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Based on review of facility documents, personnel files (PF) and staff interview (EMP), it was determined one of thirteen personnel files did not include all required documents per the job description (PF10).

Evangelical Community Hospital. American Heart Association Life Support Training. "POLICY: Hospital job descriptions designate which positions require Basic Life Support (BLS), Advanced Cardiac Life Support (ACLS) and Pediatric Advanced Life Support (PALS). The Hospital abides by evidence informed resuscitation practices recognized by the International Liaison Committee on Resuscitation (ILCOR). The Hospital accepts resuscitation credentials awarded through the American Red Cross (ARC), American Heart Association (AHA), or other organizations that provide training administered in accordance with the AHA and/or ILCOR guidelines. For the convenience of employees, the Hospital provides access to online ARC certification through (name of educational provider)".

Job description labeled "Nursing Coordinator Acute Care ... Qualifications ... 3. BLS and ACLS, are required. ... "

Review of PF10 on October 31, 2024, revealed PF10 contained a job description for Nursing Coordinator Acute Care signed and dated October 29, 2024. PF10 did not contain the required ACLS documentation.

Interview with EMP4 and EMP13 on October 31, 2024, at 1100 confirmed the findings noted above.

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure an order for restraint was obtained for non-violent restraint use in two of two medical records reviewed (MR74 and MR75).

Findings include:

Review on October 31, 2024 of the facility policy "Physical Restraints/Chemical Restraints," last reviewed April 10, 2024, revealed "Purpose: The purpose of this policy is to 1. prevent interference/obstruction with medical treatment (such as self extubation and intubation). 2. protect medical devices (such as intravenous lines, in-dwelling urinary catheters, and feeding tubes). 3. prevent falls and injury. 4. control disruptive behavior (such as agitation, wandering, and combativeness). 5. prelude the possibility of harming self, staff and other patients. ... Procedures: ... 2. Use of Restraints in Medical or Post-Surgical Care: a) When clinically indicated, the restraint procedure is implemented by an RN who is trained in restraint technique upon a physician's/L.I.P. (Licensed Independent Practitioner) order. Physician/L.I.P. may delegate ordering restraint to physician assistant or advance practice nurse in both behavioral health and acute care non-behavioral health care settings. ... d) A restraint order expires after 24 hours and must be reordered if restraints continue to be required. ..."

Review on October 31, 2024 of MR74 revealed the patient had bilateral soft wrist restraints in place beginning January 1, 2024, at 0949, and discontinued January 10, 2024, at 1200. Documentation noted restraints orders on January 1, 2024, at 0949, January 2, 2024, at 1041, and January 3, 2024, at 0947. There were no orders for restraint use on January 4, 2024, January 5, 2024, January 6, 2024, January 7, 2024, January 8, 2024, January 9, 2024, or January 10, 2024.

Interview with EMP1 and EMP4 on October 31, 2024, at 1323, confirmed the findings noted above in MR74. EMP1 confirmed the restraint order on January 2, 2024, at 1041, was later than the 24- hour time frame.

Review on October 31, 2024 of MR75 revealed the patient had bilateral soft wrist restraints in place beginning January 5, 2024, at 0944, and discontinued January 16, 2024, at 2330. Documentation noted restraint orders on January 5, 2024, at 0944, January 6, 2024, at 1251, January 7, 2024, at 0738, January 8, 2024, at 0958, January 9, 2024, at 1004, January 10, 2024, at 0816, January 11, 2024, at 1017, January 12, 2024, at 0826, January 13, 2024, at 1113, January 14, 2024, at 1119, January 15, 2024, at 1019, and January 16, 2024, at 0906.

Interview with EMP1 and EMP4 on October 31, 2024, at 1335, confirmed the findings noted above in MR75. EMP1 confirmed the restraint orders on January 6, 2024, at 1251, January 8, 2024, at 0958, January 9, 2024, at 1004, January 11, 2024, at 1017, January 13, 2024, and at 1113, January 14, 2024, at 1119, were ordered later than the 24-hour time frame.

Based on observation, review of facility policy and dish machine temperature logs, and staff (EMP) interview, it was determined the facility failed to ensure dietary supervisory staff monitored the dish washer temperature logs and intervened when final dish washer rinse temperatures did not meet minimum temperatures for sanitation in forty-five (45) of ninety (90) days reviewed.

Findings include:

Review on October 29, 2024, of " Dishwashing and Flatware Washing " policy, last reviewed by the facility on November 10, 2023, revealed: " Purpose: To assure that all dishes and flatware are properly cleaned and sanitized to maintain the health and well-being of clients. Dish machine temperatures of wash, rinse, and surface are recorded three times daily on the Temperature Log. If temperatures are below minimum, staff will notify Director, Operations Manager, Cook, or Plant Engineering Department. ... "

Tour and observation conducted on October 29, 2024, at 1050 of the dietary services department revealed the October dishwasher temperature monitoring log located in the dishwasher area.

