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Based on observation and record review, the facility failed to remove outdated vacutainer blood collection tubes according the facility's policy from 1 of 1 supply carts resulting in the potential for less-than-optimal outcomes for three patients present in the facility. Findings include:

On 11/13/2024 at 1140, six vacutainer blood collection tubes in the top drawer of the facility's hyperthermia cart were observed to be expired. Three green vacutainer blood collection tubes had an expiration date of 9/30/2024 and three blue vacutainer blood collection tubes had an expiration date of 8/31/2024. Director of Operating Room Services Staff V confirmed the findings at the time of discovery.

According to the facility's policy "Supplies Inventory and Outdates," dated 6/2024, the policy revealed that "On the 25th of each month the Midnight Shift Certified Nursing Assistant will check all supplies for the expiration dates" and "Any items that are outdated will be removed from inventory and a requisition will be placed with Materials Management."

Based on observation and interview, the facility failed to ensure Emergency Medical Equipment was available for use, resulting in the possibility of adverse outcomes for all patients that present to the Emergency Department (ED).

On 11/13/2024 at 1123 a tour of Room 1 in the ED was conducted with Staff L (ED RN) and revealed the Broslow Bag (Emergency Resuscitation Kit for pediatric patients) did not have the most current version of the Broslow Tape (the tape used to measure patient length which provides medication dosing and appropriate equipment sizes) is available for use. The Broslow Tape in the Kit was dated 2002(a) and the most current edition available is 2019. When queried if a current (2019) version of the Broslow Tape was available for use, Staff L revealed "this is the only one I am aware of".

On 11/13/2024 at 1130 during the tour of the ED Staff L was queried if the facility had a Precipitous Birth Kit available for use. Staff L revealed the kit could be found in the "Clean Supply Room" and directed surveyor to an unmarked room located near the ED. Upon entry into the supply room, the area was found to be in disarray and a cart located in the corner contained various obstetric supply kits. The Precipitous Birth Kit was found in sterile packaging dated 2003 with a cardboard box of teddy bears and the exhaust hose for an air purifying system was on top of the cart.

On 11/14/2024 at 0935 an interview with the Director of Infection Control (Staff I) and a tour of the "Clean Supply Room" was conducted. Staff I revealed she had been notified about the infection and quality control concerns related to the supplies in the room and the facility is "going to have the kits re-sterilized and clean the area".

Based on observation, interview, and record review, the facility failed to provide and maintain adequate physical facilities for the safety and needs all patients and was found not in compliance with the requirements for participation in Medicare and/or Medicaid 42 CFR Subpart 485.623(c), Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care, resulting in the potential for negative outcomes up to and including death in the event of a fire. Findings include:

See tag:

C-0912 - Failure to maintain physical plant space
C-0930 - Failure to comply with applicable provisions of the 2012 edition of the Life Safety Code
C-0914 - Failure to maintain patient-care equipment

Based on observation, interview and record review, the facility failed to maintain the hospital building's walls and flooring in various areas rendering these areas not cleanable, resulting in the possible spread of infectious agents to all patients in the facility. Findings include:

1. On 11/13/24 at 1100 peeling paint from the walls in linen storage room next to room 154 was observed. Staff D was asked why the paint was peeling and Staff D stated they were not aware of the peeling paint in the room. They also stated no ticket was submitted by staff for repair in the Spiceworks system.

2. On 11/13/24 at 1102 peeling paint and degraded plaster were observed behind the toilet in room 154's bathroom. Staff D was asked if they knew of this and Staff D stated they were not aware. They stated that they replaced a valve in the plumbing for the toilet approximately 10 years ago and the plaster is now degrading from this repair. They also stated no ticket was submitted by staff for repair in the Spiceworks system.

3. On 11/13/24 at 1120 peeling paint and degraded plaster were observed behind the toilet in room 171's bathroom.

4. On 11/13/24 at 1132 two 6 inch by 6 inch floor tiles were missing underneath the steam autoclave in the central supply cleaning room as well as 2 rags and a bucket under the plumbing supply lines for the autoclave were observed. Staff D was asked why the tiles were missing and why the rags and bucket were there and Staff D stated that the tile was missing for as long as they can remember and were not aware that the rags and bucket were there.

5. On 11/13/24 at 1232 it was observed that approximately two feet of baseboard was missing on the south wall of the laboratory. Staff D was asked why this baseboard was missing and they stated that it must have been missed after completing a renovation construction project along this wall.

Based on interview and record review, the hospital failed to provide a preventative maintence program for mechanical equipment in the hospital resulting in potential failure of this equipment that could result in bad outcomes for patients being treated at the hospital. Findings include:

1. On 11/13/24 records were requested for preventative maintenance that was performed on the air handling units and exhaust fan units serving the hospital and Plant Operations staff D could not provide these records. They stated that the hospital had a server change approximately a year ago and these records were lost. Staff D was asked why another program was not created. Staff D stated that they haven't been able to create another one.

