HospitalInspections.org

Due to the manner and degree of the deficient practice, the facility failed to meet the Condition of Participation for agreements, in the area of provider credentialing.

Based on observation, interview, and record review, the facility failed to:

-Ensure individuals employed as medical providers had current credentials and privileges to medically treat patients in the facility. (See C874)

Based on observation, interview, and record review, the facility failed to ensure staff members employed as medical providers had current credentials and privileges to medically treat patients in the facility. This deficient practice had the potential to affected all patients who received medical care by these providers. Findings include:

During an observation on 9/10/24 at 9:15 a.m., staff member K was providing anesthesia services for an outpatient colonoscopy procedure.

During an interview on 9/10/24 at 10:10 a.m., staff member K said his last work day would be 9/11/24, as he would be retiring.

During an interview on 9/11/24 at 12:50 p.m. staff member D stated he was responsible for reviewing the credentials for providers before requests were taken to the Governing Board. Staff member D stated all initial requests for privileges are provisional for 90 days and at the end of 90 days he would recommend privileges with out provisions. Staff member D stated providers are re-approved for privileges every two years, based on his recommendations.

A review of staff member K's credentialing file on 9/11/24, showed he was granted privileges to practice at the facility on 10/29/2019 and was valid through 6/30/2021. Staff member K's credentials and privileges were not reviewed after 6/30/2021. Staff member K continued to provide care to patients in the operating room after his privileges had expired. Staff member K's privileges had been expired for 1,169 days at the time of the survey.

A review of staff member H's credentialing file on 9/11/24, showed she was granted privileges to practice at the facility on 6/20/2022 and was valid through 6/30/2024. Staff member H's credentials and privileges were not reviewed after 6/30/24. Staff member H continued to provide care to patients in the emergency room and hospital after her privileges had expired. Staff member H's privileges had been expired for 73 days at the time of the survey.

During an interview on 9/11/24 at 4:33 p.m., staff member A stated he was not sure what happened with the reappointment of privileges for the providers. Staff member A stated, "there is no excuse for this."

Review of a facility document titled, "[Facility Name] Medical Staff Bylaws," dated 9/29/22, showed:
"... Article V: Terms of Appointment and Reappointment:
A. All appointments, reappointments, and delineation of privileges and assignments are at the discretion of the Board of Directors upon recommendations of the Medical Staff.
... C. Appointments shall be for a period of not more than two medical staff years. Medical Staff reappointments shall be made in even numbered years ...For the proposes of these By-Laws the medical staff year commences on the first day of July and ends on the thirtieth day of June ..."[sic]

Based on observation, interview, and record review, the facility failed to implement a procedure for ensuring expired medications were not accessible and removed from use in the emergency department. This deficient practice has the potential to affect all patients requiring medication in the emergency department. Findings include:

During an observation on 9/11/24 at 9:33 a.m., staff member AA unlocked the medication crash carts located in the emergency room.

The following medication was found to be past the expiration date:
- Epinephrine Drip Kit -5% dextrose 250 ML, expiration date of 7/24,
- 4 vials of dopamine Hcl 200mg/5ml (40mg/ml) expiration date of 4/1/24, and
- 3 boxes of Atropine 0.5 mg/5ml (0.1mg-ml), expiration date of 4/24.

During an interview on 9/11/24 at 10:10 a.m., staff member AA stated she was unsure who was responsible for checking the medications in the crash carts.

During an interview on 9/11/24 at 4:44 p.m., staff member B stated staff member L was the one that was checking the crash carts for outdated medications and supplies. Staff member B stated it was not being checked regularly.

During an interview on 9/11/24 at 4:49 p.m., staff member L stated she had not been doing the outdate checks since March and she was not sure who was currently doing them, but at one time there was a "traveler" who was checking the crash carts.

Review of a facility policy titled, "Crash Cart," with a last approved date of 2/2024, showed:
"... The crash carts are to be checked every month for inventory and outdates." ...

Based on observation, interview, and record review, the facility failed to implement a procedure for ensuring expired supplies were replaced prior to the expiration date. This deficient practice had the potential to affect any patient requiring supplies in the emergency department. Findings include:

During an observation on 9/11/24 at 9:33 a.m., staff member AA unlocked the crash carts located in the emergency room.