Review of the Dish Machine Temperature Monitoring Chart for October 2024 revealed the dishwasher did not reach the minimum final rinse temperatures (temp) of 180 degrees Fahrenheit (F) on the following dates: October 1, 2024 (9:00 A.M. temp 179F, 6:00 P.M. temp 171F), October 8, 2024 (6:00 P.M. temp 177F), October 9, 2024 (6:00 P.M. temp 179F), October 13, 2024 (6:00 P.M. temp 172F), October 14, 2024 (6:00 P.M. temp 173F), October 15, 2024 (6:00 P.M. temp 168F), October 16, 2024 (6:00 P.M. temp 169F), October 23, 2024 (6:00 P.M. temp 179F), October 24, 2024 (6:00 P.M. temp 159F), and October 28, 2024 (1:00 P.M. temp 179F and 6:00 PM temp 178F). There was no indication of interventions taken for the dishwasher not meeting minimum temperatures during the final rinse documented on the log.


Review on October 29, 2024, at approximately 1100, of the Dish Machine Temperature Monitoring Chart for September 2024 revealed the dishwasher did not reach the minimum final rinse temperatures (temp) of 180 degrees Fahrenheit (F) on the following dates: September 5, 2024 (6:00 P.M. temp 179F), September 7, 2024 (9:00 AM temp 172F), September 8, 2024 (1:00 P.M. temp 170F), September 11, 2024 (6:00 P.M. temp 173F), September 12, 2024 (6:00 P.M. temp 169F), September 13, 2024 (6:00 P.M. temp 173F), September 14, 2024 (6:00 P.M. temp 178F), September 16, 2024 (1:00 P.M. temp 177F), September 17, 2024 (1:00 P.M. temp 179F and 6:00 P.M. temp 171F), September 19, 2024 (6:00 P.M. temp 176F), September 20, 2024 (1:00 P.M. temp 179F), September 23, 2024 (6:00 P.M. temp 176F), September 24, 2024 (6:00 P.M. temp 178F), September 27, 2024 (1:00 P.M. temp 179F) and September 28, 2024 (1:00 P.M. temp 170F). There was no indication of interventions taken for the dishwasher not meeting minimum temperatures during the final rinse documented on the log.

Review on October 29, 2024, at approximately 1105, of the Dish Machine Temperature Monitoring Chart for August 2024 revealed the dishwasher did not reach the minimum final rinse temperatures (temp) of 180 degrees Fahrenheit (F) on the following dates: August 3, 2024 (9:00 A.M. temp 170F), August 6, 2024 (1:00 P.M. temp 177F and 6:00 P.M. temp 174F), August 7, 2024 (1:00 P.M. temp 173F and 6:00 P.M. temp 172F), August 8, 2024 (6:00 P.M. temp 170F), August 9, 2024 (6:00 P.M. temp 170F), August 12, 2024 (9:00 A.M. temp 160F), August 13, 2024 (9:00 A.M. temp 160F and 6:00 P.M. temp 171F), August 14, 2024 (9:00 A.M. temp 177F), August 15, 2024 (9:00 A.M. temp 178F), August 16, 2024 (9:00 A.M. temp 176F), August 17, 2024 (9:00 A.M. temp 170F), August 21, 2024 (9:00 A.M. temp 170F and 6:00 P.M. temp 170F), August 22, 2024 (9:00 A.M. temp 170F and 6:00 P.M. temp 172F), August 23, 2024 (9:00 A.M. temp 171F), August 24, 2024 (9:00 A.M. temp 172F), August 25, 2024 (9:00 A.M. temp 170F), August 26, 2024 (9:00 A.M. temp 170F and 6:00 P.M. temp 175F), August 27, 2024 (9:00 A.M. temp 170F and 6:00 P.M. temp 176F), August 28, 2024 (9:00 A.M. temp 170F and 6:00 P.M. temp 178F) and August 29, 2024 (9:00 A.M. temp 170F and 6:00 P.M. temp 171F). There was no indication of interventions taken for the dishwasher not meeting minimum temperatures during the final rinse documented on the log.

Interview with EMP6 on October 29, 2024, at approximately 1125 confirmed the above findings. EMP6 stated they realized about a week ago the dishwasher wasn't maintaining minimum final rinse temperatures. EMP6 revealed Plant Engineering was contacted on October 29, 2024 to fix the dishwasher. EMP6 stated it was EMP5 and EMP6's responsibility to oversee the Dish Machine Temperature Monitoring Chart logs.

Based on review of facility documents and staff interview (EMP), it was determined the facility failed to ensure safety was maintained with temperature monitoring on a hot pack and a cold pack machine.

Findings include:

Review on October 31, 2024 of the facility policy "Hydra Therm Hot Packs " last reviewed March 15, 2024, revealed "Purpose: To ensure patient safety when receiving heat therapy. To ensure staff safety in the utilization of Heat Therapy using Hydra Therm hot packs and machine. To ensure staff are appropriately preparing for application of heat therapy. To ensure proper care of the equipment. Policy: The Rehabilitation Staff will adhere to the stated protocol and listed procedures when administering Heat therapy as a component of patient care. Procedure: ... 5. Care of Equipment: ... e. The hydrocollator should be emptied, thoroughly cleaned, and refilled every 3 months or sooner, if water discoloration occurs."

