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Based on record review and staff interviews, the hospital leadership failed to provide training and maintain competencies of respiratory care services provided to the patients for 2 (#18 and #23) of 2 nursing staff. The hospital leadership failed to provide respiratory care per acceptable standards of practice. Also, the hospital failed to maintain the sterility of the airway and intubation supplies that were available on the 3 of 3 hospital crash carts. In addition, the hospital leadership failed to follow the hospital policy "Competency Assessment And Maintenance."

The facility provides respiratory services to patients by the nursing staff with a Respiratory Director who provides guidance. The home base for the Respiratory Director was a sister hospital that was 36 miles away. An interview with Respiratory Director #9 reported that she has no set schedule when she visits the facility. The Respiratory Director #9 stated, "I only come when the staff calls me."

During a tour of the Emergency Department on the morning of 08/13/2024 observed a new "Trilogy Ventilator."

A review of Registered Nurse Staff #18's employee file revealed no training or competency assessment on the "Trilogy Ventilator". Also, the file revealed the last nursing proficiency record (skills checklist) was dated 02/04/2019 for respiratory care services. The file indicated a Skill Lab checklist was conducted on 04/07/2023, but there were no respiratory care services checked.

A review of Licensed Practical Nurse Staff #23's employee file revealed no training or competency assessment on the "Trilogy Ventilator". Also, the file revealed the last licensed nurse Self-assessment (skills checklist) was dated 11/20/2019 for respiratory care services.

An interview with Respiratory Director #9 on 08/13/2024 at 9:30 AM revealed that there had not been an in-service held with the nursing staff on the new "Trilogy Ventilator."

During a tour of the Emergency Department on 08/13/2024 at 10:30 AM observed 3 Cash Carts.

* Observed on each crash cart was a "laryngoscope roll".
The "laryngoscope roll" consisted of various sizes of blades and a
Laryngoscope. Some of the blades were in plastic covers and some were open to air with no covering. There was no way to determine if the blades were clean and ready for emergency use.

* In emergency room #1 a "Glidescope" (an instrument used to assist with intubation) was observed with four (4) disposable blades in the basket along with the GlideScope. The disposable blades were #7.0 in size and had expired on 04/06/2024. There was a stylet (an instrument used to assist with intubation) that had expired on 06//2023.


A review of the policy titled, "Competency Assessment And Maintenance" dated 06/2024 revealed the following:

"Policy Statement:

This policy outlines the procedures for assessing and maintaining the competency of staff in patient care and diagnostic procedures. Competency assessments are designed to ensure staff members possess the necessary knowledge, skills, and abilities to perform their duties effectively and safely.

Scope:

This policy applies to all staff members involved in patient care and diagnostic procedures within the hospital, including but not limited to physicians, nurses, allied health professionals, and support staff.

Procedures:

A. Identification of Competency Requirements:

1. Hospital policies and procedures shall identify patient care and diagnostic procedures that require staff members to demonstrate specific competency.
2. Competency requirements may include external certifications such as Advanced Cardiac Life Support (ACLS), Basic Life Support (BLS), or specialty certifications relevant to particular departments or roles usually listed in the job description.
3. Internal certifications may also be required for procedures such as minimal sedation, moderate sedation, deep anesthesia, Monitored Anesthesia Care (MAC), or technique-specific certifications.

B. Competency Assessment:

1. Upon hire, transfer to a new department or introduction of new procedures, staff members shall undergo competency assessments as per the hospital's policies and procedures.

2. Competency assessments may include written tests, practical demonstrations,
direct observation of performance, simulation exercises, or a combination of these methods.
3. Competency assessments shall be conducted by qualified individuals, which may include department managers, educators, preceptors, or designated competency assessors.

C. Maintenance of Competency:

1. Competency in patient care and diagnostic procedures shall be maintained through ongoing education, training, and performance evaluation.
2. Staff members shall participate in continuing education programs, workshops, and in-service training sessions to enhance their skills and knowledge as required by
their roles and responsibilities.
3. Performance evaluations shall include periodic assessments of competency to ensure staff members remain proficient in their assigned duties.

D. Documentation and Record-keeping:

1. Documentation of competency assessments, certifications, and training shall be maintained in each staff member's personnel file.
2. Records of completed competency assessments, certifications, and training shall be retained in accordance with hospital policies and regulatory requirements.

E. Non-Compliance:

1. Failure to comply with this policy may result in disciplinary action, up to and including retraining, suspension, and/or termination of employment."


An interview with Chief Nursing Officer #22 on 08/13/2024 at 10:30 AM acknowledged that the laryngoscope and blades were not covered and that the disposable blades for the GlideScope had expired. Also, the hospital's policy was not followed.

Based on observation and staff interviews, the hospital staff failed to maintain a clean and orderly premise and ensure proper maintenance of the hospital in 6 (Main Lobby, Conference Room, Entrance Hallway, Radiology Department, Outside Building, Emergency Room) of 6 areas.

Findings included:


During a tour of the hospital on the afternoon of 8/12/2024 at 1:15 PM with the Facility Administrator the following observations were made:

Main Lobby entrance to the facility:

* A hole located in the ceiling of the lobby by the speaker.

* There were two holes located in the ceiling of the lobby.

* Dead bugs, dust, and debris in the light of the lobby.

* Electrical cord hanging freely in the lobby.


Conference Room:

In conference room water droplets were leaking from two ceiling tiles onto the conference room table.


Entrance Hallway:

* There were 3 conference chairs in the main hallway and a floor-cleaning machine that was blocking the egress.

* Rust and dirt were found on air vents in the patient hallways and in departments of the radiology, emergency room, and inpatient rooms.

* Multiple water leak stains were observed in the ceiling tiles throughout the building.

* The ceilings in the patient bathrooms had bubbled and peeling paint.


Radiology Department:

* Observed in the routine radiology room the paint was peeling off the ceiling and discolored.

* Observed holes in the wall in the X-Ray room which allows bugs and rodents to enter the facility. The walls were dirty and covered in rust.

* There was a black substance on the walls of the routine radiology room.

* The bathroom in the routine radiology room observed a black substance around the ceiling vent and the wallpaper was peeling off the wall.

* Paint missing from bathroom door in X-Ray room which could not be cleaned adequately due to exposed raw wood.

* The baseboard was missing in the X-ray room. Blue tape was found on the bathroom door in the X-ray room to prevent the door from hitting a piece of x-ray equipment.