The following supplies were found to be outdated:
- one (1) Provent blood sampling kit with Heparin for gases and electrolytes, with an expiration date of 9/1/24,
- two (2) Pediatric Colorimetric CO2 Detector 1-15 kg, with an expiration date of 8/14/24,
- six (6) Illinois bone marrow aspiration/ interosseous infusion needle, with an expiration date of 8/3/24,
- two (2) size 1 McGrath Mac disposable laryngoscope blades, with an expiration date of 8/7/24,
- two (2) size 2 McGrath Mac disposable laryngoscope blades, with an expiration date of 8/7/24,
- one (1) package of sterile surgical gloves, with an expiration date of 9/1/24, and
- one (1) IV start kit, with an expiration date of 7/2023.

During an interview on 9/11/24 at 10:10 a.m., staff member AA stated she was unsure who was responsible for checking the medications or supplies in the crash carts.

During an interview on 9/11/24 at 4:44 p.m., staff member B stated staff member L was the one that was checking the crash carts for outdated medications and supplies. Staff member B stated it was not being checked regularly.

During an interview on 9/11/24 at 4:49 p.m., staff member L stated she had not been doing the outdate checks since March and she was not sure who was currently doing them, but at one time there was a "traveler" who was checking the crash carts.

Review of a facility policy titled, "Crash Cart," with a last approved date of 2/2024, showed:
"... The crash carts are to be checked every month for inventory and outdates." ...

Based on interview and record review, the facility failed to have a process in place to ensure Nurse Practitioners and Physicians Assistants notified a Doctor of Medicine or Osteopathy when an inpatient admission occurred for 2 (#s 4 and 17) of 23 sampled patients. This deficient practice had the potential to affect the quality of care for patients admitted to the facility. Findings include:

Review of the following medical records failed to show the Nurse Practitioner, or the Physician Assistant notified the physician, of the admission to inpatient status:
- Patient #4, admitted on 9/6/24, discharged on 9/10/24, and
- Patient #17, admitted on 7/16/24, discharged on 7/19/24.

During an interview on 9/10/24 at 3:00 p.m., staff member E stated if he was notified of an admission electronically though the medical record he could sign off the required documentation quickly, but if he was not notified though the medical record it took longer to review and sign off on the documentation. Staff member E did not recall having been notified of the admission for patient #4 or patient #17.

Based on interview and record review, the facility failed to inform each patient receiving care within the emergency room and outpatient setting of their visitation rights for 17 (#s 1, 3, 5, 6, 7, 10, 11, 12, 13, 14, 15, 16, 18, 19, 20, 21, and 23) of 23 sampled patients. This deficient practice has the potential to affect all patients receiving services in the emergency room and as an outpatient. Findings include:

Record review of patient #1's EMR with an admission date of 9/1/24, failed to contain a notification of visitation rights.

Record review of patient #3's EMR with an admission date of 8/13/24, failed to contain a notification of visitation rights.

Record review of patient #5's EMR with an admission date of 9/6/24, failed to contain a notification of visitation rights.

Record review of patient #6's EMR with an admission date of 9/8/24, failed to contain a notification of visitation rights.

Record review of patient #7's EMR with an admission date of 9/9/24, failed to contain a notification of visitation rights.

Record review of patient #10's EMR with an admission date of 9/5/24, failed to contain a notification of visitation rights.

Record review of patient #11's EMR with an admission date of 4/27/24, failed to contain a notification of visitation rights.

Record review of patient #12's EMR with an admission date of 5/12/24, failed to contain a notification of visitation rights.

Record review of patient #13's EMR with an admission date of 6/6/24, failed to contain a notification of visitation rights.

Record review of patient #14's EMR with an admission date of 7/1/24, failed to contain a notification of visitation rights.

Record review of patient #15's EMR with an admission date of 8/28/24, failed to contain a notification of visitation rights.

Record review of patient #16's EMR with an admission date of 8/5/24, failed to contain a notification of visitation rights.

Record review of patient #18's EMR with an admission date of 9/10/24, failed to contain a notification of visitation rights.

