HospitalInspections.org

.
Based on record review, document review and interview, the facility failed to provide for one of one Patient (Patient#1) the Important Message from Medicare. This deficient practice had the potential to affect all Medicare patients by not being able to determine when the Important Message from Medicare was provided.

Findings:

Review of Patient #1 electronic medical record (EMR) under the scanned in tab, revealed the Important Message from Medicare had the patient's signature but failed to include the date and time as required by the facility's policy.

Review of the document titled, "Important Message from Medicare" revealed, "1. All Medicare inpatients will be provided a copy of the IMM letter. 2. The form must be explained to the patient or representative when provided ... I will need your signature acknowledging that I've [sic] provided this letter to you ...3. Obtain the signature from the patient or representative. 4. Be sure the patient has entered the correct date and time on the form ....."

Interview on 11/11/21 at 3:30 PM, the Director of Quality confirmed the Important message from Medicare was not dated and timed. He/She stated, "that there is a blank for the date and time and we expect them to use it."
.

.
Based on policy reviews, document review, record reviews, observations, and interviews, the hospital failed to meet the requirement of the Condition of Participation of Provision of Services. This deficient practice had the potential to affect the three current inpatients and staff and any future patient admitted for services and future staff employed to provide services.

The cumulative effects of this deficient practice resulted in an Immediate Jeopardy (IJ) (a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death) situation.

The surveyor notified the hospital that an IJ existed on 11/11/21 at 9:35 PM, related to 485.635 Provision of Services. The hospital submitted a removal plan and the IJ was removed on 11/12/21 at 5:05 PM. The removal plan included the following:

1. On 11/11/21 at 6:15 PM, Patient #24 was assigned an individual safety monitor who did not have any other duties. The monitor was instructed verbally to continuously monitor the patient visually at all times, including when in the bathroom/shower. The monitor verbalized understanding.

2. On 11/11/21 at 7:00 PM, ligature and high-risk items in emergency department (ED) Room 2 were assessed, and the following items were removed: intravenous pole with electrical cords; cardiac monitor with multiple hanging wires; four boxes of exam gloves; plastic garbage bag in a large garbage can. Due to presence of high-risk items remaining in this room, any patient determined to be at moderate or high risk for suicide would need to remain on continuous visual observation while using this room.

3. On 11/11/21 at 7:30 PM, high risk items in the shower room/bathroom were assessed, the following items were removed - four-ounce bottle of shampoo and body wash gel; plastic bag in disposal bin and garbage can. Due to presence of high-risk items remaining in this room, any patient determined to be at moderate or high risk for suicide that needs to use the shower/bathroom would need to remain on continuous visual observation while using this room.

4. On 11/11/21 at 10:45 PM, staff caring for the at-risk patient were given education on continuous observation and how to provide a safe environment. This includes never leaving the patient alone; maintaining visual observation at all times, even when the patient is in the bathroom; and reassessing the environment for hazardous items.

5. On 11/11/21 at 11:00 PM, the following plan was implemented:

a. The "PSMC [Providence Seward Medical Center] 1:1 Monitoring with Continuous Observation: Guidelines to Provide a Safe Environment" form will be reviewed and signed by all persons assigned to care for any patient determined to be at moderate or high risk for suicide. This education will be signed daily before starting their one to one (1:1) assignment.

b. The charge nurse will be responsible for ensuring the staff review and sign the forms. The charge nurse will forward all forms to the nursing office. The Senior Manager of Patient Care services or designee will review patient observation logs against the "PSMC 1:1 Monitoring with Continuous Observation" forms to ensure all staff who were assigned the 1:1 have completed it.

c. The primary nurse caring for the suicidal patient needing continuous observation will monitor the 1:1 sitter for compliance with the guidelines outlined in the form.

d. The Senior Manager of Patient Care Services or designee will also monitor 1:1 compliance by rounding periodically throughout the unit when suicidal patients are present.

e. Any non-compliance found with this guidance will be addressed immediately by the charge nurse and/or Senior Manager of Patient Care Services or designee.

f. The policies "Suicide Risk Guideline" and "Suicide Risk Assessment" and "Care of the Suicidal Patient" will be reviewed and updated as needed.

6. On 11/12/21 at 10:00 am, the following plan was implemented:
Daily audits of the required education forms, documentation, and compliance with the 1:1 standard will occur when a patient at moderate or high risk for suicide is admitted. The audits will be completed by the Senior Manager of Patient Care Services or designee.