* Observed holes in the wall in the X-ray room which allow bugs and rodents to enter the facility. The walls were dirty and covered in rust. The paint was missing, and the walls could not be adequately cleaned.


Outside of the building:


* Multiple cardboard boxes and trash were left outside the building by the emergency room entrance.

* A pallet of facility supplies that had been delivered and left outside in the sunshine all afternoon. The surveyor first observed the pallet of supplies at 1:30 PM and at 5:00 PM the supplies remained outside in direct sunlight.

* The metal doors to the outside storerooms were rusted and with peeling paint. There were 4 sets of rusted doors.


During a tour of the facility on the morning of 8/13/2024 at 10:15 AM with Chief Nursing Officer #22 the following observations were made:


Emergency Room (ER):

*Rust on the wall running down from the Air conditioning vent into the
patient sterile supply metal cabinet in ER#1.

* Rust and debris on the metal cabinet containing patient sterile supplies in
ER#1.

* ER #1's ceiling had bubbled and peeling paint.

During the tour of the hospital, the above findings were confirmed with Facility Administrator#1 and Plant Operation Manager #15 on 8/12/2024 and Chief Nursing Officer #22 on 8/13/2024.

Based on record review and confirmed in interview, the governing body failed to ensure the medical staff bylaws were followed. When nursing staff received a verbal order, the Practitioner failed to authenticate those verbal orders within 48 hours for two of two patients reviewed.

Findings include:

Review of the medstaff by laws adopted 1/24/2024 on page 61, it stated "All orders for treatment shall be in writing or electronically documented. A verbal order shall be considered in writing if dictated to a duly authorized registered nurse (RN), an LVN functioning within his/her sphere of competence ...all phone orders shall be obtained and documented by the appropriate authorized persons and shall include the name of the practitioner dictating the order. The responsible Practitioner shall authenticate such orders within 48 hours, including date and time."

Random review of patient orders revealed the following verbal orders for Patient #N and Patient #T with no authentication from the practitioner (Staff #30) within 48 hours.

Patient #N (Verbal orders entered by staff #23)
08/09/2024
Nursing Picc/midline site care and caps changed Q7 days and PRN
Medication Allopurinol 100 MG tab daily
Medication Pantoprazole 40 MG tab daily
8/11/2024
Nursing Foley Cath
8/12/2024
Dietary - Promod liquid protein 30 mL twice daily

Patient #T (Verbal orders entered by staff #23)
8/07/2024
Medication NF-Linezolid Intravenous Solution 2mg/1M 100 mg Q12 hours
Medication Hydralazine HCL tab 50 MG three times a day
Medication - Spironolactone 25 mg daily

In an interview on 8/14/2024 at 11:50 AM, in the administrator's office, Staff #22 confirmed the above findings.

Based on record review and staff interviews, the hospital's nursing leadership failed to ensure there was an adequate number of direct care staff to provide care to meet the needs of the patients and follow the hospital's Nurse Staffing Plan and Matrix. Also, the hospital's nursing leadership failed to ensure the LVN (Licensed Vocational Nurse) was always supervised by a Registered Nurse.


A review of the hospital's staffing and patient census levels was conducted in the administrative office with Staff # 3 (Director of Nursing) on 08/13/2024 at 3:30 PM.

A review of the hospital's, "Standard Staffing Guidelines Grid" revealed,

"Census: 1-6 Patients M/S-Swing Bed: 1 RN, 1 licensed nurse and 0.5 CNA
Census: 7-10 Patients M/S-Swing Bed: 1 RN, 2 licensed nurses and 0.5 CNA
ER: 1 RN, 1 licensed nurse, 0.5 CNA"

April 12, 2024

A review of the patient census log for dayshift of April 12, 2024, revealed,

There were 4 patients in the Emergency Room and 7 patients were admitted to the Medical-Surgical Floor.

A review of the nurse staffing on dayshift of April 12, 2024, revealed,

Staff # 33 (Registered Nurse) was scheduled in the Emergency Room from 7 am-7 pm. There was no other staff scheduled in the Emergency Room from 7 am-7 pm.

Staff # 34 (Registered Nurse) and Staff # 35 (Certified Nursing Assistant) were scheduled on the Med-Surg Floor from 7 am-7 pm.

The nursing leadership did not follow the hospital's "Standard Staffing Guidelines Grid" on the dayshift of April 12, 2024.

An interview was conducted with Staff # 3 on 08/13/2024 at 3:45 PM in the administrative office. Staff # 3 acknowledged there was not enough staff present on the dayshift of April 12, 2024, and stated, "I was on vacation and the 7th patient should have never been admitted to the hospital. If I was not on vacation, the 7th patient would not have been admitted."

April 22, 2024

A review of the nurse staffing on nightshift of April 22, 2024, revealed,

Staff # 36 (Registered Nurse) was working in the Emergency Room. Staff # 36 was the only Registered Nurse scheduled to work in the entire hospital on the night shift of April 22, 2024. Staff # 37 (Licensed Vocational Nurse) was working on the Med-Surg Floor on the night shift of April 22, 2024. Staff # 36 was unable to take a lunch break because there was no other Registered Nurse available to work in the Emergency Room and provide oversight to the LVN working on the Med-Surg Floor.

June 1, 2024
A review of the nurse staffing on dayshift of June 1, 2024, revealed,

Staff # 18 (Registered Nurse) was working in the Emergency Room. Staff # 18 was the only Registered Nurse scheduled to work in the entire hospital on the dayshift of June 1, 2024. Staff # 23 (Licensed Vocational Nurse) was working on the Med-Surg Floor. There was no Registered Nurse available to provide oversight to Staff # 23 on the Med-Surg Floor.

In an interview with Staff # 23 (Licensed Vocational Nurse) on 08/13/2024 at 2:00 PM in the administrative conference room, Staff # 23 was asked by the surveyor what kind of intravenous (IV) push medications she administered. Staff # 23 stated, "Dilaudid, Lopressor, Morphine, Digoxin are some examples." The surveyor asked if she had been deemed competent to give those medications via IV push. Staff # 23 stated, "I was checked off years ago but that was at another hospital, not this one."

A review of Staff # 23's personnel files revealed she had not been deemed competent to administer IV push medications such as Dilaudid, Morphine, Lopressor, and Digoxin.

Staff # 23 was working alone, unsupervised on the Med-Surg Floor on the dayshift of June 1, 2024.