Review on October 31, 2024 of the facility policy, "Cold Pack Utilization and Cleaning, last reviewed January 10, 2024, revealed "Purpose: To ensure safe utilization of cold packs in cryotherapy in the treatment of patients and to ensure proper maintenance of equipment. ... Procedures: The rehabilitation staff will proceed with the following outlined procedures in the application of cold therapy, utilizing cold packs. ...7. Care of Equipment ... d. The cooling unit/freezer should be cleaned every 30 days."

Review on October 31, 2024 of the "Hydrotherm Daily Cleaning Log," for January 1, 2024-October 31, 2024 revealed the equipment was last cleaned on March 31, 2024.

Interview with EMP14 on October 31, 2024, at 1400, confirmed the findings noted above for the Hydrotherm Daily Cleaning Log.

Review on October 31, 2024 of the "Cold Pack Daily Cleaning Log," for January 1, 2024-October 31, 2024 revealed the equipment was not cleaned for the months of January, February, March, May, July, August or October 2024.

Interview with EMP14 on October 31, 2024, at 1415, confirmed the findings noted above for the Cold Pack Daily Cleaning Log.

Based on observation, review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure that outpatients had signed general consent to healthcare services form (which contains consent to treatment, patient rights and responsibilities, authorization of billing/financial responsibility, advanced directives, and receipt of notice of privacy practices) prior to providing services in four (4) of four (4) MRs reviewed for the West Branch outpatient phlebotomy area. (MR70, MR71, MR72 and MR73).

Findings include:

Review on October 31, 2024, of facility policy " Registration General Consent, " reviewed on July 11, 2024, revealed: " Purpose: Requirements for obtaining general consent for treatment from patients. Policy: During the registration process and prior to the service being provided the General Consent for Health Care Services for [sic] is reviewed with and signed by the patient (or the patient's Authorized Representative and is witnessed by staff ... Procedures: Obtaining Signature on General Consent for Treatment 1. As part of the registration/admitting process, the General Consent for Treatment must be signed by each patient or his/her legally authorized representative upon each encounter and scanned into [name of computer program] ... b) If the patient is unable to consent, obtain consent from a legally authorized representative. c) If a patient otherwise capable of giving valid consent is unable to write, the patient may make his or her mark on the line designated for a signature or may otherwise communicate consent in a manner acceptable to the physician. Such consent shall occur in the presence of two witnesses d) If a patient is unable to sign, and no legally authorized representative is present, verbal consent may be obtained and documented as such on the form in the presence of two witnesses. ... 2. If the patient or his/her Authorized Representative refuses to sign this consent, the issue should be referred to the appropriate manager for resolution. 3. When consent is due but not obtained prior to a patient ' s visit or admission, the registration/admitting staff are responsible for following-up and obtaining consent as soon as possible and prior to the patient ' s discharge. If, following good faith efforts, the staff is still unable to obtain consent, staff must enter the reason in the notes section of the registration system. ... "

Tour and observation conducted on October 31, 2024, at 1110 with EMP2 and EMP5 at the hospital-based provider location West Branch outpatient phlebotomy revealed MR70 in the phlebotomy registration area. MR70 then proceeded to the phlebotomy area. This surveyor observed staff request insurance information and check for a provider order. This surveyor did not observe MR70 sign a consent to health care services form prior to phlebotomy service. After MR70 left, this surveyor requested to see the forms completed for the registration process. There was no general consent for health care services form signed for the service.

During the time of the tour, EMP5 stated staff only ask for the physician's order (if a physical form) and insurance cards at this location. EMP5 confirmed pre-registration does not occur elsewhere. EMP5 confirmed there was no general consent for health care services form in MR70.

Interview on October 31, 2024, with EMP10 at 1131, and EMP11 at 1147, confirmed there was no general consent for health care services form completed by the West Branch outpatient phlebotomy site. EMP10 stated that the patient coming to the location was their consent. EMP11 stated there was no registration clerk at this location.

Review of additional West Branch outpatient phlebotomy MRs with EMP5 on October 31, 2024, at 1249, revealed the following:

Review of MR71 contained physician orders for the labs drawn on October 31, 2024. There was no general consent for health care services form completed.

Review of MR72 contained physician orders for the labs drawn on October 31, 2024. There was no general consent for health care services form completed.

Review of MR73 contained physician orders for the labs drawn on October 31, 2024. There was no general consent for health care services form completed.

Interview with EMP5 on October 31, 2024, at the time of MR review, confirmed the findings noted above.

Tour and observation were conducted on October 31, 2024, at 1221 with EMP2 of the Central Registration area which included registration for the main hospital's outpatient phlebotomy patients.

Interview on October 31, 2024, at 1221 with EMP12 revealed that for every visit the patient would complete the general consent for health care services form. Review of this form contained the following items: consent to treatment, patient rights and responsibilities, authorization of billing/financial responsibility, advanced directives, and receipt of notice of privacy practices. EMP12 also indicated if the patient was new to the facility, registration staff would also review the acknowledgement of notice of privacy practices, and universal authorization for the release of sensitive medical information forms.