Findings:

1. The hospital failed to ensure the registered nurse (RN) assigned the nursing care of each patient in accordance with the patient's needs and the specialized qualifications and competence of the staff. Patient #24 had a physician order to be on 1:1 observation, and Patient #25 had a physician order to have a sitter at the bedside. However, observation on 11/11/21 at 5:10 PM revealed Patient #24 and Patient #25 were being observed by one staff member, Certified Nursing Assistant (CNA) #1, who did not have documentation of training on observing psychiatric patients. This deficient practice had the potential to cause serious injury, serious harm, serious impairment, or death of Patient #24 and Patient #25 and any future patient admitted to the hospital. (Refer to C1046)

2. The hospital failed to ensure the staff assessed patients for pain and reassessed patients' pain level after administration of pain medication for four (Patient #1, Patient #4, Patient #5, Patient #21) of five patient records reviewed for pain medication assessments and assessment of effectiveness of pain medication. These findings have the potential to cause harm to all patients admitted to hospital having pain. (Refer to C1049)

3. The hospital failed to ensure that patient care policies were developed and approved by the Medical Staff for one of four policies reviewed for approval. These findings had the potential to cause harm to the three current inpatients and any future patient receiving care at the hospital. (Refer to C1008)

4. The hospital failed to have an agreement with Company B that was providing food services to Hospital A. This deficiency had the potential to cause harm by failure to ensure adequate food for the three current inpatients and any future patient receiving care at the hospital. (Refer to C1040)

5. The hospital failed to have an agreement with Company B that was providing laundry services to Hospital A. This deficiency had the potential to cause harm by failure to ensure adequate clean linen was provided to the three current inpatients and any future patient receiving care at the hospital. (Refer to C1042)

6. The hospital failed to ensure visitors followed the recommended Center for Disease Control and Prevention (CDC) guidelines for continued COVID-19 management. The hospital failed to screen surveyors upon entrance to the hospital for COVID symptoms on 11/11/21, 11/12/21, and 11/13/21. This deficient practice had the potential to cause long-term health problems or death to the three current inpatients, any future patient presenting for services, current staff and any future staff employed, and visitors. (Refer to C1206)

.
Based on policy review and interview, the facility failed to ensure that one of four patient care policies reviewed were approved by the Medical Staff. These findings have the potential to affect all patients receiving care at the facility by failure to have patient care policy that were developed approved by the medical staff.

Findings:

Review of the facility's pain medication assessment policy titled, "Pain Management, 8888465 dated 8/19 indicated it was not reviewed and approved by the medical staff."

Interview with the Senior Manager of Patient Care Services on 11/11/21 at 3:30 PM, confirmed there was no indication the policy titled "Pain Management, 8888465 dated 8/19 was ever reviewed and approved by the medical staff."

He/She could not provide copies of the medical staff minutes that the policy was approved by the medical staff.

.

.
Based on record review and interview, the facility failed to have an agreement with the facility (Company B), that provided food services to Hospital A. These findings have the potential to affect all inpatients receiving care at the facility.

Findings:

Review of Hospital A's agreements and contract list, failed to include an agreement with the facility (Company B) who provided food service for Hospital A.

In an interview on 11/10/21 at 11:15 am, the Senior Manage of Patient Care Services confirmed that Hospital A did not have a written agreement with Company B to provide food service to Hospital A.
.

.
Based on record review and interview, the facility failed to have an agreement with the facility, (Company B), that provided laundry services to Hospital A. This deficient practice has the potential to affect all patients receiving care at the facility.

Findings:

Review of the facility's agreement and contract list, revealed that Hospital A did not have an agreement with Company B, who provided laundry services for Hospital A.

In an interview on 11/10/21 at 11:15 am, the Senior Manage of Patient Care Services that Hospital A did not have a written agreement with Company B, who provided laundry service to Hospital A.
.

.
Based on policy review, record review, interviews, and observations, the hospital failed to ensure the registered nurse (RN) assigned the nursing care of each patient in accordance with the patient's needs and the specialized qualifications and competence of the staff. Specifically, Patient #24 had a physician order to be on one-to-one (1:1) observation, and Patient #25 had a physician order to have a sitter at the bedside. However, observation on 11/11/21 at 5:10 PM revealed Patient #24 and Patient #25 were being observed by one staff member, Certified Nursing Assistant (CNA) #1, who did not have documentation of training regarding observing psychiatric patients. This deficient practice had the potential to cause serious injury, serious harm, serious impairment, or death of Patient #24 and Patient #25 and any future patient admitted to the hospital.

The Senior Manager of Patient Care Services (SMPCS) and Director of Quality (DQ) were informed of the Immediate Jeopardy (IJ) on 11/11/21 at 9:35 PM.

Findings:

Review of the facility's policy titled "Suicide Risk Assessment and care of the Suicidal Patient," revised March 2021, indicated ". . . Brief all staff that escort patients out of their room, or staff that enters patient room, on the patient's safety status needs. . . If the patient is on Moderate to High Risk/CVO, the patient will be accompanied by the assigned staff member during bathing and toileting. The staff member remains outside the bathroom door (leaving the door slightly ajar) during hygiene and toileting activities to allow for privacy. If a staff member must enter, it is to be female staff to female patient and male staff to male patient, when possible. . . All other non-essential items will be removed if they pose a risk to the patient's safety. Examples include but are not limited to: a. IV [intravenous] tubing b. Oxygen tubing c. Telephone cords d. Bandage scissors e. Sharps container f. Shower head, if has flexible head g. Stethoscopes h. Hemostats i. Gloves j. Waste-basket plastic liners k. Antibacterial hand cleanser 3. Additional room considerations: if room modifications are needed for patient safety, please contact facilities to assist in room evaluation and modification (i.e. [that is] shorter call light, equipment removal, room alterations)."