According to the Texas Board of Nursing regarding the LVN Scope of Practice,

"The Texas Nursing Practice Act (NPA) and the Board's Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVNs). The LVN scope of practice is a directed scope of practice and requires the appropriate supervision of a registered nurse, advanced practice registered nurse, physician assistant, physician, dentist, or podiatrist. The LVN, with a focus on patient safety, is required to function within the parameters of the legal scope of practice and in accordance with the federal, state, and local laws, rules, regulations, policies, procedures, and guidelines of the employing health care institution or practice setting. The LVN is responsible for providing safe, compassionate, and focused nursing care to assigned patients with predictable health care needs."

A review of the hospital's policy, "Master Staffing Plan PCMC" with a revision date of 01/2023 revealed,

"Palacios Community Medical Center Emergency Department is a 3-bed Emergency Room that offers 24-hour care 7 days a week including holidays. The Master Staffing plan is designed to meet the patient's needs and the specialized qualifications and competencies of the hospital staff available. Historical data on patient arrival times and lengths of stay is used to determine the number of staff and start times for the department.
A charge nurse is assigned for each 12-hour shift. During periods of high census, the charge nurse collaborates with the Med/Surg nurse to determine staff resources available from other departments to be deployed to the Emergency Department, or to assist in patient throughput. Additional supplemental staff is provided based on the influx, acuity, and assessment of the patient's care needs. Currently, the Emergency Department is staffed by 1 licensed nurse each shift. Shifts are as follows: 7 am-7 pm and 7 pm-7 am. A certified nurse aide or ER tech in the form of an emergency medical technician will be scheduled 7a-7p and 7p-7a."

A review of the hospital's policy, "Nurse Staffing Plan" with a revision date of 08/2024 revealed,

"POLICY: In compliance with Legislative findings, Sec. 257.002, the Nursing Administration of Palacios Community Medical Center, supported by the Board of Directors, shall adopt, implement, and enforce a nurse staffing plan ensuring that an adequate number and skill mix of nurses are available to meet the level of patient care needed at all times.
PROCESS: NURSE STAFFING PLAN: The Nurse Staffing Plan will reflect current standards established by private accreditation organizations, governmental entities, and other health professional organizations. It will follow approved staffing guidelines for patient care units that allow for adequate licensed personnel to provide nursing care to all patients which will be based on multiple nurse and patient considerations.
1. Patient characteristics and number of patient admissions, discharges, and or transfers.
2. Intensity of care provided.
3. Scope of service provided.
4. Considerations of architecture, and geography of the unit, availability of technology.
5. Staff characteristics including tenure, preparation, experience, and competencies of staff.
6. Determined by the nursing assessment and in accordance with evidence-based safe nursing standards.
A. It will set minimum staffing levels for patient care units that are
a. Based on multiple nurse and patient considerations, and
b. Determined by the nursing assessment in accordance with evidence-based safe nursing standards,
c. Include a method of adjusting the staffing plan for each patient care unit to provide staffing flexibility to meet patient needs and,
d. Include a contingency plan when patient care needs unexpectedly exceed direct patient care staff resources.
e. A Nursing Leader will be on-call, 24 hours/day, 7 days per week in order to ascertain that staffing is adequate and safe on a daily, shift-by-shift basis.
f. The hospital will report annually to the Department of State Health and Human Services on whether the hospital's governing body has adopted a nurse staffing policy as required by Section 257.003;
MANDATORY OVERTIME: Mandatory overtime is defined as being required to work, other than on-call time, when not scheduled including beyond hours or days scheduled. Neither the length of the shift (whether 4, 8, 12, or 16 hours) nor the number of shifts scheduled to work whether 4, 5, or 6 a week is the determining factor in defining mandatory overtime. When mandatory overtime is utilized as a means of meeting staffing needs, the Nursing Administrator shall:
A. Document the basis and justification for mandatory overtime.
B. Develop an action plan for the reduction or elimination of the use of mandatory overtime o meet staffing needs.
C. Exception: Emergency or unforeseen event of any kind that does not regularly occur and is in accordance with the hospital Disaster Plan ..."

An interview with Staff # 3 (Director of Nursing) was conducted on 08/13/2024 at 4:00 PM in the administrative office. Staff # 3 acknowledged the hospital did not have enough staff to provide appropriate oversight to LVNs as required by the Texas Board of Nursing. Staff # 3 stated, "I try not to admit more than 6 patients because I know staffing is a challenge and I want to make sure the patients and the staff are safe."

Based on observation, record review, and staff interviews, the hospital's pharmacy staff failed to maintain accurate records of medications and prescription pads. Also, the hospital's pharmacy staff failed to ensure medications stored within the hospital were within the manufacturer's expiration date and inaccessible for patient use.

During a tour of the hospital on 08/13/2024 at 11:00 AM with Staff # 5 (Pharmacy Director), the surveyor observed the following:

Two, 200 mg (milligrams)/20 ml (milliliter) vials of Propofol Injectable Emulsion (Diprivan) were stored in the medication cabinet inside the medication room. Staff # 5 was unaware there were any anesthetic medications stored in the medication cabinet. The Propofol was not accounted for and the records for the quantity of Propofol in the hospital were not accurate.

Propofol is a non-barbiturate sedative, used in hospital settings by trained anesthetists for the induction, maintenance of general anesthesia, and sedation of ventilated adults receiving intensive care, for a period of up to 72 hours.

Propofol is not classified as a controlled substance under the CSA (Controlled Substance Act) however, according to the DEA's (Drug Enforcement Administration) Diversion Control Division, "Case reports and surveys published in the scientific literature indicate that propofol (commonly referred to as 'milk of amnesia') is abused for recreational purpose, mostly by anesthetists, practitioners, nurses, and other health care staff. Some fatalities occurred from propofol abuse."

The surveyor observed a set of 5 (five) blank prescription pads in the medication cabinet inside the medication room. There was no record of the quantity of prescription pads and the staff who had access to the prescription pads.

The surveyor observed a tackle box located in a cabinet in the medication room. The tackle box contained respiratory drugs and equipment including:

*one packet of Albuterol Sulfate 0.5mg/3ml solution with an expiration date of December 2023
*eight packets of pediatric Albuterol Sulfate 1.25mg/3ml with an expiration date of October 2021
*seven packets of Albuterol Sulfate 5mg/3ml with an expiration date of May 2023
*four packets of Atrovent 0.5mg/2.5ml with an expiration date of October 2022
The respiratory drugs were expired and available for patient use.