Record review of patient #19's EMR with an admission date of 9/10/24, failed to contain a notification of visitation rights.

Record review of patient #20's EMR with an admission date of 9/11/24, failed to contain a notification of visitation rights.

Record review of patient #21's EMR with an admission date of 8/22/24, failed to contain a notification of visitation rights.

Record review of patient #23's EMR with an admission date of 9/10/24, failed to contain a notification of visitation rights.

During an interview on 9/11/24 at 2:06 p.m., staff member W said the facility did not provide ER patients and outpatients with a notification of patient rights.

During an interview on 9/11/24 at 4:40 p.m., staff members A and B stated they had not been providing patients in the ER or outpatient setting with any notification of patient rights. Staff member A stated he was not aware they needed to be provided in the ER or outpatient settings.


47752

Based on interview and record review, the facility failed to ensure there was a process in place to verify the completeness of medical records for 7 (#s 2, 3, 4, 7, 8, 13, and 17) of 23 sampled patients. This deficient practice had the potential to affect all patients receiving care in the facility. Findings include:

Review of patient #2's electronic medical record, with an admission date of 7/30/24, failed to show a comprehensive assessment within 14 days of admission.

Review of patient #3's electronic medical record, with an admission date of 8/13/24, failed to show a co-signature of the history and physical by a physician.

Review of patient #4's electronic medical record, with an admission date of 9/6/24, failed to show notification of a physician for admission, and co-signature of the history and physical by a physician.

Review of patient #7's electronic medical record, with a treatment date of 9/6/24, failed to show a signed consent to treat.

Review of patient #8's electronic medical record, with an admission date of 4/10/24 , failed to show a discharge plan.

Review of patient #13's electronic medical record, with a treatment date of 6/6/24, failed to show a signed consent to treat.

Review of patient #17's electronic medical record, with an admission date of 7/16/24, failed to show notification of a physician for admission and a co-signature of the history and physical by a physician.

During an interview on 9/11/24 at 3:33 p.m. staff member W stated, "Ultimately it is my responsibility to make sure the medical records are complete. I do not have anything in place to make sure this occurs. I know it needs to happen though. Currently, I do not have a policy or procedure in place."

Based on interview and record review, the facility failed to ensure a physician co-signed the history and physical for acute inpatient admissions for 2 (#s 3 and 17) of 23 sampled patients. This deficient practice had the potential to affect all patients admitted to the hospital. Findings include:

Review of patient #3's EMR, dated 8/13/24 to 8/28/24, showed patient #3 was admitted to inpatient status on 8/13/24 by staff member CC. No physician co-signature was noted on the admisssion history and physical.

Review of patient #17's EMR, dated 7/16/24 to 7/19/24, showed patient #17 was admitted to inpatient status on 7/16/24 by staff member H. No physician co-signature was noted on the admission history and physical.

During an interview on 9/10/24 at 3:00 p.m., staff member E stated he was responsible for co-signing inpatient history and physicals and providing oversight to the mid-level providers in the hospital. Staff member E stated if he was notified of an admission electronically though the medical record, he could sign off the required documentation quickly, but if he was not notified though the medical record it took longer to review and sign off on the documentation. Staff member E stated he had 30 days to complete the co-signature for the history and physicals, but at times get behind. Staff member E could not recall co-signing the history and physical note for patient #3 or patient #17.

During an interview on 9/11/24 at 3:30 p.m., staff member W stated, "It does not look like staff member E was notified of admission and the history and physical was not sent to him for review and co-signature."

Review of a facility document titled, "[Facility Name] APP Practice Guidelines," undated, showed:
"... 3. Required physician consultation and/or notification of a physician under the following circumstances:
... 3.3. Whenever a patient is admitted to the CAH by a nurse practitioner, physician assistant, or clinical nurse specialist, the Facility Medical Director (FMD) is notified of the admission through the EMR.
3.4. Physician chart co-signature for all admissions by a nurse practitioner, physician assistant, or clinical nurse specialist to be completed within 30 days."

Due to the manner and degree of the deficient practice, the facility failed to meet the Conditions of Participation for Surgical Services.