Review of the "PSMC [Hospital A's name initials] Suicide Risk Guideline," updated 9/15/20, indicated ". . . If CSSR-S scores Moderate to High Risk, place on immediate Moderate to High Risk/Continuous Visual Observation until assessed by [Company A], who will determine if pt [patient] needs to be held involuntarily and ex-parte needed . . . Moderate to High Risk/Continuous Visual Observation (CVO) Safety Protocol Orders Order Suicide Precautions in Epic [electronic medical record documentation system] Order 1:1 patient . . . Interventions 1:1 required, not to be left unattended Zip the room/cord management No restroom privileges w/o [without] staff Remove plastic bags . . .Secure ALL belongings (no phones/tablets) . . . Documentation . . . CNA/PCT [certified nursing assistant/patient care technician] (use Continuous Visual Observation Flowsheet): Patient Visual Observation- q [every] 30 min [minutes] Safe environment- q 1 hr [hour]."

Observation on 11/11/21 at 5:10 PM revealed CNA #1 was seated in the hall across from Emergency Department (ED) Room 2 while assigned to observe Patient #24 who had a physician order to be observed 1:1 and Patient #25 who had a physician order for a sitter at the bedside. CNA#1 was observed seated in a chair in the hall facing Patient #24's room with CNA#1's chair outside and to the side of the door of Patient #25's room (which was across the hall from Patient #24's room). Observation revealed Patient #24 was in the Shower Room, which was located next to Patient #24's room with the Shower Room door cracked slightly open. When seated in the chair used by CNA#1 for observation, the surveyor could not see Patient #24 in the Shower Room, and the shower curtain was pulled closed. CNA#1 confirmed at this time that CNA#1 could not see Patient #24 when Patient #24 was in the shower.

Observation of ED Room 2 on 11/11/21 at 5:50 PM revealed the following safety risks: electric bed with electrical cord; intravenous pole with electrical cords hanging; cardiac monitor with multiple hanging wires; otoscope with coiled tubing; four boxes of exam gloves; plastic garbage bag in a large garbage bin; mounted sharps container. Observation of the Shower Room, located next to ED Room 2, revealed the following safety risks: hand-held shower with attached five to six feet metal cord; shower knob presenting a ligature risk; toilet plumbing was not contained; four ounce bottle of shampoo and body wash gel; plastic bag in the wall-mounted bin next to the toilet and in the garbage can; wall-mounted filled alcohol hand sanitizer able to be opened with liquid and two C batteries; shower curtain that was not breakaway; alarm cord approximately five feet long.

1. Review of copies of Patient #24's electronic medical record (EMR) provided by Senior Manager of Patient Care Services (SMPCS) indicated Patient #24 was admitted on 11/7/21. Review of "physician orders" dated 11/7/21 at 2:24 PM indicated Patient #24 was to be observed 1:1. Review of Patient #24's "Behavioral Health - [Company A] - Crisis Risk Assessment and Plan," documented on 11/7/21 at 4:30 PM by Licensed Clinical Social Worker (LCSW) #2, indicated ". . . Client is a 14-year-old . . . who has extensive history of SI [suicidal ideation], depression, PTSD [post traumatic stress disorder], ADHD [attention deficit hyperactive disorder] rage, oppositional defiant behavior and anxiety. . . Client had multiple, fresh marks on her left forearm from self-mutilation. Client initially reported no reason why she had increased SI, so much so, that she had decided to complete suicide. . . Client has a history of suicidal attempt by over-dosing on her mother's prescribed cough syrup. . ." Further review indicated Patient #24 answered "yes" to the following questions: do you have a plan to harm yourself; do you have the means to act on the plan; can you contract for your safety. Assessment indicated Patient #24's body movement was restless; behavior was compulsive, controlling, preoccupied, and restless; mood was "not feeling anything;" affect was changeable; facial expression was not within normal limits; grandiose delusions; insight: "difficulty acknowledging presence of psychological problems and mostly blames others for problems; judgement was not within normal limits; impaired ability to make reasonable decision severe." LCSW #2 documented Patient #24's "Crisis Treatment Plan/Services" as "Due to client's risk of harm, therapist assessed the client needs acute psychiatric admission. . ."

Review of Patient #24's Company A's "Crisis Intervention Progress Note" documented on 11/11/21 at 10:55 AM by Licensed Professional Counselor (LPC) indicated Patient #24 was restless, irritable, and had suicidal ideation or plan. Further review indicated "She continues a strong desire to harm herself and remains unable to contract for safety due to deficiencies in her support systems and an unwillingness of her and her guardian to participate in treatment. Client continues to present with oppositional behaviors and refused to cooperate fully with the follow-up evaluation. . . Client remains distrustful of clinical and medical staff and refuses to cooperated [sic] with fully [sic] with her care. She continues to protect the information surrounding her self -mutilation and insists this behavior will continue. . ."