The surveyor observed 2 (two) locked Pyxis Medication cabinets in the hallway outside of the Emergency Room Nurses' Station. The Pyxis cabinets were on wheels and located in the hallway with an entrance and exit door to the outside. The Pyxis cabinets could be removed from the wall by unplugging them and rolling them away, which would allow controlled substances and other prescription drugs to be easily taken from the hospital. Also, the Pyxis cabinets were blocking the fire exit and egress.

A review of the Job Description for "Pharmacy Director" signed March 10, 2024, by Staff # 5 revealed,
"POSITION SUMMARY: Plans, organizes, and directs the provision of pharmacy services for in-patients and out-patients of the hospital and health system. Establishes policies, procedures, and departmental objectives. Supervises departmental personnel and all functions including establishing pharmaceutical requirements, stock levels, and the receipt, control, and issue or sale of controlled substances and other pharmaceuticals ...1.3 Accurately fills floor stock, patient medication drawers, and special area drug boxes when needed ...1.6 Monitors pharmacy for outdated drugs ...1.8 Monitors all aspects of controlled substance control ordering, reconciling, receiving, and inventory control."

A review of the hospital policy, "Drug Storage Inspections" with a revision date of 08/2022 revealed,

"POLICY: The Pharmacy will inspect all areas of drug storage within the hospital on a monthly basis, including clinics and outpatient treatment areas.
PROCEDURES: 1. The inspection will ascertain that proper storage conditions exist. 2. The following items will be included in the inspection:
*The drug supply is "in date."
*The refrigerators are at a proper temperature.
*Proper labeling is in place.
*No unauthorized drugs are in the areas.
*Emergency drug supplies at a proper level and in date.
*General condition of the area.
*Proper temperature and security.
3. The PIC shall sign all forms and they shall be filed and kept for a period of no less than 2 years as indicated by TSBP."

During an interview with Staff # 5 on 08/13/2024 at 12:00 PM in the hallway outside of the pharmacy, Staff # 5 acknowledged that the Propofol and prescription pads were unaccounted for. Staff # 5 stated, "I didn't even know these were kept in here". Staff # 5 acknowledged numerous respiratory drugs that were expired and available for patient use and stated, "These medications should not be in here. I didn't know they were here". Staff # 5 was made aware the Pyxis cabinets were blocking the egress and needed to be made secure.

Based on surveyor observations, review of facility policies, review of patient charts, and confirmed in interview, the facility failed to ensure policies included procedures that met the nutritional needs for five of five patients reviewed.

Findings included:

Surveyor observations on 8/12/2024 at 3:50 PM revealed Staff #29 preparing dinner for the five inpatients (Patient #T, U, S, V, N). In an interview with Staff #29 at 3:30 PM, she stated that she gets new diet orders each day. Review of the diet orders she used with a 'Run Date of 8/10/2024' included the following diets for the inpatients that day. She stated the orders were the same as 8/10/2024.

Patient #T - Cardiac Diet, with instructions "no beef"
Patient #U - Cardiac Diet
Patient #S - Diabetic Diet
Patient #V - regular diet, but handwritten note "cardiac"
Patient #N - Regular Diet with handwritten note "Vegetarian"

Surveyor observed that each plate for each patient was similar-salisbury steak, green beans, mashed potatoes, and side salad. However, Patient #T and Patient #N had chicken instead of Salisbury steak.

In an interview with Staff #29 on 8/12/2024 at 4:30 PM, she stated that Cardiac diet was the regular meal of Salisbury steak with no salt packs included in their tray. The Diabetic diet was the regular meal of Salisbury steak with no sugar packets included in their tray (for the tea). And the Vegetarian diet included a substitution of a chicken breast instead of the steak. Patient #T received chicken because he preferred no beef.

In an interview with Staff #13 at 4:40 PM, he stated that vegetarian should not include chicken. He was unaware why Patient #N had chicken as her protein. He also stated that the facility had no alternate protein for a vegetarian diet. He stated that he would provide extra vegetables if needed instead of the protein.

In an interview with Patient #N on 8/14/2024 at 10:20 AM in her room, she stated "she's been a vegetarian since she's eight." She also stated that she has trouble cutting up her food and required the assistance of the tech with her food.

Review of Patient #N patient record revealed a verbal order of Regular diet at admission on 08/09/2024. A dietary consult was also ordered on 08/09/2024. No consult was available for review by the end of survey on 08/14/2024.

Review of documentation available revealed no procedure to ensure patients received the appropriate diet and/or dietary consult as ordered.

In an interview on 8/14/2024 at 11:40 AM, in the administrator's office, Staff #22 confirmed the above findings.

Based on review of facility agreements, review of patient charts, and confirmed in interview, the facility food services failed to meet inpatients' nutritional needs. The dietician failed to approve menus and provide dietary consults for five of five patients reviewed.

A. Approved menu
B. Dietary Consult

Findings included:

Review of the facility agreement for Dietitian Services executed 9/19/2023, it stated "dietitian shall assess nutritional needs of the patients and complete nutritional assessments in coordination with Facility's Food Service Director. All dietary consulting services rendered for the benefit of the patients of Facility shall be done so without regard to race, color, national origin, religion, age, sex, physical disability, or any other bases protected by law; dietitian shall review patient's health care plans, if requested, and provide written recommendations as appropriate or as requested by Facility; dietitian shall provide guidance and training to the Food Service Director and dietary staff as required; dietitian shall participate in the planning and conducting of in-service education programs related to dietary rules, policies, and procedures, as requested by facility; dietitian shall participate, as requested, in meetings of Facility's quality assurance committee; dietitian shall approve all menus for use in Facility and provide budgetary advice as to food costs, if requested; dietitian shall inspect all areas of the dietary department, including, but not limited to, sanitation, equipment functioning, food service operations, and compliance with pertinent federal, state, and local laws. Dietitian shall be available at various mealtimes to observe dining operations."

A. Approved menu

Review of the breakfast and lunch menu posted in the kitchen desk computer titled "PCMC Weekly Lunch Menu had the following meals for each weekday:

"Breakfast: Monday Eggs, Biscuits & Gravy potatoes, pigs; Tuesday eggs beans, bacon, sausage, potatoes, oatmeal; Wednesday Eggs, Bacon, Beans, Pancakes, cream of wheat; Thursday Eggs over easy w jal[apenos] & onions, beans, potatoes, sausage, biscuits; Friday Eggs, Bacon, Potatoes, Taco, Muffins, Pigs

Lunch: Monday Carne Quisada, Spanish Rice & charro beans, squash; Tuesday Chicken Spaghetti, garlic bread, mix veggies; Wednesday Beef Tacos, Mac & Cheese, green beans; Thursday Baked Chicken, sweet potatoes, cauliflower; Friday Beef Stew, corn bread"

Surveyor also observed posted a list of dishes and food items on the wall by the food prep area.