Based on observation, interview, and record review, the facility failed to:

1. Meet acceptable standards of practice for Endoscopy cleaning and record keeping.

During an observation and interview on 9/10/24 at 9:47 a.m., staff member L was observed wiping down the colonoscope with water-soaked gauze sponges and sucking sterile water through the colonoscope. Staff member L then transported the colonoscope to the soiled utility and placed it into the sink. The leak test device was retrieved from a cardboard box on a shelf, attached to the colonoscope and a leak test was attempted. The testing device had a leak and would not hold pressure to test the scope. Staff member L then filled the sink with water and proceeded to clean the scope per manufacturer recommendations. Staff member L said for pre-cleaning, she wiped down the surface of the scope with sterile water and sucked the irrigation through the scope. She had not been told she should be using an enzymatic detergent. Staff member L said she had another leak test device but did not attempt to locate the device.

During an observation and interview on 9/10/24 at 9:53 a.m., staff member L removed her soiled gloves, donned clean gloves, did not wash her hands or remove the soiled gown from the colonoscopy procedure, reached into the disinfectant solution and removed a clean colonoscope. The disinfectant solution was not marked with an expiration date. Staff member L rinsed the colonoscope and flushed the channels. The scope was placed on a hanger on the wall. Staff member L said the disinfectant solution should have been marked with an out date. Staff member L said she had tested the solution with a test strip to make sure it was still viable. Staff member L said the testing and tracking of endoscope cleaning was not recorded. The facility had ordered an aerated cabinet for storage but it had not arrived. Staff member L said the endoscopes were hung on the wall for storage. The endoscopes were not cleaned prior to use, after being stored.

During an interview on 9/11/24 at 9:42 a.m., staff member R said the disinfectant should be labeled with an outdate. Staff member R stated there was not a log for tracking the cleaning of endoscopes.

Review of manufacturer recommendations, "Pentax Cleaning Instruction Summary," not dated, showed:
"Bedside Pre-Cleaning:
Immediately after completion of the procedure begin pre-cleaning in examination room
...1. Wipe insertion tube 3 times with enzymatic detergent soaked sponge
...4. ...Flush the channel with
a. 15 ml detergent solution
...Leak Testing:
...3. Perform DRY leak test watching needle in gauge to detect any major leaks
...5. Move scope, with leak tester attached to basin of clear water
6. Angulate scope and look for Champagne like bubbles ..."

2. Meet acceptable standards of practice for labeling of medication drawn into a syringe, Maintenance of Emergency Crash Cart medications, and Malignant Hyperthermia management.

During an observation on 9/10/24 at 9:17 a.m., staff member K was observed administering IV medications in unlabeled syringes during an outpatient procedure.

During an interview on 9/10/24 at 10:10 a.m., staff member K said his syringes were not labeled with medications. Staff member K said "No one messes with my stuff, I get irate if they do." Staff member K said staff knew better than to touch his medications.

During an interview on 9/11/24 at 9:42 a.m., staff member K said all medications drawn up in a syringe should be labeled.

During an observation and interview on 9/10/24 at 1:46 p.m., staff member L said the operating room did not have a full crash cart but had a crash cart "of sorts". A cart was observed to be located behind the anesthesia area in a corner. Located on top of the cart was a defibrillator that was last checked on 5/9/24, anesthesia circuits, laryngeal mask airways (LMA) x 2, a bin of medication label stickers, and a cardboard box with a Germ away electrical device placed on top. Upon inspection, the first two drawers were empty, the third drawer contained 3 expired emergency IV medication kits:
-Norepinephrine drip kit, Dextrose 5% 500 ml IV bag, expiration 3/2024, Norepinephrine ampoule 4ml, expiration 4/30/24
-Epinephrine drip kit, dextrose 5% 250 ml IV bag, expiration 7/2024, Epinephrine ampoule 1ml, expiration 8/2024
-Dobutamine drip kit, Dobutamine 250 ml pre-mix IV bag, expiration 6/2024

During an interview on 9/11/24 at 9:42 a.m., staff member R said the department had "kind of a crash cart," and the crash cart was not complete because many of the items needed were in the anesthesia cart. Staff member R said the there was no check list for the cart and the defibrillator only required checking every 6 months. Staff member R said she was not aware the crash cart would fall under the facilities crash cart policies and procedures. Staff member R said the scrub tech was responsible for checking the cart for outdated medications.