Based on observation, interview, and record review, the facility failed to provide and maintain adequate physical facilities for the safety and needs all patients and was found not in compliance with the requirements for participation in Medicare and/or Medicaid 42 CFR Subpart 485.623(c), Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care, resulting in the potential for negative outcomes up to and including death in the event of a fire. Findings include:

See following K tags from corresponding LSC survey:
K-321
K-761
K-781
K-908
K-919
K-923

Based on interview and record review, the facility failed to investigate a grievance according to the facility's policy for 1 (P-1) of 20 patients reviewed, resulting in the loss of the patient's right to resolution of a grievance, and the potential for less-than-optimal outcomes. Findings include:

According to medical record, P-1 was discharged from the facility's Emergency Department on 9/20/2023. On 9/21/2023 at 0930, P-1 called the facility to make a complaint. Director of Risk Management Staff E received the complaint and according to the facility's "Patient Relations Communication Form/Grievance Form," P-1 "states he is calling to complain about the ER physician. States seven times he has had panic attacks." The form also revealed that P-1 "usually receives Xanax or an IV (intravenous)." P-1 "was here at 6:15 a.m." P-1 stated "he has never felt so humiliated. He had to drive all the way to (another city)."

According to the "patient/caller desired resolution" section of the Grievance Form, P-1 "never stated desired resolution."

According to the "actions taken to address complaint/concern" section of the Grievance Form: P-1 "was here in our ER around 6 am with Physician Staff H and came to our ER today around 3 p.m. with Physician Staff S. (Police Officer) from the (local police department) was called. (Police Officer) talked to the patient and stayed during the time P-1 was here."

According to the "Follow-up/problem resolution section of the Grievance Form:" "Due to the nature of P-1's continued inappropriate and unacceptable behaviors in the Emergency Department will discuss issuing a no trespassing letter. The letter will state patient can only come to our hospital for an emergency."

According to the "Is patient satisfied with resolution?" section of the Grievance Form, the report revealed that the "no" box was checked (the patient was not satisfied with resolution) with the following information: "Phone call made to patient. Patient still upset with (facility). After discussion, a no trespassing letter was not sent due to nature of patient's violent behavior and concern that patient would come after hospital staff after receiving letter."

According to the "Complaint/Concern" section of the Grievance Form: P-1's concern was labeled as a "complaint" and the complaint was "Unsubstantiated."

On 11/14/2024 at 1020, Director of Risk Management Staff E was asked why the complaint was not handled as a grievance and Staff E said they believed it was a "complaint."

According to the facility's policy "Patient Relations: Complaints, Grievances, and Appeals Process," dated 3/2024, the policy revealed that a definition of a complaint was "A written or verbal concern from a patient, or patient's designated representative about care and/or services provided by (the facility) that can be promptly resolved by informal means." The definition of a grievance was "A formal written or verbal grievance that is filed by a patient or a patient's designated representative when a patient issue cannot be resolved promptly by (the facility's) staff."

Based on observation and interview, the facility failed to store patient care equipment away from dirty equipment in 1 of 1 storage areas observed, resulting in the potential for transmitting infectious diseases to the three patients in the facility at the time of observation. Findings include:

On 11/13/2024 at 1115, a patient sliding board was observed stored upright in a storage room with the head of the sliding board touching the dirty floor. A dirty mop head was observed at the head of the sliding board contacting both the sliding board and the dirty floor. The mop handle was leaning against the sliding board. Director of Nursing (DON) Staff C was queried if the storage room was a clean or dirty storage room and Staff C said "clean." DON Staff C confirmed the findings at the time of discovery.

Based on observation and interview the facility failed to post EMTALA signs in the areas most likely to be noticed by all individuals that enter the emergency department (ED) via the ambulance entrance resulting in the potential for all patients that enter the facility through this entrance to be uninformed of their rights. Findings include:

On 11/13/2024 at 1110 during a tour with the Director of Nursing (Staff C) of the ED ambulance entrance, it was observed that the facility failed to have EMTALA (Emergency Medical Treatment and Active Labor Act) signage notifying patients of their rights under EMTALA. Staff C was queried where EMTALA signs were posted in the ED. Staff C responded that EMTALA signage was posted in the main entrance waiting area of the facility. Staff C was then queried if EMTALA signage was posted in the ambulance entrance, which is also used as an after hour entrance for all patients presenting to the ED. Staff C stated the only area that she has ever had the EMTALA signage posted was in the front entrance area.