One list had breakfast food items and the other list had another lunch menu.

"Monday Scramble eggs, bacon for regular & Cardiac, sausage for diabetic, biscuits, oatmeal; Tuesday hard fried eggs, bacon, toast, cream of wheat; Wednesday Scramble eggs, bacon, French toast, dry cereal; Thursday scramble eggs, bacon, grits; Friday eggs bacon, pancakes, malt-o-meal
Monday-tortilla tilapia, sides-rice & veggie mix; Tuesday Meatloaf, rice, mix veggies; Wednesday Grilled chicken breast with alfredo sauce, butter pasta, asparagus; Thursday Pot roast, butter red potatoes, broccoli; Friday Roast bake chicken, mashed sweet potatoes, steamed carrots."

In an interview with Staff #29 on 8/13/2024 at 09:30 am in the kitchen, she stated that she used the posted menus in the prep area. She stated that she prepared whatever she had available for dinner, but there were no set menus.

Surveyor observations on 8/12/2024 at 4:50 PM revealed Staff #29 delivering dinner for the five inpatients (Patient #T, U, S, V, N) that included salisbury steak (or chicken), green beans, mashed potatoes, and side salad. No documentation of an approved menu to include the meal observed were available for review.

In a phone interview with Staff # 12 on 8/13/2024 at 3:20 PM, she confirmed that she is currently working with Staff #1 on getting a menu approved. She stated that the facility has a "core diet" and that she's working with the facility to work on "extensions" of the diet. However, no diet is approved.

B. Dietary consult

Random review of patient charts revealed no documentation of a dietary consult for one of three patients reviewed (Patient #N).
Review of Patient #N chart revealed a verbal order entered for a dietary consult on 8/09/2024. Review of patient chart revealed no documentation of a dietary consult.

In an interview with staff #22 on 8/14/2024 at 11:50 AM, she confirmed that there was no dietary consult for Patient #N. She stated that a new dietician had started recently for the facility and that she had a new process of doing the consults. She stated that the dietician would come and consult with the patient, and she would email the recommendation to Staff #1 and Staff#3 and that it would be printed and placed in the patient chart.

Surveyor requested a policy on 8/14/2024 at 12:00 PM for how consults were monitored and none were provided by the end of survey on 8/14/2024.

Based on observation, policy review, record review, and staff interviews, the facility failed to have an active facility-wide program for surveillance, prevention, and control, as evidenced by:

A. failure to ensure its policies and procedures were implemented to prevent potential risk of patients consuming contaminated food from improperly sanitized cookware and serve ware (manual ware washing) and unmonitored cook and service temperature of food prior to service (Cross refer to C1206-I).

B. failure to ensure policies and procedures were implemented and enforced when temperatures were not being maintained in the dietary areas (Cross refer C1206-II).

C. failure maintain a clean and sanitary environment to avoid sources and transmission of infections when the facility was not maintained (Cross refer C1208).

D. failure to ensure systems are in place for tracking infection surveillance when infection control rounds were not performed (Cross refer C1225).

E. failure to provide competency-based training and education to personnel providing contracted services in the CAH, on the practical applications of infection prevention and control guidelines, policies, and procedures when Contracted Staff #31 failed to maintain cleanliness of linen bags and failed to wash hands after doffing gloves (Cross refer C1239).

I. Based on review of facility policy, manufacturer's instructions, surveyor observations, staff credentials, and confirmed in interview, the facility failed to ensure its policies and procedures were implemented to prevent potential risk of patients consuming contaminated food from improperly sanitized cookware and serve ware (manual ware washing) and unmonitored cook and service temperature of food prior to service.

A. Manual ware washing
B. Cooking and Service Temperature

Findings included:

A. Manual ware washing
Review of the facility policy Cleaning Dishes-Manual Dishwashing (Policy Stat ID 15835044), it stated "dishes and cookware will be cleaned and sanitized after each meal. Clean and sanitize sinks prior to beginning. Prepare sinks according to the chart below. Place a few dishes into the sink at a time. Clean thoroughly with a clean cloth or sponge. Scrub items as needed using a scouring pad. Rinse in sink 2 and sanitize in sink 3 following the directions below.

Sink 1: Wash
Wash dishes in detergent and warm water to remove all soil:
A. prepare the clean sink by measuring the appropriate amount of water into the sink and marking the sink with a water line.
B. Determine the appropriate amount of detergent to be used and follow the manufacturer's directions for use.
C. Water should be at 110F.

Sink 2: Rinse
Rinse dishes in clean warm water:
A. Prepare the clean sink with hot water.
B. Rinse the dishes thoroughly before placing in the sanitizing sink.

Sink 3: Sanitize
Sanitize dishes:
A. Measure the appropriate amount of sanitizing chemical into the appropriate amount of water (following the manufacturer's guidelines). Water should be 75 to 100 F.
B. Test the sanitizing solution in the sink using the manufacturer's suggested test strips to assure appropriate level.
C. Place the dishes in the sanitizing sink. Allow to stand according to the manufacturer's guidelines for sanitizer.
D. Allow dishes to air dry. Invert dishes in a single layer to air dry. Check all dishes to be sure they are clean and dry prior to storing."

Surveyor observations on 8/12/2024 at 4:30 PM in the kitchen revealed the kitchen staff used Keystone Lavender Pot and Pan Detergent.

Review of the instructions for use the Keystone Lavender Pot and Pan Detergent, it stated "wash: fill sink using 1 ounce of Keystone Lavender Pot and Pan detergent per 20 gallons of hot water (110-120 F) according to soil load. Rinse with hot water. Sanitize with food contact sanitizer. Let air dry."

Surveyor observations on 8/12/2024 at 4:30 PM in the kitchen revealed the kitchen staff used Quat Tabs Quaternary Sanitizing Tablets for sanitizing food contact surfaces.

Review of the 8 oz bottle of Quat Tabs (SUPC 5256670) revealed "use 1 tablet per 1 ½ gallons of water."

During preparation of dinner trays on 8/12/2024, Staff #29 manually wiped dry plates and silverware that had not had time to air dry from lunch service with a cloth towel.