During an interview on 9/10/24 at 12:13 p.m., staff member B said crash carts are to be checked and documented each shift.

Review of a facility policy titled, "Crash Cart," with a last approved date of 2/2024, showed:
"... The crash carts are to be checked every month for inventory and outdates. ..."

During an observation on 9/10/24 at 1:55 p.m., the Malignant Hypothermia (Hyperthermia) container was observed to contain: [sic]
-Dextrose 50% injection x2, expiration 3/24 with a note dated 8/15/24, "on backorder"
-Dantrium 20mg vials x6, expiration 4/23 with a note dated 8/15/24, "shortage, on waiting list"
-Dantrium 20 mg vials x 6, expiration dated 3/26 and one vial expiration dated 4/26. (insufficient quantity)

Review of a facility document, "Malignant Hyperthermia," revision dated 5/2021, showed:
"... In the event of a real or suspected case of MH (Malignant Hyperthermia), [Facility Name] anesthesia, medical, surgical, and nursing staff will follow the guidelines set forth by the Malignant Hyperthermia Association of the United States. ..."

Review of Malignant Hyperthermia Association of the United States guidelines (www.mhaus.org), dated 2024, showed:
"...1. Dantrium/Revonto- 36 vials should be available in each institution where MH can occur ..."

3. Meet acceptable standards of practice for Sterile Processing of instruments and testing.

During an observation and interview on 9/10/24 at 1:46 p.m., staff member L explained the process for decontamination and processing of instrument trays. Staff member L removed a cloth instrument wrap and demonstrated how an instrument tray was processed. Staff member L explained that instrument trays were wrapped in a cotton wrap. Staff member L said she was not aware of the Association of periOperative Registered Nurses' (AORN) guidelines for single use, non-woven materials to be used for wrapping instruments. Staff member L then showed a cupboard with single use instrument wrap available for use. Staff member L said the biological indicators used for sterilization testing were read at 48 hours. Staff member L said she did not hold the instrumentation load for the full 48 hours, for the biological indicator to be read. She would distribute the instruments for use based on the steam indicator reading. Staff member L said she thought when the steam indicator changed and showed the instrument was sterile, the instrumentation was cleared for use. Staff member L said she had not been provided updated sterile processing recommendations since she was trained "many years ago".

During an interview on 9/11/24 at 9:42 a.m., staff member R said she had her CNOR (Certified Perioperative Nurse) certification. Staff member R said the facility follows AORN recommended standards. Staff member R said she was having a difficult time getting the single use wrap during COVID and thought the cloth wraps were acceptable. Staff member R said the instrument sterilization biological was to be read at 48 hours and the instruments were to be held until the load was cleared based on the biological. Staff member R said she had provided education to staff on "many topics" but was unable to produce any documentation of education provided.

4. Provide an updated history and physical and assess anesthesia risk for outpatient procedures. (See C1144)

5. Follow staff bylaws and provide anesthesia privileges. (See C1145)

Based on interview and record review, the facility failed to assess anesthesia risk for outpatient procedures for 1 (#22) of 3 sampled surgical records; and failed to include a history and physical the day of the procedure, to include a heart and lung evaluation for 3 (#19, 22, and 23) of 3 sampled surgical records. This deficient practice had the potential to affect all patients having outpatient procedures performed. Findings include:

Review of patient #19's electronic medical record, failed to contain an updated history and physical for the procedure dated 9/10/24, by staff member D.

Review of patient #22's electronic medical record, failed to contain an updated history and physical and anesthesia risk assessment for the procedure dated 8/22/24, by staff member Y.

Review or patient #23's electronic medical record, failed to contain and updated history and physical for the procedure dated 9/10/24, by staff member D.

During an interview on 9/11/24 at 9:42 a.m., staff member R said an anesthesia risk assessment is not performed for outpatient procedures, and she was not aware it was a requirement. Staff member R said patients were referred to the facility for pain injections and a history and physical or update was not performed for those procedures. Staff member R said the provider was to update the history and physicial for outpatient procedures the day of the scheduled procedure.

