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A. Based on observation and staff interview, it was determined the facility failed to ensure dietary services was furnished in accordance with applicable State regulations. The dietary department failed to retain a sample of potentially hazardous foods from the menu of each meal under adequate refrigeration for a period of at least twenty-four (24) hours after serving. This failure has the potential to adversely affect all patients at the facility.

Findings include:

A tour of the dietary services department was conducted on 3/29/22 at 9:00 a.m. During the tour, no samples of potentially hazardous foods were located in the refrigerator.

An interview was conducted with the Director of the Dietary Services during the above noted tour. The Director concurred no potentially hazardous foods samples from each meal are kept for at least twenty-four (24) hours after serving.

B. Based on staff interview, it was determined the facility failed to provide in-service or training to radiology personnel including management of radiation hazards and equipment safety in accordance with State regulations. This failure has the potential to adversely affect all patients and staff who present to the radiology department.

Findings include:

An interview was conducted with the Radiology Manager on 3/30/22 at 10:39 a.m. The Manager concurred no in-service or training has been documented as occurring for radiation hazards and equipment safety for the radiology staff.

Based on document review and staff interview, it was determined the facility failed to ensure all emergency department (ED) physicians employed to provide services in the ED maintained certification in advanced cardiac life support (ACLS) as per Medical Staff By-Laws/Rules and Regulations. This failure was identified in one (1) of four (4) ED physicians reviewed (Physician #1). This failure has the potential to adversely affect all patients who present to the ED with a cardiac emergency.

Findings include:

A review of the ACLS certifications for the ED physicians revealed Physician #1 failed to have a current ACLS certificate. Physician #1's ACLS certification was dated 6/22/19.

A review of the Medical Staff By-laws and Rules and Regulations, dated 11/30/15, stated in part: "All physicians employed to provide services in the Emergency Department shall maintain current certification in advanced cardiac life support (ACLS)."

An interview was conducted with the Director of the ED on 3/30/22 at approximately 10:30 a.m. The ED Director concurred Physician #1 did not have an active ACLS certification. The Director also concurred all ACLS certifications are good for only two (2) years.

A. Based on document review and staff interview, it was determined the facility failed to ensure all nursing staff who provide care in the intensive care unit (ICU) had updated competencies for providing care in the ICU. This failure was identified in four (4) of ten (10) registered nurses (RN) providing patient care in the ICU and has the potential to adversely affect all patients.

Findings include:

A review of the training and competency for all nursing personnel providing care in the ICU revealed a Specialty Care Unit Annual Skills Checklist for RN #1 dated 8/30/19, a Specialty Care Unit Annual Skills Checklist for RN #2 dated 8/2014, a Specialty Care Unit Checklist for RN #3 dated 8/2009 and a Specialty Care Unit Checklist for RN #4 dated 9/2011.

An interview was conducted with the Nurse Manager of the Specialty Care Unit on 3/29/22 at approximately 1:30 p.m. The Nurse Manager concurred all trainings and competencies for the Specialty Care Unit staff should be completed annually. The Nurse Manager concurred training for RN #1 was 2019, RN #2 was 2014, RN #3 was 2009, and RN #4 was 2011.

B. Based on observation, document review, and staff interview it was determined the facility failed to ensure nursing staff were completing the daily checks on the external defibrillator used in the intensive care unit (ICU). This failure has the potential to adversely affect all patients receiving care in the ICU.

Findings include:

A tour of the facility conducted on 3/28/22 at 12:30 p.m. with the Nurse Manager of the ICU revealed the crash cart log for March 2022 revealed no documentation of daily checks for 3/2, 3/7, 3/8, 3/9, 3/12, 3/15, 3/19, and 3/20/22.

A review of the policy titled "Equipment Checks," (no date), stated in part: "Defibrillators are checked by RN or CNA [Certified Nursing Assistant] on 3-11 shift ... The cardiac cart must be checked daily by the individual appointed by the charge nurse on 7-3 shift."

An interview was conducted with the Nurse Manager during the above noted tour. The Nurse Manager concurred the crash cart had not been checked as per policy.

Based on document review and staff interview it was determined the hospital failed to ensure the total procedure time, the names of nursing personnel in attendance during the procedure, and the pre-operative and post-operative diagnosis was documented in the operative log for all patients. This failure has the potential to adversely affect record keeping for all procedures performed in the operating rooms.

Findings include:

A review of hospital policies revealed there was no policy or procedure for completing the operative log in the surgical department.

A review of the hospital book entitled "Recovery Room Register" revealed staff were using it as their operative log, and it did not contain the total procedure time, the names of the nursing personnel in attendance, or the pre-operative and post-operative diagnosis for any operative procedures listed in the register.

A review of a black notebook, identified as an operative log staff are also using, revealed it had the procedure start and stop time but did not contain the total procedure time, the names of any nursing personnel in attendance, or the pre-operative or post-operative diagnosis for any operative procedures listed.

An interview was conducted with the Utilization Review nurse on 3/29/21 at approximately 1:00 p.m. and he/she agreed with the above findings.

A. Based on observation and staff interview, it was determined the facility failed to provide a sanitary environment to avoid sources and transmission of infections and communicable diseases. This failure was identified during a tour of the nursing unit and has the potential to adversely affect all patients with the potential exposure to infections and communicable diseases.

Findings include:

A tour of the facility's medical/surgical nursing unit conducted on 3/28/22 at 12:30 p.m. with the Director of Nursing (DON) revealed a patient supply cart located in the hallway of the nursing unit which had a purse, patient clothing and a small pack of opened batteries.

During the above noted tour, the DON concurred with the findings of the supply cart.

B. Based on observation, document review and staff interview, it was determined the dietary service department failed to provide a sanitary environment to avoid sources and transmission of infections and communicable diseases. This failure has the potential to adversely affect all patients at the facility.

Findings include:

A tour of the dietary service department conducted on 3/29/22 at 9:00 a.m. revealed the freezer had large amounts of boxes of frozen foods sitting on the floor. The surveyor was unable to step into the freezer due to the boxes sitting on the floor.

A review of the policy titled "Dietary Services," last revised 05/2013, stated in part: "lll. Food Products and Storage: ... 2. Food must be stored sufficiently above floor level."

During the above noted tour, the Director of Dietary Services concurred there were large amounts of boxes of frozen foods in the freezer sitting on the floor.

Based on document review and staff interview, it was determined the facility failed to provide timely notice of discharge or transfer of patients in swing bed status. This failure was identified in three (3) of eleven (11) discharges from swing bed status (patients #21, 22 and 23). This failure has the potential to adversely affect all patients being discharged from the facility.

Findings include:

A review of the transfer/discharge of patient #21 revealed the patient was admitted to swing bed status on 1/28/22 and was discharged on 2/11/22. No notice of discharge was made by the facility prior to the patient's discharge.

A review of the transfer/discharge of patient #22 revealed the patient was admitted to swing bed status on 2/14/22 and was discharged on 2/18/22. No notice of discharge was made by the facility prior to the patient's discharge.

A review of the transfer/discharge of patient #23 revealed the patient was admitted to swing bed status on 2/9/22 and was discharged on 2/28/22. No notice of discharge was made by the facility prior to the patient's discharge.

An interview was conducted with the Social Worker (SW) on 3/30/22 at 12:15 p.m. The SW concurred no notice of discharge was made by the facility for patients #21, 22 and 23 prior to discharge.