After delivering dinner trays on 8/12/2024 to patients, Staff #29 came back to manually wash the dishes at 5:00 PM.

Surveyor observed the kitchen sink used to manual wash were three separate shallow bowl sinks. Staff #29 filled the middle and third sink with hot water. Staff #29 did not temp the water. The first sink had a hole; therefore, Staff #29 used the hand sink (next to the 3 sinks) to wash the dishes. She pumped 4 pumps of the Lavender Pot and Pan detergent in the third sink and placed 4 tablets in the middle sink. Staff #29 manually washed a one-time use foil pan in the third sink, further washed it in the hand sink and sanitized it in the middle sink. It was allowed to air dry afterwards for possible reuse. No sink was used to rinse the dishes.

In an interview with Staff #13 on 8/12/2024 at 5:20 PM, he stated he is unaware of the volume of the sink, but that staff should use 1 tablet for the sanitizing sink and two pumps of the detergent. He also stated he was unaware the first sink had a hole and was inoperable.

In an interview on 8/12/2024 at 5:25 PM, surveyor requested training documentation of Staff #29, but Staff #13 stated that training is only done verbally, and no documentation was available.

B. Cooking and Service Temperature

Review of the Kitchen reference guide posted in the refrigerator Safe Minimum Cooking Temperature, it stated "use this chart and a food thermometer to ensure that meat, poultry, seafood, and other cooked foods reach a safe minimum internal temperature. Remember you can't tell whether meat is safely cooked by looking at it...

Ground meat and meat mixtures
Beef, Pork - 160 F
Turkey, Chicken 165 F

Fresh Beef, Veal, Lamb Poultry
Steaks, Roasts - 145 F
Chicken & turkey - 165 F

Eggs & Egg dishes- 160 F

Seafood
Fin fish - 145 F

Random review of the Meal Temperature Log from May to August 2024 revealed no temperatures documented for the food prepared for the following six of ten days reviewed.

8/12/2024 lunch
tilapia

8/8/2024 breakfast, lunch
eggs
orange chicken

8/3/2024 breakfast, lunch, dinner
eggs
beef
tuna

7/20/2024 breakfast, lunch, dinner
eggs
turkey
beef

6/30/2024 breakfast
eggs

6/19/2024 breakfast, lunch, dinner
eggs
meatballs
chicken caldo

In interview on 8/12/2024 at 4:40 PM, Staff #29 stated that she does take temperatures of the food, but she forgets to log it. However, she stated that she only takes the cook temperature. She does not monitor the holding or service temperature.




51020


II. Based on observation, record review, and staff interviews the facility failed to ensure policies and procedures were implemented and enforced when temperatures were not being maintained in the dietary areas.

Findings were:
On the afternoon of 08/12/24 observed in the dietary kitchen area with Staff #13, Dietary Director: freezer temperature monitoring log dated August 2024 had 3 out of 23 temperatures recorded as out of range with no corrective action.

On the afternoon of 08/12/24 observed in storage room with Staff #13, Dietary Director:
*refrigerator #1 had unmarked/unlabeled/undated food and no temperature monitoring logs. Staff #13 temped at 41 degrees Fahrenheit (F), out of range.
*refrigerator/freezer #2 had unmarked/unlabeled/undated food and no temperature monitoring log. Staff #13 temped freezer at 19 degrees F, out of range.
*freezer #3 had unmarked/unlabeled/undated food and no temperature monitoring log, and a layer of ice buildup.

In interview with Staff # 13, stated he "had no knowledge" of above-mentioned refrigerators/freezers and provided the facility-based policy titled "Temperature Control of Refrigerator & Freezer" last revised 04/2022, stated in part, "A. The temperature will be checked daily in refrigerators used for drug storage in order to assure proper temperatures are maintained for medications.
1. Refrigerator: Temp between 2 degrees Celsius (36 degrees Fahrenheit) and 8 degrees Celsius (46 degrees Fahrenheit)
2. Freezer: Temp between -20 degrees Celsius (-4 degrees Fahrenheit) and -10 degrees Celsius (-14 degrees Fahrenheit)
B. Temperature logs are documented and maintained."

According to the FDA [U.S. Food & Drug Administration] food facts found at: https://www.fda.gov/media/80676/download, states in part, "To ensure that your refrigerator is doing its job, it's important to keep its temperature at 40 °F or below; the freezer should be at 0 °F."

On the afternoon of 08/12/24 observed with Staff #13 the kitchen dry storage room was hot/muggy. Staff #13 confirmed room temperature was not monitored.

According to the USDA [US Department of Agriculture] found at: https://www.fsis.usda.gov/food-safety/safe-food-handling-and-preparation/food-safety-basics/shelf-stable-food, states in part, "Shelf-Stable Food Safety: Foods that can be safely stored at room temperature ...".

Based on observation, record review, and staff interviews the facility failed maintain a clean and sanitary environment to avoid sources and transmission of infections when the facility was not maintained.

Findings included:

On the afternoon of 08/12/24 the following was observed on a tour with Staff #1, the Facility Administrator:

In storage room uncovered clean mop heads.

On the afternoon of 08/12/24 the following was observed on a tour with Staff #13, the Dietary Director:
In storage room:

*refrigerator #1 with unmarked/unlabeled/undated food and no temperature monitoring log

*refrigerator/freezer #2 with unmarked/unlabeled/undated food, no temperature monitoring log, and freezer temperature was 19 degrees Fahrenheit

*freezer #3 with unmarked/unlabeled/undated food, no temperature monitoring log, and a layer of ice buildup

*In kitchen dry storage room floor un-swept/un-mopped, had no bottom rack splatter guards on four shelves, rust build-up on multiple shelves, and stored corrugated cardboard boxes throughout (which can harbor insects/pests).

On the morning of 08/13/24 the following was observed on tour with Staff #3, DON/Infection Control:
*In storage room: corrugated cardboard boxes, cracks and chipping paint on floors/ceilings/walls, un-swept/un-mopped floor, and a chemical bottle on top of refrigerator #1

*In shower room: uncovered clean linen

*East exit door light shining through door cracks allowing pest and other debris to enter hospital

*Linen closets in ER hallway and main hallway had hospital gown ties touching the floor and baseboards covered with spider webs

*Empty patient room #111 had dead bugs and trash debris on floor. Staff #3, DON/Infection Control, confirmed the room was ready for admission although "staff was using it to store partition and weight scale."

*MedSurg nurses' station had standing fan build-up of dirt, dust, and rust on fan blades/ blade cage

*MedSurg shower/restroom had cracked wall approximately 2.5 feet across, missing/bubbling paint along toilet and under sink.

