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Based on interview and record review, the hospital's Governing Body failed to ensure contracted services were included in the Quality Assessment and Performance Improvement (QAPI) Program to assess that the services provided met the facility's quality standards for five contracts of five contracts reviewed. The facility contracted nine services, of which seven of them provided direct or indirect patient care. This had the potential to put all patients at risk for substandard quality care and compromised their health and safety. The facility census was 38.

Findings Included:

1. Review of five out of five written contracts presented to the team were outdated, and had no QAPI written into the contract.

Review of the facilities QAPI meeting minutes showed no review of the services provided by contracts.

During an interview on 04/11/19 at 12:10 PM, Staff RR, Central Operations Director, stated that the agreement for pediatric ventilators (a machine that pushes air into a patients lungs when they cannot breathe on their own) preventative maintenance was not a formal written contract. There was a verbal agreement between him and the company representative for cleaning and maintenance.

During an interview 04/11/19 at 1:57 PM, Staff UU, Chief Executive Officer (CEO), stated that the current process in place for contract regulation and review was not an acceptable practice.



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Based on interview, record review, and policy review, the facility failed to ensure staff followed facility policy when they failed to perform emergency cart tasks as required for two crash carts (also known as emergency cart, mobile cart which contains emergency medical supplies and medications) of two crash carts reviewed. This failed practice had the potential to allow ineffective or nonfunctional equipment to be used for emergency patient care. The facility census was 38.

Findings included:

1. Review of the facility's policy titled, "Crash Cart and Airway Bag (contains emergency equipment related to breathing)," reviewed 02/2019, showed:
- The facility would maintain an emergency cart for use in emergency situations.
- Crash carts would contain a cardiac monitor (a device that records the rate and rhythm of the heart), Automated External Defibrillator (AED, a device that automatically analyzes the heart rhythm and treats with an electrical therapy if necessary), backboard (medical device that is placed under a patient to stabilize their movement), and sharps container (trash receptacle to store used needles after they have been used).
- A daily check of the emergency cart would occur by respiratory therapy and would be documented on the daily crash cart checklist.

Review of the East Unit emergency response equipment daily checklist on 04/11/19 at 10:17 AM, showed that the emergency cart checks were not conducted on 04/10/19.

Review of the East Unit weekly glucometer (a small, portable machine used to measure a type of sugar in the blood) quality control testing (a procedure or set of procedures intended to ensure that a manufactured product adheres to a defined set of quality criteria) log showed that tests were not conducted for the weeks of 02/27/19 and 03/13/19.

During an interview on 04/11/19 at 10:17 AM, Staff MM, Registered Nurse (RN), Nurse Manager, stated that respiratory therapy staff were responsible for emergency cart daily equipment checks. Staff MM stated that nursing staff were responsible for emergency cart weekly glucometer quality control tests when weekly cart checks were conducted.

Review of the West Unit emergency response equipment daily checklist on 04/09/19 at 2:30 PM, showed that the emergency cart checks were not conducted on 02/09/19, 02/10/19, and 02/25/19.

Review of the West Unit weekly glucometer quality control testing log showed that tests were not conducted for the weeks of 02/13/19 and 02/20/19.

During an interview on 04/09/19 at 2:30 PM, Staff A, Clinical Operations Manager, stated that respiratory therapy staff were responsible for emergency cart daily equipment checks. She further stated that they were to account for all of the emergency response equipment and to ensure the items were plugged in and functioned properly. Staff A stated that nursing staff were responsible for emergency cart weekly glucometer quality control tests when weekly cart checks were conducted.

Based on record review, policy review, and review of the Revised Statutes of Missouri (RSMo), the facility failed to ensure restraints were ordered only by a physician, when the facility allowed Nurse Practitioners (NPs) to order non-violent restraint (devices used to restrict a person's movement of their arms or legs, to promote medical healing and/or diminish patient risk of suffering or physical harm) for two current patients (#23 and #24) of two current patient and two discharged patient records reviewed. This failure had the potential to cause poor nursing care outcomes for restrained patients. The facility census was 38.