Review of a facility document, "Interventional Pain Management Program," with a revision date of November 2022, showed:
"...Evaluation for appropriate treatment is done by the CRNA prior to performing the procedure. This includes:
...4. Perform a limited, focused physical assessment pertinent to the patient/client's condition. ..."

Review of a facility document, "Risk Classification of Anesthesia Patients," with a revision date of May 2021, showed:
" ...Policy:
...only patients classified as class I, II or III will be electively scheduled for anesthesia-related procedures at the hospital. All patients who are classified in other physical status categories will be evaluated on an individual basis for surgery.
Procedure:
A. Upon admission to the preoperative area, all patients will be evaluated by a Certified Registered Nurse Anesthetist (CRNA). One of the components of this evaluation will include an assignment of a "Physical Status" (PS) classification ..."

Based on observation, interview, and record review, the facility failed to follow staff bylaws and provide anesthesia privileges for 1 (#K) of 8 sampled providers. This deficient practice had the potential to affect all patients receiving anesthesia services from provider K. Findings include:

During an observation on 9/10/24 at 9:15 a.m., staff member K was providing anesthesia services for outpatient colonoscopy procedures.

During an interview on 9/10/24 at 10:10 a.m., staff member K said his last workday would be 9/11/24, as he would be retiring.

During an interview on 9/11/24 at 12:50 p.m., staff member D stated he was responsible for reviewing the credentials for providers before requests were taken to the Governing Board. Staff member D stated all initial requests for privileges are provisional for 90 days and at the end of 90 days he would recommend privileges without provisions. Staff member D stated providers are re-approved for privileges every two years, based on his recommendations.

A review of staff member K's credentialing file on 9/11/24, showed he was granted privileges to practice at the facility on 10/29/2019 and was valid through 6/30/2021. Staff member K's credentials and privileges were not reviewed after 6/30/2021. Staff member K continued to provide care to patients in the operating room after his privileges had expired. Staff member K's privileges had been expired for 1,169 days at the time of the survey.

Review of a facility document, "Responsibilities of Anesthesia Services," revision dated 5/2021, showed:
"... The Anesthesia staff is responsible to the [Facility Name] and it's Board of Directors for the day-to-day provision of safe and appropriate anesthesia care for all patients receiving ansthesia services.
...Procedure:
A. To maintain a staff of one highly qualified associate, 24 hours per day, who is priileged by the medical staff to provide services. ..."

Review of a facility document titled, "[Facility Name] Medical Staff Bylaws," dated 9/29/22, showed:
"... Article V: Terms of Appointment and Reappointment:
A. All appointments, reappointments, and delineation of privileges and assignments are at the discretion of the Board of Directors upon recommendations of the Medical Staff.
... C. Appointments shall be for a period of not more than two medical staff years. Medical Staff reappointments shall be made in even numbered years ...For the proposes of these By-Laws the medical staff year commences on the first day of July and ends on the thirtieth day of June ..." [sic]

Based on interview and record review, the facility failed to ensure the individual employed as the Infection Prevention and Control Specialist was qualified through education, training, experience, and/or certification in infection prevention and control practices. This deficient practice had the potential to affect all patients receiving care and staff providing care at the facility. Findings include:

During an interview on 9/10/24 at 2:03 p.m., staff member P stated she had started her Infection Prevention training, but had only completed a few modules. Staff member P stated she knew the education was to be completed within 30 days. Staff member P stated she started the Infection Control Training in August. Staff member P stated she was appointed by the Governing Board in May 2024.

Record review of the facilities personnel file for staff member P showed the Infection Prevention Education was started in August 2024 but had not been completed.

Based on interview and record review, the facility failed to provide education to all staff related to infection prevention and control practices in the facility. This deficient practice had the potential to affect all staff providing care at the facility and all patients receiving care at the facility. Findings include:

During an interview on 9/10/24 at 2:03 p.m., staff member P stated she and staff member Z had not provided any staff education regarding infection prevention.

A review of a facility document titled, "Infection Control Program," with an approval date of August 2023, showed:
"... Program Goals
... Provide education and other services that are designed to change the attitudes and behaviors of employees when indicated, in order to facilitate the creation of an environment in which consistent optimal standards of care can be achieved."

