titled, "Food and Supply Storage," revised 05/2021, showed directives for staff that all food shall be stored in such a manner as to prevent contamination to maintain safety and wholesomeness of the food for human consumption. Date and rotate items.

Observation on 10/26/21 at 1:15 PM on the Medical/Surgical Unit in the patient refreshment/snack area, showed drawers that contained buttery spread, mayonnaise, coffee, jelly, sugar packets, salt/pepper packets and graham crackers with no expiration dates.

During an interview on 10/26/21 at 1:20 PM, Staff M, Quality Director, stated that she would not be able to know when these foods expired.

Observation on 10/26/21 at 2:20 PM on the Adolescent Psychiatric Unit in the patient refreshment/snack area, showed drawers that contained ketchup, honey mustard, mayonnaise, sugar and sweetener packets with no expiration dates.

During an interview on 10/26/21 at 2:25 PM, Staff SS, Nursing Vice President, stated that she would not be able to know when these foods expired, but dietary replaced these items frequently.

15. Review of the oven cleaning instructions provided by the hospital, showed that the ovens should be cleaned with soap and water daily and rinse and dry with a clean cloth. For stubborn accumulations, a commercial oven cleaner may be used. To remove grease and food splatter that have baked on the equipment, apply cleanser to a damp cloth or sponge and rub cleanser on the metal in the direction of the polishing lines on the metal. Soil and burnt deposits which do not respond to the above procedure can usually be removed by scouring the surface with scouring pads or stainless scouring pads.

Observation on 10/27/21 at 10:40 AM, in the kitchen, showed ovens which had a gummy residue (burned on grease) on the inside and outside and had unknown particles which were on the surface of the oven lip.

During a concurrent interview, Staff UU, Food Service Director, stated that the ovens were cleaned on a daily basis with soap and water. She stated that the manufacturer had never cleaned the ovens.

16. Review of the hospital's policy titled, "Medications General Administration," revised 09/2021, gave directive for staff to cleanse top of the medication vial with an alcohol wipe before drawing up the prescribed dose of medication.

Observation on 10/27/21 at 8:40 AM on the Medical/Surgical unit showed Staff N, RN, Charge Nurse, remove the cap from a vial of blood thinner and draw up the medication with a needled syringe. Staff N did not cleanse the top of the medication vial prior to drawing up the medication.

During an interview on 10/27/21 at 8:45 AM, Staff N stated that she should have cleaned the top of the vial before drawing up the medication, she was nervous and forgot to do this.

Observation on 10/27/21 at 9:30 AM on the Telemetry Unit, showed Staff PP, RN, remove the cap from a vial of pain medication and draw up the medication with a needled syringe. Staff PP did not cleanse the top of the medication vial prior to drawing up the medication.

During an interview on 10/27/21 at 9:35 AM, Staff PP stated that she does not cleanse the top of the medication vial if it was brand new and had never been opened.

Observation on 10/27/21 at 10:00 AM on the Telemetry Unit, showed Staff RR, RN, remove the cap from a vial of antibiotic solution and draw up the medication with a needled syringe. Staff RR did not cleanse the top of the medication vial prior to drawing up the medication.

During an interview on 10/27/21 at 10:30 AM, Staff K, Telemetry Unit Manager, stated that her expectation of nursing staff was to clean the top of medication vials prior to drawing up the medication and IV dressings should be dated and timed.

During an interview on 10/28/21 at 11:30 AM, Staff E, Infection Control RN, stated that his expectations were that all surfaces within the hospital should be cleanable and the plywood used in the patient windows was not cleanable. He stated that all staff should perform hand hygiene when entering and exiting a patients room and between glove changes. Adolescent Psych patient cups should not be reused because there was no way to guarantee they were properly cleaned between patient use. Any supply like oral airways should be in individualized packages; not placed unwrapped in a plastic box. All blood glucose controls and strips should be dated for expiration and that any supply used for patients should be dated when opened. IV tubing and dressings should be labeled per hospital policy.



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Based on interview, record review and policy review, the hospital failed to ensure that one Emergency Department (ED) physician (Staff NNN) of two ED physician medical staff personnel records reviewed, maintained required advanced lifesaving certifications. This had the potential to lead to poor outcomes and possibly death when emergency care was necessary. The ED saw approximately 1782 patients per month. The facility census was 46.

Findings included:

1. Review of the hospital's document titled, "Medical Staff - Rules and Regulations," revised 07/2020, showed that the qualifications for clinical privileges in Emergency Medicine was certification in Advanced Trauma Life Support (ATLS, certification for medical providers in the management of acute trauma cases) and certification in Advanced Cardiac Life Support (ACLS, specific life saving measures taken by certified health professionals when a patient's heartbeat or breathing stops) and Pediatric Advanced Life Support (PALS, specific life saving measures taken by a certified health professionals when a pediatric patient's heartbeat or breathing stops).

Review of the credentialing file and recent work schedule for Staff NNN, Emergency Department (ED) Medical Director, showed the following:
- He was reappointed to the Medical Staff on 04/01/21, after an annual appraisal.
- His ACLS certification expired 07/2021.
- His PALS certification expired 07/2021.
- In 08/2021, Staff NNN worked 15 days in the ED.
- In 09/2021, Staff NNN worked 13 days in the ED.
- In 10/2021, Staff NNN worked 13 days in the ED.
- From 11/1/21 through 11/4/21, Staff NNN worked 3 days in the ED.

Staff NNN, ED Medical Director had worked 44 days in the ED with expired ACLS and PALS certifications. This had the potential to negatively affect ED patient safety and care.

During an interview on 11/04/21 at 9:45 AM, Staff YYY, Credentialing Coordinator, stated that she was not aware that the ED Medical Director's ACLS and PALS was expired. She had only been at her current position for two weeks.