Review of CNA #1's personnel file with LN #5, Nurse Educator, indicated no documentation that CNA #1 had received training on providing care to psychiatric patients and observing patients 1:1.

In an interview on 11/11/21 at 5:50 PM, CNA #1 stated "it wasn't clear to me that I was to watch both of them [meaning Patient #24 and Patient #25]." CNA #1 stated CNA #1 didn't go to the bathroom with Patient #24 when Patient #24 took a shower, because CNA #1 "had to watch Patient #25 also."

In an interview on 11/13/21 at 8:42 am, LN #5 confirmed she had no documentation to present that CNA #1 had received training on caring for psychiatric patients and providing 1:1 observation.

2. Review of copies of Patient #25's EMR provided by SMPCS indicated Patient #25 was admitted on 11/10/21 at 5:18 PM. Review of Patient #25's "physician orders" revealed Patient#25 was to have a "sitter at bedside."

Review of Patient #25's "ED Triage Note" dated 11/10/21 at 12:27 PM indicated "Pt [patient] states that he was going to shoot himself 2 weeks ago and last night he tried to freeze himself to death by opening up the windows. Pt states he currently has thoughts of hurting himself and wants to be evaluated by Company A."

Review of Patient #25's C-SSRS (Columbia-Suicide Severity Rating Scale) completed on 11/10/21 at 12:32 PM indicated Patient #25 answered "yes" to the following questions: "1. In the past month, have you wished you were dead or wished you could go to sleep and not wake up? 2. In the past month, have you actually had any thoughts of killing yourself? 3. Have you been thinking about how you might kill yourself? 4. Have you had these thoughts and had some intention of acting on them? 5. Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan?6. Have you EVER done anything, started to do anything, or prepared to do anything to end your life? . . ." Patient #25 was scored as "High Risk."

Review of Patient #25's "[Company A] - Crisis Intervention Progress Note" documented on 11/11/21 at 10:30 am by LPC indicated ". . . Client remains at the ER [emergency room] and continues to see his situation as dire and "unfixable." He fixates on a reportedly toxic relationship between him and his caregiver and expresses significant loss of meaning and purpose for not being able to fully care for himself. Client expresses a strong desire to escape from the pain of his life using any means necessary. . . Client's affect and tome remain flat, and he does not appear to have a support network sufficient enough to assure his safety. Client presents to this clinician to be be [sic] of high risk for harming himself or completing suicide. . .. Client will remain at [Hospital A] Emergency room under medical hold until placement in an acute psychiatric care unit can be established.

In an interview on 11/11/21 at 6:10 PM, LN #1 confirmed CNA #1 was assigned to observe both Patient #24, who was on 1:1 observations and Patient #25, who was to have a sitter at the bedside. When asked about one individual performing 1:1 observation and sitting at a patient's bedside of a patient in a room across the hall from a patient on 1:1, LN #1 confirmed it would not be possible for one individual to do both tasks. LN #1 offered no explanation for CNA #1 being assigned to observe Patient #24 and provide 1:1 and as the "sitter at the bedside" for Patient #25.

.

.
Based record review, policy review and interview, the facility failed to ensure that licensed nursing staff assessed the patient's pain level prior to and after administration of a pain medication. These findings have the potential to cause harm to four of five patients (Patient #1, Patient #4, Patient #5, and Patient #21) who experienced pain and received pain medications.


Findings:


1. Review of Patient #1 electronic medical record (EMR), under the medication tab, vital signs tab, and pain assessment tab, revealed documentation that Patient #1 received Dilaudid (a strong opioid pain medication) on 11/10/21 at 0345. There was no documentation of Patient#1's pain level prior to the administration of a pain medication or a reassessment of the effectiveness of the pain medication after the Dilaudid was administered.

2. Review of Patient#4 EMR under the medication tab, vital signs tab, and pain assessment tab, revealed Patient#4 received Dilaudid on 03/09/21 at 2256. The pain level at the time of administration of pain medication was the score of eight out of 10. The reassessment of the effectiveness of the pain medication was not documented after administration.

Review of Patient #4 EMR revealed that Tylenol (pain medication) was administered on 03/11/21 at 0817. There was no documentation of Patient #4's pain level prior to receiving the Tylenol. There was no documentation on 3/11/21 at 1846 of a post-assessment of Patient#4's pain level after receiving the Tylenol and there was no documentation of a post assessment on 3/13/21 at 1659 after receiving the Tylenol pain medication.

Review of Patient #4 EMR revealed that there was no documentation of a pain assessment following administration of Tramadol on 3/9/21 at 2037. There was no documentation on 3/11/21 at 4:39 and on 03/15/21 at 9:55, of Patient#4's pain level prior to administration of the Tramadol and no documentation of a post assessment for effectiveness.