Based on interview and record review, the facility failed to ensure the individuals employed as the Infection Prevention and Control Specialists provided competency-based training and education to all personnel and staff, including medical staff, on the practical applications of antibiotic stewardship guidelines, policies, and procedures. This deficient practice had the potential to affect all patients receiving care and all staff providing care in the facility. Findings include:

During an interview on 9/10/23 at 2:03 p.m., staff member P stated she had not done any kind of education with staff or providers on antibiotic stewardship guidelines, policies, or procedures. Staff member E stated staff member Z handles the antibiotic stewardship program. Staff member E stated she had never spoken with the medical staff or any staff about any type of antibiotic stewardship guidelines. Staff member P stated, "Staff member Z had not done any training with staff or providers at this time, but it is something we want to do."

Staff member Z was not available for interview prior to the end of the survey.

Review of a facility policy titled, "Antibiotic Stewardship [Facility Name] Policy and Procedure," with a last approval date of May 2023, showed:
"... Procedure:
... 2. Orientation, training and education of staff will emphasize the importance of antibiotic stewardship and will include how inappropriate use of antibiotics affects individual residents and the overall community.
3. Training and education will include emphasis on the relationship between antibiotic use and:
a. Gastrointestinal disorders
b. Opportunistic infections (e.g. C. difficile, candida albicans, etc.)
c. Medication interactions; and
d. The evolution of drug-resistant pathogens."[sic]

Based on interview and record review, the facility failed to complete a comprehensive assessment on a swing bed patient within 14 days of admission for 1 (#2) of 23 sampled patients. This deficient practice had the potential to affect all patients admitted for swing bed services.

A review of patient #2's EMR, dated 7/30/24, showed admission to swing bed. No comprehensive assessment was completed within 14 days of admission.

A review of patient #2's paper swing bed chart, dated 7/30/24, showed no comprehensive assessment had been completed within 14 days of admission.

During an interview on 9/11/24 at 3:30 p.m., staff member W stated, "it does not look like the comprehensive assessment was completed. If the assessment is not in the EMR or the paper chart, then I don't think it was done."

During an interview on 9/11/24 at 4:40 p.m., staff member B stated the comprehensive assessment for patient #2 should have been completed by nursing staff.

Review of a facility document titled, "Swing Bed Comprehensive Assessment and Care Planning, undated, showed:
... "2. The assessment process will include direct observation and communication with the resident ...
A. With in 14 calendar days after admission ...
B. Not less often than once every 12 months.
... 4. The comprehensive assessment will be completed by the charge nurse and reviewed and signed by the Director of Nursing."

Due to the manner and degree of the deficient practice, the facility failed to meet the Conditions of Participation for Patient Rights.

Based on interview, and record review, the facility failed to:

- inform each patient receiving care within the emergency room and outpatient setting of their visitation rights. (See C1056)

- inform patients and/or their representatives of their rights prior to providing or discontinuing care. (See C2502)

- inform outpatients of their right to formulate individual advance directives. (See C2515)

- provide patients with notification of their right to receive care in a safe setting, free from abuse or harassment prior to providing care in the ER or outpatient setting. (See C2525)


47752

Based on interview and record review, the facility failed to inform patients and/or their representatives of their rights prior to providing or discontinuing care for 18 (#'s 1, 3, 4, 5, 6, 7, 10, 11, 12, 13, 14, 15, 16, 18, 19, 20, 21, and 23) of 23 sampled patients. This deficient practice has the potential to affect all patients receiving care in the facility to acknowledge their patient rights. Findings include:

Review of patient #1's EMR showed an admission date of 9/1/24. No acknowledgement of patient rights was in the medical record.

Review of patient #3's EMR showed an admission date of 8/13/24. No acknowledgement of patient rights was in the medical record.

Review of patient #4's EMR showed an admission date of 9/6/24. No acknowledgement of patient rights was in the medical record.

Review of patient #5's EMR showed an ER admission date of 9/6/24. No acknowledgement of patient rights was in the medical record.

Review of patient #6's EMR showed an ER admission date of 9/8/24. No acknowledgement of patient rights was in the medical record.