*ER med room pill crusher had rust and residual pill dust

*ER storage area had a hole approximately 5 inches wide by 3 inches long

*Restroom on East Hall missing drywall under sink


On the afternoon of 08/13/24, Staff #3, DON/Infection Control, confirmed the above findings during the tour.



29191


EMERGENCY ROOM

During a tour of the facility's emergency room on the morning of 8/13/2024 at 10:15 AM with Chief Nursing Officer #22 the following observations were made in Emergency Room #1

* There were debris particles in the plastic bins holding patient care supplies.

* A thick layer of dust in the metal cabinet that holds sterile patient care supplies.

* Personal shoes and a hair dryer were stored in the same cabinet as the patient's Nutrition
supplements.

RADIOLOGY DEPARTMENT

* A white refrigerator was found stored behind the CT (Computed Tomography) scanner. There were personal staff food items inside the refrigerator. The refrigerator was dirty and had dirt and dust debris inside of it.

A interview with Chief Nursing Officer #22 on 8/13/2024 at 10:30 AM confirmed the patient care supplies were being stored in unclean bins and theshelves had thick coat of dust.


43549


EMERGENCY ROOM

Observation of each the emergency room (#1 and #2) locked crash carts on 08/13/2024 at 12:40 PM revealed the following:

Five (5) Metal facility sterilized laryngoscope blades, various sizes EXP 6/10/22, and four on 5/21/22

Three (3) Alaris Triumph latex surgical glove packs Lot 0098003280-3 expired 08/01/24

Three (3) Alaris Triumph latex surgical glove packs Lot 0038655770-2 expired 02/23

Three (3) Alaris Triumph latex surgical glove packs Lot 10534444465-3 expired 04/24

Two (2) Covident Shiley Intubating Stylet LOT 19F0681JZX EXP 6/24/24

Two (2) Covident Sonde oral tracheal tube cuffed 4.0 mm LOT 17LO464JZX EXP 12/13/22

Two (2) Covident Sonde oral tracheal tube cuffed 4.5 mm LOT18B0068JZX EXP 1/31/23

One (1) Covident Sonde oral tracheal tube cuffed 5.0 mm LOT17G0545JZX EXP 7/23/22

ONE (1) Covident intubation Stylet 10 F LOT19F0681JZX EXP 6/24/24

Two (2) Flexi-Set Uncuffed Endotracheal Tube 3.0 LOT 17IG20 EXP 8/28/22

ONE (1) Sheridan Uncuffed Endotracheal Tube 2.0 LOT 73A1800055 EXP 1/2/23

ONE (1) Hudson Pediatric SOFTECH Nasal Canula LOT 190335 EXP 6/7/24

ONE (1) Hudson Pediatric SOFTECH Nasal Canula LOT 131354 EXP 1/11/24

One (1) Portex Tracheal Tube 2,5 mm LOT 3514687 EXP 10/23/22

ONE (1) Hudson/ Sheridan 2.0 Uncuffed tracheal tube LOT 73A1800055 EXP 1/2/23

Four (4) LNCS SpO2 pediatric adhesive sensor EXP 1/11/24

Two (2) Alaris Pump Infusion Sets Ref 2426-0500 Lot (10) 21013202 expired 1/13/24

Two (2) Heparin 25,000 USP units per 250 ml in 5% Dextrose 200-liter bags. Lot 12SEH12. EXP Date 5/24
Four (4) Medline IV Start Kit Lot # (10) 22 NBG503 EXP 5/31/24

Pro-Vent Arterial Blood Sampling Kit with Dry Lithium Heparin 4053V 746 EXP 5/18/23

Three (3) Braun Introcan Safety IV Cath 18 G 1.3 X 32 mm LOT # 19C25G361 EXP 3/1/24

Two (2) Braun Introcan Safety IV Cath 20 G 1.1 X 25 mm LOT # 19F02G8391 EXP 6/1/24

Two (2) Braun Introcan Safety IV Cath 22 G 0.9 X 25 mm LOT # 18N14D8271 EXP 12/1/23

One (1) Smiths medical 2-way Stopcock LOT 394355 EXP 5/5/23

Nine (9) BD 10 mm Syringe Leur Lock Tip LOT 7319660 EXP 11/30/22

One (1) Robertazzi Nasopharyngeal Airway 36 F LOT 19C01 EXP 2/28/24

One (1) Robertazzi Nasopharyngeal Airway 30 F LOT MD042 EXP 10/22

One (1) CareFusion Pediatric/Infant Lumbar Puncture X Needle 22 G X 1 ½ " Spinal Needle LOT 0001445789 EXP 5/31/24

Vyarie, Broslow / Hinkle (Pediatric Emergency System supplies): Yellow IV Delivery module. 7700YIV Lot 0004234334 EXP 7/31/24

Vyarie, Broslow / Hinkle (Pediatric Emergency System supplies): Blue IV Delivery module. Lot 0004215878 EXP 7/31/24

Vyarie, Broslow / Hinkle (Pediatric Emergency System supplies): Orange IV Delivery module. Lot 0004234334 EXP 7/31/24

Vyarie, Broslow / Hinkle (Pediatric Emergency System supplies): Purple IV Delivery module. Lot 0004217124 EXP 7/31/24

Vyarie, Broslow / Hinkle (Pediatric Emergency System supplies): Green IV Delivery module. Lot 0004215112 EXP 7/31/24

Broslow / Hinkle (Pediatric Emergency System supplies):

Yellow - King LTS-D Ambu bag 40-55 ml LOT # APR19-27 EXP 4/1/19

Red - King LTS-D Ambu bag 50-70 ml LOT # APR19-28 EXP 4/1/19

Purple - King LTS-D Ambu bag 60-80 ml LOT # FEB18-02 EXP 2/1/18

In a review of the facility policy "Crash Cart check Off" Effective 8/24, it stated:

"Purpose: To assure that crash carts are stocked with medications, supplies and equipment inworking order ready for emergent patient care.

Every Month:

It will be the responsibility of the RN/LVN on duty to preform or assign crash cart checks.
Nursing Staff will check supplies and replace any that are about to expire or need to be replaced.
If the lock is opened, the cart must be checked for content and check supplies restocked if needed. Notify pharmacy, and then locked.

Pharmacy Staff: Will check drugs and replace those about to expire comparing each medication, sterile tray and its expiration date with the medication and tray list.