3. Review of Patient #5's EMR under the medication tab, vital signs tab, and pain assessment tab, revealed Patient #5 received Tylenol on 08/30/21 at 09:52. The pain level at the time of administration was documented as complaints of pain or discomfort. There was no score documented. The reassessment of the effectiveness of the pain medication was not documented after administration of the Tylenol.

4. Review of Patient #21's EMR under the medication tab, vital signs tab, and pain assessment tab, documented Patient #21 received Morphine 7.5 milligram (mg), (a strong opioid pain medication), on 4/18/21 at 1350. The pain level at the time of administration of pain medication was a score of six out of 10. There was no documentation of a reassessment of the effectiveness of the pain medication.

Interview with the Senior Manager Patient Care Services on 11/11/21 at 2:30 PM, confirmed the pain assessments or reassessments were not documented for Patient #1, Patient #4, and Patient #21.

During an interview on 11/11/21 at 2:57 PM, LN#3 confirmed the lack of documentation for Patient #5.

Review of the facility's policy titled, "Documentation Requirements 4997309" revised 9/21, Pain Assessment revealed:

"If pain is present or there is a change in pain and location, complete a comprehensive pain assessment that includes: location and description, onset, duration and variation or rhythm, nonverbal cues of pain expression, and effects of pain on acceptable comfort level
Reassessment is completed according to the patient condition and the expected response to intervention ...Opioid Therapy: Upon initiation, increasing of therapy or combining analgesic regimens based on range order dosing ... Document the following: Sedation level, Quality of respirations."
.

.
Based record review and interview, the facility failed to have a dated and timed patient consent treatment form for five (Patient#1, Patient#4, Patient#5, Patient #18, and Patient#20) out of seven patients' consents reviewed. These findings have the potential for the facility to provide treatments prior to obtaining the patients' or guardians' consent.

Findings:

Review of Patient #1's Electronic Medical Record (EMR) revealed the patient signed the admission consent on 11/10/21, The consent was found under the scanned documents tab, but the consent for medical treatment was not dated and timed. The consents all had a blank line for both the time and date.

Review of Patient #4's EMR revealed the patient signed the admission consent on 03/09/21. The consent was found under the scanned documents tab, but the consent for medical treatment was not dated and timed. The consents all had a blank line for both the time and date.

Review of Patient #5's EMR revealed the patient signed the admission consent on 08/29/21. The consent was found under the scanned documents tab, but the consent for medical treatment was not dated and timed. The consents all had a blank line for both the time and date.

Review of Patient #18"s EMR revealed the patient signed the admission consent on 10/07/21. The consent was found under the scanned documents tab, but the consent for medical treatment was not dated and timed. The consents all had a blank line for both the time and date.

Review of Patient #21's EMR revealed the patient signed the admission consent on 12/02/21. The consent was found under the scanned documents tab, but the consent for medical treatment was not dated and timed. The consents all had a blank line for both the time and date.

Interview with the Senior Manager of Patient Care Services on 11/11/21 at 2:30 PM, confirmed, the consents for medical treatments were not dated and timed for the following, Patient #1, Patient #4, Patient #5, Patient #18, and Patient # 20.

In an interview with the Director of Quality on 11/11/21 at 3:15 PM, he/she stated, " I could not find a policy on dating and timing signatures in the medical record." He/She stated, "the form contains a blank for the date and time and we expect it to be signed and dated."
.

.
Based on observation, interview, and document review, the facility staff failed to screen visitors for COVID-19 as directed in the Center for Disease Control and Prevention (CDC) guidelines. Failure to follow recommendations from the CDC could result in patient's, staff, and visitors being exposed to COVID-19. This deficient practice had the potential to affect all patients, staff, and visitors.

Findings:

On 11/11/21 at 07:45 AM, 11/12/21 at 08:00 AM, and 11/13/21 at 07:30 AM, the facility staff failed to screen the surveyors for COVID-19 prior to the surveyors entering the facility through the Emergency Department entry. The outside doors to the Emergency Department were kept locked. Upon ringing the bell for entrance, the staff came to the door and allowed the surveyors to enter.

During an interview on 11/12/21 at 3:45 PM, the Senior Manager for Patient Care Services, stated that facility staff are required to screen and check the temperature, then document the information of all visitors upon entering the facility. The Senior Manager of Patient Care Services stated that the "staff usually screened all persons entering the facility, and probably did not think we needed to be screened."

Review of CDC's "Interim Additional Guidance for Infection Prevention and Control" dated 09/17/20 revealed, "Recommendations ...all visitors should be assessed before entering the healthcare facility for symptoms of acute respiratory illness consistent with covid 19 guidelines, and they should not be allowed to enter the facility ...Placing a staff member near all entrances (outdoors if weather and facility layout permit,) or in the waiting room area, to ensure everyone (patients, HCP (health care personnel,) visitors) is screened for symptoms consistent with COVID-19 or close contact with someone with SARS-CoV-2 (the virus that causes coronavirus disease (COVID-19) infection before they enter the treatment area and ensure they are practicing source control."
Review of the facility's policy titled, "COVID-19 Plan Policy 10106012" dated 07/21 revealed on page 4 "1. a. Points of entry should be limited to allow for symptom monitoring of patients and visitors."
.