Findings included:

1. Review of the facility's policy titled, "Restraint Use," reviewed 02/2019, showed:
- Advanced Practice Nurses (APNs) may write orders for restraints, but those orders must be co-signed by a Physician.
- The use of restraints must be in accordance with the order of a Physician or APN.
- In emergency application situations, an order must be obtained from a Physician or APN either during the emergency application of the restraint, or immediately after the restraint has been applied.
- Each episode of restraint must be initiated in accordance with the order of a Physician or APN.
- Each order for restraint must be renewed every 24 hours and co-signed by a physician if ordered by an APN.
- Notification of the use of restraint to the attending physician must be documented in the medical record if ordered by an APN.

Record review of RSMo 630.175 showed that an APN who is in a collaborative practice with a physician, can only write restraint orders for behavioral health patients in hospitals that only provide psychiatric care, and in dedicated psychiatric units of general acute care hospitals.

Review of orders for Patient #23 showed a non-violent restraint order dated 03/02/19 at 8:19 AM, written by Staff VV, APN.

Review of orders for Patient #23 showed a non-violent restraint order dated 03/30/19 at 8:52 AM, written by Staff CC, APN.

Review of orders for Patient #24 showed a non-violent restraint order dated 03/16/19 at 9:36 AM, written by Staff CC, APN.

Based on observation, interview, record review, and policy review, the facility failed to ensure all medications were secure for one emergency cart of two emergency carts observed. This failure had the potential to allow unauthorized access of medications by personnel, visitors, and patients. The facility census was 38.

Findings included:

1. Review of the facility's policy titled, "Crash Cart (mobile cart which contains emergency medical supplies and medications and Airway Bag (contains emergency equipment related to breathing)," reviewed 02/2019, showed emergency carts would be secured with a breakaway lock (numbered, plastic, tamper-evident lock that opens with a twist and pull, but cannot be resealed).

Observation on 04/11/19 at 10:17 AM, showed the unattended East Unit emergency cart did not have a breakaway lock in place.

Review of the East Unit's Emergency Cart Checklist Signature Sheet dated for the month of April 2019, showed that on 04/09/19, a new breakaway lock number was not entered (left blank) after nursing staff completed the weekly emergency cart content checklist.

During an interview on 04/09/19 at 2:30 PM, Staff A, Clinical Operations Manager, stated that numbered breakaway locks were changed weekly, on Wednesdays, when two nurses verified cart content and expiration dates. Staff A further stated carts were checked and locks were changed immediately after an emergency event.

During an interview on 04/11/19 at 10:20 AM, Staff MM, Registered Nurse (RN), Nurse Manager, confirmed the emergency cart was not secured with a breakaway lock and stated that there should have been a lock in place.

During an interview on 04/11/19 at 10:32 AM, Staff JJ, RN, Nursing Supervisor, stated that additional breakaway locks for emergency carts were available and located in a locked cabinet in the manager's office.

Based on observation, interview, and policy review, the facility failed to ensure that outdated, mislabeled, or otherwise unusable emergency medications were unavailable for patient use in one emergency cart (West Unit) of two emergency carts observed. This failed practice had the potential to affect all patients admitted to the facility with a life-threatening situation. The facility census was 38.

Findings included:

1. Review of the facility's policy titled, "Crash Cart (mobile cart which contains emergency medical supplies and medications) and Airway Bag (contains emergency equipment related to breathing)," reviewed 02/2019, showed that emergency carts would contain medications needed for an emergency response, which included a sealed (locked) medication tray maintained by pharmacy staff.

Review of the facility's policy titled, "Medication Area Inspection," reviewed 02/2019, showed that any medication(s) in a container with a missing label would be returned to the pharmacy to prevent administration to the patient.