The list of medications and trays with their expiration dates are to be checked monthly. Medications are to be replaced and cleaned wit Sani-Cloth disposable cloths as necessary.

Facility Policy: Drug Storage Inspections Effective 8/22

The Pharmacy will inspect all areas of drug storage within the hospital monthly including clinics and outpatient treatment areas.

PROCEDURES:
The inspection will ascertain that proper storage conditions exist.
The following items will be included in the inspection.
The drug supply is in date.
Emergency drug supplies at proper level and in date...."

An interview on 08/14/2024 at 2:20 PM with Staff #18 RN stated, "The crash carts can be checked if there is time for the one RN on duty but must be checked during the hours pharmacy personnel are in house which is three days a week and not always for a full eight hours. RN #18 stated the break-a-way med cart locks are kept in the pharmacy and can only be gotten from pharmacy staff."

An interview on 08/14/2024 at 3:05 PM Staff #22 Chief Nursing Officer confirmed the supplies were outdated that were laid out after checking the carts. Chief Nursing Officer stated, "The expired meds and supplies in the Emergency rooms (ER) was "Because the 'Nurses are Lazy.'" She stated the Registered Nurses (RN) should check the cart whenever. When asked how an RN was to delegate her time when there is one nurse in house assigned to two ER rooms, admission nursing intakes and an average of six patients in the hospital area she stated the Licensed Vocational Nurse (LVN) can help. She stated the RN can get a lock from the pharmacy and relock the crash carts when done. When asked if the RNs had access to the break-away locks to relock the carts she initially stated they did, she then said she didn't know.

Based on staff interviews and record review, the facility failed to ensure systems are in place for tracking infection surveillance when infection control rounds were not performed.

Findings were:

In interview on the morning of 08/13/24, Staff #3, DON/Infection Control, stated she had not been trained on infection control rounds and they had not been performed.

In interview on the afternoon of 8/13/24, Staff #4, Quality/Infection Control Director, stated Staff #3 was not trained on infection control rounds, and confirmed that neither had performed infection control rounds.

Facility-based policy titled, "Infection Control Nurse" effective 06/2024, stated in part, "Position: To ensure proper education for the Infection Control Nurse.
Description:
...The Infection Control Nurse is located at [affiliated facility] and will coordinate activities and surveillance with the DON at [named facility] that will act and carry out the duties in the absence of the Infection Control Nurse."

Based on observation, record review, and staff interviews the facility failed to provide competency-based training and education to personnel providing contracted services in the CAH, on the practical applications of infection prevention and control guidelines, policies, and procedures when Contracted Staff #31 failed to maintain cleanliness of linen bags and failed to wash hands after doffing gloves.

Findings were:

On the morning of 08/13/24 observed Contracted Staff member #31, placing two linen bags (of clean mop heads) on dirty floor in the storeroom, then placed dirty linen bags from the floor into a cart. Contracted Staff member #31 donned gloves, transferred dirty linen bags onto another cart and placed onto the right side (dirty side) of truck. He then doffed gloves, grabbed the linen bags (with clean mop heads) and placed on left side (clean side) of truck. Contracted Staff member #31 stated he had not received training from the CAH; he reported he was going to wash his hands prior to leaving facility.

On the afternoon of 08/13/24 Staff #4, Quality and Infection Control Director, reported Directors provide infection control education to their staff.

On 08/14/24 Staff #32, EVS Director, confirmed contracted linen staff had not received competency-based training and education in the CAH, on the practical applications of infection prevention and control guidelines, policies, and procedures.
Facility-based "Infection Prevention and Control Plan" effective date 06/20/2024 stated in part, "Infection Prevention Nurse: ...provide education to [corporate name] personnel, patients, and visitors with an emphasis on the importance of their role in infection prevention."

Based on review of facility documents, staff interview, and facility-based policy and the facility failed to involve all departments of the CAH in the QAPI [Quality Assurance and Performance Improvement] program design and scope when Dietary, Environmental Services, and Respiratory were excluded from QA.

Findings were:

Review of the Quality meeting minutes for January through June 2024 revealed no information submitted from Dietary, Environmental Services, and Respiratory.

In an interview on the afternoon of 8/13/24, Staff #4, Quality and Infection Control Director, confirmed not all departments were represented in the Quality meetings.

Facility-based "Quality Assurance/Performance Improvement Plan" effective date 06/2024 stated, "Plan: Introduction: All services, including contracted and departments throughout the facility utilize the Quality Assurance/ Performance Improvement Plan established here."

Based on review of records and staff interviews, the facility failed to notify the OPO [Organ Procurement Organization], in a timely manner, for 1 of 7 patients (Patient AA) who passed in the facility.


Findings were:

Review of Patient AA's medical record revealed Patient AA passed while in the facility. There was no documented notification to OPO found.

In an interview of the morning of 8/14/24, Staff #21, Director of HIM [Health Information Management] confirmed there was no documented notification to OPO for Patient AA.

Facility policy titled "Organ and Tissue Donation Definitions" last reviewed 11/2023, stated in part, "D. Timely Notification:
1. For potential tissue donors, timely notification will be any time within one hour after cardiac systole.
2. For potential organ donors, timely notification will be any time prior to, or within one hour, of the time the patient is found to meet the criteria for imminent death ..."

Based on observation and interview, the facility failed to post conspicuously in the facility's emergency department or in a place likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than traditional emergency departments (that is, entrance, admitting area, waiting room, treatment area) a sign (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in active labor (EMTALA); and to post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital or rural primary care hospital (e.g., critical access hospital) participates in the Medicaid program under a State plan approved under Title XIX.

Findings included:

Observations conduced on 8/12/24 at 2:35 PM of the facility's emergency department (ED) entrance, waiting room, and treatment areas revealed there was not a posting or sign specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in active labor (EMTALA); and there was not a posting (in a form specified by the Secretary) with information indicating whether or not the rural primary care hospital participates in the Medicaid program under a State plan approved under Title XIX.

During an interview on 8/13/24 at 4:25 PM with the Chief Nursing Officer (CNO) confirmed there was not a posting or a sign in the facility's ED entrance/waiting, and treatment areas specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in active labor (EMTALA); and there was not a posting (in a form specified by the Secretary) with information indicating whether or not the rural primary care hospital participates in the Medicaid program under a State plan approved under Title XIX. The CNO stated she was aware of the required EMTALA posting and is surprised that it was not posted in the ED; further stating, maybe it was taken down when they were painting.