.
Based on record reviews, review of facility document, and interviews, the hospital failed to ensure the swing-bed patient was notified of discharge and the reasons for the move in writing and in a language and manner they understand, a copy of the notice was sent to a representative of the Office of the State Long-Term Care Ombudsman, and the notice included the reason for the discharge, the effective date of discharge, the location to which the patient was discharged, a statement of the patient's appeal rights that included the name, address, and telephone number of the entity receiving such requests, and the name, address, and telephone number of the Office of the Date Long-Term Care Ombudsman. This was evident for three (Patient #4, Patient #5, Patient #6) of three swing-bed patient records reviewed for discharge notification. This deficient practice had the potential to affect any future patient admitted for swing-bed services.

Findings:

Review of the "Notice of Medicare Non-Coverage [NOMNC]" form indicated the form included the following information: patient name; date of birth; patient number; effective date coverage will end; right to appeal; how to ask for an immediate appeal; phone number for the quality improvement organization (QIO); patient signature line and date that indicated "I have been notified that coverage of my services will end on the effective date indicated on this notice and that I may appeal this decision by contacting my QIO." There was no evidence that the form included the reason for discharge, that a copy would be sent to the Office of the State Long-Term Care Ombudsman, the location to which the patient was discharged, and the name, address, and telephone number of the Office of the State Long-Term Care Ombudsman as required by the federal regulations.

No policy related to notification of the swing-bed patient prior to discharge was presented during the survey conducted from 11/10/21 through 11/13/21.

Review of the swing-bed Electronic Medical Record (EMR) for Patient #4 indicated Patient #4 was admitted on 03/9/21 and discharged 3/16/21 with a diagnosis of sepsis, acute renal insufficiency, and acute right elbow cellulitis. Review of Patient #4's medical record indicated a NOMNC form was not completed at the time of discharge from swing-bed services.

Review of the swing-bed EMR for Patient #5 indicated Patient #5 was admitted on 8/29/21 with a diagnosis of Alzheimer's disease with behavioral disturbance, generalized weakness, and acute renal insufficiency and discharged on 8/30/21. Review of Patient #5's medical record indicated a NOMNC form was not completed at the time of discharge from swing-bed services.

Review of the swing-bed EMR for Patient #6 indicated Patient #6 was admitted on 3/12/21 with a diagnosis of status post transmetatarsal amputation, right foot arthritis, hypertension, and type 2 diabetes and discharged on 3/23/21. Review of Patient #6's medical record indicated a NOMNC form was not completed at the time of discharge from swing-bed services.

In an interview on 11/11/21 at 3:56 PM, Licensed Nurse (LN) #3 stated the only thing given to patients at discharge from swing-bed is the after-discharge summary.

In an interview on 11/11/21 at 2:16 PM, Licensed Clinical Social Worker (LCSW) #1 stated the swing-bed patient is given a NOMNC form notifying them that they will be discharged. After reviewing the EMRs, LCSW #1 stated the form was not completed for Patient #4, Patient #5, and Patient #6.
.

.
Based on personnel file review, and interviews, the hospital failed to ensure staff were educated on abuse, neglect, exploitation, misappropriation of property, or mistreatment as evident in six (Certified Nursing Assistant (CNA) #1, Licensed Nurse (LN) #3, LN #6, Senior Manager Patient Care Services (SMPCS), Director of Quality (DQ), Physical Therapist (PT)) of 12 personnel records reviewed for training on abuse, neglect, exploitation, misappropriation of property, or mistreatment. This deficient practice had the potential to affect the three current inpatients and any future patient admitted for inpatient, observation, and swing-bed services.

Findings:

Review of CNA #1's personnel file indicated CNA #1 was hired on 2/11/21 and was currently employed. Review of CNA #1's personnel file indicated there was no documentation of training on abuse, neglect, exploitation, misappropriation of property, or mistreatment.

Review of LN #3's personnel file indicated LN #3 was hired on 1/15/13 and was currently employed. Review of LN #3's personnel file indicated there was no documentation of training on abuse, neglect, exploitation, misappropriation of property, or mistreatment.

Review of LN #6's personnel file indicated LN #6 was currently employed. Review of LN #6's personnel file indicated there was no documentation of training on abuse, neglect, exploitation, misappropriation of property, or mistreatment.

Review of SMPCS's personnel file indicated SMPCS was hired on 2/20/12 and was currently employed. Review of SMPCS's personnel file indicated there was no documentation of training on abuse, neglect, exploitation, misappropriation of property, or mistreatment.

Review of DQ's personnel file indicated DQ was hired on 2/26/07 and was currently employed. Review of DQ's personnel file indicated there was no documentation of training on abuse, neglect, exploitation, misappropriation of property, or mistreatment.

Review of PT #1's personnel file indicated PT #1 was hired on 2/12/13 and was currently employed. Review of PT #1's personnel file indicated there was no documentation of training on abuse, neglect, exploitation, misappropriation of property, or mistreatment.