Observation and concurrent interviews on 04/09/19 at 2:30 PM, showed the West Unit emergency cart contained a sealed seizure (excessive activity in the brain which causes uncontrolled jerking movements) medication tray that failed to have a label with an expiration date. Staff A, Clinical Operations Manager, verified the seizure medication tray did not have a label with an expiration date and stated that it should. Staff A removed the tray from the emergency cart and presented it to Staff DD, Pharmacy Director. Staff DD stated that she forgot to place the label on the tray.

Based on observation, interview, record review, and policy review, the facility failed to ensure staff removed outdated/expired medical supplies for two emergency carts (West and East Units) of two emergency carts observed. These failed practices had the potential to allow ineffective or harmful medical supplies and equipment to be used for emergency patient care. The facility census was 38.

Findings included:

1. Review of the facility's policy titled, "Crash Cart (mobile cart which contains emergency medical supplies and medications) and Airway Bag (contains emergency equipment related to breathing)," reviewed 02/2019, showed:
- The facility would maintain emergency carts for use in emergency situations.
- Emergency carts would contain medical supplies needed for emergency response.
- Carts would be opened and checked weekly by nursing staff to ensure items contained were the correct quantity and had not expired, and checks would be documented on the Crash Cart Content Checklist.
- Missing or expired items would be replaced and the carts would be re-locked.

Observation of the West Unit emergency cart on 04/09/19 at 2:30 PM, showed an artificial airway (medical device used to transport oxygen into a person's lungs) that expired 02/2019.

Review of the West Unit Weekly Emergency Cart Content Checklist on 04/09/19 at 2:30 PM, showed that on 04/03/19, an artificial airway (expired 02/2019) was present and the expiration date was checked.

During an interview and concurrent observation on the West Unit on 04/09/19 at 2:30 PM, Staff A, Clinical Operations Manager, stated she was already aware the facility had an expired artificial airway in the emergency carts and that the replacement order had arrived and was on her desk. Staff A further stated that the expired item would be pulled from the carts and exchanged with the new replacement item the following day, 04/10/19, when nursing staff were scheduled to conduct the weekly cart checks. Staff A then returned the expired item to the emergency cart for potential patient use.

Review of the East Unit Weekly Emergency Cart Content Checklist on 04/11/19 at 10:17 AM, showed that on 04/03/19, three medical supplies on the cart were documented as present and expired. One of those items included the same expired artificial airway (expired 02/2019) identified on the West Unit. The three expired items remained on the cart for potential patient use until 04/09/19.

Based on observation, interview, and policy review the facility failed to ensure that:
- Containers of food and food additives were marked with the date originally opened or an expiration date.
- Dry storage food was kept in appropriate containers to keep them from being contaminated.
- Sanitary conditions were maintained within the food preparation area.
This practice created an opportunity for expired, old food/food additives, and contaminated food to be served and cause food borne illness. This could potentially affect all patients and staff that consumed food in the facility. The facility census was 38.

Findings included
1. Review of the facility's policy titled, "Dietary Manual," reviewed 02/19 showed direction to staff that all food containers are to be clearly labeled and dated, and food should be stored in a safe and sanitary manner.

Observation in the walk-in refrigerator on 04/10/19 at 10:00 AM showed:
- Open plastic bags of food with the top open and without properly dated labels.
- An open bag of cheese without a way to close it and without properly dated labels.
- Open boxes of an adult nutritional drink and a children's nutritional drink without properly dated labels.

2. Observation in the dry storage area on 04/10/19 at 10:15 AM showed all food, and food prep items were stored in the original cardboard boxes they were shipped in and were not properly labeled.

During an interview on 04/10/19 at 10:30 AM, with Staff W, Dietary Manager, stated that all containers should have been labeled with the date they were opened. He stated it was policy to discard unused items 30 days after they were opened.

3. Observation of the food prep area on 04/10/19 at 10:25 AM showed a broken two burner industrial size deep fryer covered in grease and dust, stored next to the grill that was used to prepare patient and visitors food. Right above the grill and gas stoves were sprinkler heads that hung from the ceiling. The sprinklers were covered in grease and dust.