In an interview on 11/13/21 at 8:42 AM, LN #5 confirmed LN #5 was the nurse educator and responsible for staff education. LN #5 confirmed there was no documentation that CNA #1, LN #3, LN #6, SMPCS, DQ, and PT #1 had received education on abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property. LN #5 confirmed such training is required of all staff. No policy for training on abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property was provided during the interview.
.

.
Based on document review and interview, the hospital failed to meet the Condition of Participation of Emergency Preparedness (EP). The hospital failed to comply with all applicable Federal, State, and local emergency preparedness requirements by failing to maintain a comprehensive EP program, utilizing an all-hazards approach. This deficient practice had the potential to affect the three current inpatients and staff and any future patient admitted for observation, inpatient services, and/or swing-bed services and any future staff.

Findings:

1. The hospital failed to ensure the emergency preparedness (EP) policy for decontamination was implemented. This deficient practice had the potential to affect the three current inpatients and staff and any future patient admitted for services and future staff employed to provide services. (Refer to E0013)

2. The hospital failed to ensure the emergency preparedness (EP) plan addressed the system of medical documentation during a disaster that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. This deficient practice had the potential to affect the three current inpatients and staff and any future patient admitted for services and future staff employed to provide services. (Refer to E0023)

3. The hospital failed to ensure the emergency preparedness (EP) plan addressed the role the hospital would take in emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This deficient practice had the potential to affect the three current inpatients and staff and any future patient admitted for services and future staff employed to provide services. (Refer to E0024)

4. The hospital failed to ensure the emergency preparedness (EP) plan addressed the role the hospital would take in providing care and treatment at an alternate care site identified by emergency management officials under a waiver declared by the Secretary, in accordance with section 1135 of the Act. This deficient practice had the potential to affect the three current inpatients and staff and any future patient admitted for services and future staff employed to provide services. (Refer to E0026)

5. The hospital failed to ensure the emergency preparedness (EP) plan's communication plan included names and contact information for the patients' physicians. This deficient practice had the potential to affect the three current inpatients and staff and any future patient admitted for services and future staff employed to provide services. (Refer to E0030)

6. The hospital failed to ensure the emergency preparedness (EP) plan included the method for sharing information and medical documentation for patients under the hospital's care with other health providers to maintain the continuity of care and the means of providing information about the general condition and location of patients under the hospital's care. This deficient practice had the potential to affect the three current inpatients and staff and any future patient admitted for services and future staff employed to provide services. (Refer to E0033)

7. The hospital failed to ensure the emergency preparedness (EP) plan included the means of providing information about the facility's occupancy, needs, and its ability to provide assistance to the authority having jurisdiction, the Incident Command Center, or designee. This deficient practice had the potential to affect the three current inpatients and staff and any future patient admitted for services and future staff employed to provide services. (Refer to E0034)

.

.
Based on document review and interview, the hospital failed to ensure the emergency preparedness (EP) policy for decontamination was implemented. This deficient practice had the potential to affect the three current inpatients and staff and any future patient admitted for services and future staff employed to provide services.

Findings:

Review of the hospital's "Emergency Operations Plan October 2021" indicated ". . . Functional Annex C: Decontamination 1) Team Scope a. As its primary focus, [Hospital A's] Decontamination Team will provide mass casualty incident (MCI) decontamination for patients transported at [Hospital A] ED [emergency department] or who self-present at the ED. . . d. All decontamination team members will be trained to the HazMat Operations Level . . . by a qualified instructor. Initial training consists of 8 hours; with an annual 4-hour refresher. . . g. All decontamination team training will be documented by a qualified instructor. Training records will be maintained by the hospital. . ."

In an interview on 11/11/21 at 8:30 AM, Emergency Preparedness Coordinator (EPC) indicated EPC could not find records of staff decontamination training.
.

.
Based on document review and interview, the hospital failed to ensure the emergency preparedness (EP) plan addressed the system of medical documentation during a disaster that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. This deficient practice had the potential to affect the three current inpatients and staff and any future patient admitted for services and future staff employed to provide services.

Findings:

Review of the undated policy titled "Incident Response Guide: Information Technology (IT) Failure" indicated the Medical Care Branch Director would "provide for the continuation of patient care and management activities, including the documentation of medication administration, patient care, and supply use." Further review indicated the Situation Unit Leader would "Determine the affect of system interruptions on the ability to gather and share incident information and impacts." Further review indicated the Service Branch Director would "Provide alternate documentation systems and support hardware (i.e., [that is] providing laptops and printers to affected areas for temporary use until systems are fully restored) . . . Plan for migration of manual documentation to electronic processes after systems are restored." There was no documentation of the system to be used during a disaster and how patient information would be preserved, how the confidentiality of patient information would be maintained, and how the patient records would be secured and be available when needed.

In an interview on 11/11/21 at 8:30 AM, Emergency Preparedness Coordinator (EPC) indicated the EP plan did not address a system of medical documentation during a disaster that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records.
.

.
Based on document review, policy review, and interview, the hospital failed to ensure the emergency preparedness (EP) plan addressed the role the hospital would take in emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This deficient practice had the potential to affect the three current inpatients and staff and any future patient admitted for services and future staff employed to provide services.

Findings:

Review of the hospital's "Emergency Operations Plan October 2021" indicated "Surge Capabilities [Hospital A] maintains the capability to accept patients during times of an emergency. . . Company B maintains the capacity to accept a limited number of residents during times of an emergency from Hospital A . . .

Review of the undated policy titled "Incident Response Guide: Staff Shortage" indicated the Medical Care Branch Director would "Determine staff skill set required to continue patient care, and complete assessment of remaining staff to perform in alternate roles." Further review indicated the Support Branch Director would "Direct all departments to adjust staffing schedules and to send to labor pool all staff above minimum necessary to maintain critical operations." Further review indicated the Medical Care Branch Director would "Continue the evaluation of patients and patient care; reevaluate the need to reduce or cancel nonessential services. . . Reevaluate staffing needed to maintain essential services and to provide patient care. Evaluate staff working in alternate roles and all supplemental staff. . ." Further review indicated the Section Chief would "Plan for the next operational period and hospital shift change, including: Staff patterns Location of labor pool. . ." Further review indicated Finance/Administration would "Facilitate contracting for resources and services," and Operations would "Assess the impact of limited staffing on the ability to maintain the hospital infrastructure and a safe environment. Assess the impact of limited staffing in ability to maintain a secure environment. Assess the impact of limited staffing on ability to continue business operations." There was no documentation of contact information for staffing agencies that could assist in providing additional staff if needed.

In an interview on 11/11/21 at 8:30 AM, Emergency Preparedness Coordinator (EPC) indicated there was no specific contact information for obtaining additional staff in the event of a staff shortage.
.

.
Based on document review and interview, the hospital failed to ensure the emergency preparedness (EP) plan addressed the role the hospital would take in providing care and treatment at an alternate care site identified by emergency management officials under a waiver declared by the Secretary, in accordance with section 1135 of the Act. This deficient practice had the potential to affect the three current inpatients and staff and any future patient admitted for services and future staff employed to provide services.

Findings:

Review of the hospital's "Emergency Operations Plan October 2021" indicated there was no documentation of the process to be used by the hospital in providing care and treatment at an alternate care site identified by emergency management officials under a waiver declared by the Secretary

In an interview on 11/11/21 at 8:30 AM, Emergency Preparedness Coordinator (EPC) confirmed they don't have a policy that addresses the facility's role in providing care and treatment at alternate care sites under an 1135 waiver.
.

.
Based on document review and interview, the hospital failed to ensure the emergency preparedness (EP) plan's communication plan included names and contact information for the patients' physicians. This deficient practice had the potential to affect the three current inpatients and staff and any future patient admitted for services and future staff employed to provide services.

Findings:

Review of the hospital's "Emergency Operations Plan October 2021" indicated "Disaster Call List Please see current Disaster call List posted on [name of employee] upper cabinet.

Review of the "Disaster Call List" indicated the list did not include the names and contact information for the patients' physicians.

In an interview on 11/11/21 at 8:30 AM, Emergency Preparedness Coordinator (EPC) indicated the disaster call list did not have the contact information for the patients' physicians.
.

.
Based on document review and interview, the hospital failed to ensure the emergency preparedness (EP) plan included the method for sharing information and medical documentation for patients under the hospital's care with other health providers to maintain the continuity of care and the means of providing information about the general condition and location of patients under the hospital's care. This deficient practice had the potential to affect the three current inpatients and staff and any future patient admitted for services and future staff employed to provide services.

Findings:

Review of the hospital's "Emergency Operations Plan October 2021" indicated no documentation that addressed the method to be used to share information and medical documentation for patients under the hospital's care with other health providers to maintain the continuity of care and the means to be used provide information about the general condition and location of patients under the hospital's care.

In an interview on 11/11/21 at 8:30 AM, Emergency Preparedness Coordinator (EPC) indicated the EP plan did not include a process for sharing information with other health care providers and a process for providing information about the general condition and location of patients under the hospital's care.
.

.
Based on document review and interview, the hospital failed to ensure the emergency preparedness (EP) plan included the means of providing information about the facility's occupancy, needs, and its ability to provide assistance to the authority having jurisdiction, the Incident Command Center, or designee. This deficient practice had the potential to affect the three current inpatients and staff and any future patient admitted for services and future staff employed to provide services.

Findings:

Review of the hospital's "Emergency Operations Plan October 2021" indicated the plan did not include the process to be used to provide information about the hospital's occupancy, needs, and its ability to provide assistance to the authority having jurisdiction during the disaster.

In an interview on 11/11/21 at 8:30 AM, Emergency Preparedness Coordinator (EPC) indicated the EP plan did not include a process for notifying the authority having jurisdiction of the hospital's occupancy, needs, and its ability to provide assistance.
.