Review of patient #7's EMR showed an ER admission date of 9/9/24. No acknowledgement of patient rights was in the medical record.

Review of patient #10's EMR showed an ER admission date of 9/5/24. No acknowledgement of patient rights was in the medical record.

Review of patient #11's EMR showed an ER admission date of 4/27/24. No acknowledgement of patient rights was in the medical record.

Review of patient #12's EMR showed an ER admission date of 5/12/24. No acknowledgement of patient rights was in the medical record.

Review of patient #13's EMR showed an ER admission date of 6/6/24. No acknowledgement of patient rights was in the medical record.

Review of patient #14's EMR showed an ER admission date of 7/1/24. No acknowledgement of patient rights was in the medical record.

Review of patient #15's EMR showed an ER admission date of 8/28/24. No acknowledgement of patient rights was in the medical record.

Review of patient #16's EMR showed an ER admission date of 8/5/24. No acknowledgement of patient rights was in the medical record.

Review of patient #18's EMR showed an outpatient treatment date of 9/10/24. No acknowledgement of patient rights was in the medical record.

Review of patient #19's EMR showed an admission date of 9/10/24. No acknowledgement of patient rights was in the medical record.

Review of patient #20's EMR showed an outpatient treatment date of 9/11/24. No acknowledgement of patient rights was in the medical record.

Review of patient #21's EMR showed an admission date of 8/22/24. No acknowledgement of patient rights was in the medical record.

Review of patient #23's EMR showed an admission date of 9/10/22. No acknowledgement of patient rights was in the medical record.

During an interview on 9/11/24 at 4:40 p.m., staff members A and B stated they had not been providing patients in the ER or outpatient setting with any notification of patient rights. Staff member A stated he was not aware they needed to be provided in the ER or outpatient setting.


47752

Based on interview and record review, the facility failed to inform outpatients of their right to formulate individual advance directives for 5 (#s 18, 19, 20, 21, and 23) of 23 sampled patients. This deficient practice had the potential to affect all patients receiving outpatient care in the facility. Findings include:

Review of patient #18's EMR showed an outpatient date of 9/10/24. No acknowledgement of patient rights to formulate an advanced directive was in the medical record.

Review of patient #19's EMR showed an admission date of 9/10/24. No acknowledgement of patient rights to formulate an advance directive was in the medical record.

Review of patient #20's EMR showed an outpatient date of 9/11/24. No acknowledgement of patient rights to formulate an advanced directive was in the medical record.

Review of patient #21's EMR showed an admission date of 8/22/24. No acknowledgement of patient rights to formulate an advance directive was in the medical record.

Review of patient #23's EMR showed an admission date of 9/10/22. No acknowledgement of patient rights to formulate an advance directive was in the medical record.

During an interview on 9/11/24 at 2:06 p.m., staff member W said the facility did not provide outpatients with a notification of patient rights to formulate an advance directive.


47752

Based on interview and record review, the facility failed to provide patients with notification of their right to receive care in a safe setting, free from abuse or harassment, prior to providing care in the ER or outpatient setting for 17 (#s 1, 3, 5, 6, 7, 10, 11, 12, 13, 14, 15, 16, 18, 19, 20, 21, and 23) of 23 sampled patients. This deficient practice had the potential to affect all patients receiving care provided in the ER or as an outpatient. Findings include:

Review of patient #1's EMR showed an admission date of 9/1/24. No acknowledgement of the patient rights for care in a safe setting, to include abuse and harassment, was in the medical record.

Review of patient #3's EMR showed an admission date of 8/13/24. No acknowledgement of the patient rights for care in a safe setting, to include abuse and harassment, was in the medical record.

Review of patient #5's EMR showed an ER admission date of 9/6/24. No acknowledgement of the patient rights for care in a safe setting, to include abuse and harassment, was in the medical record.

Review of patient #6's EMR showed an ER admission date of 9/8/24. No acknowledgement of the patient rights for care in a safe setting, to include abuse and harassment, was in the medical record.

Review of patient #7's EMR showed an ER admission date of 9/9/24. No acknowledgement of the patient rights for care in a safe setting, to include abuse and harassment, was in the medical record.

Review of patient #10's EMR showed an ER admission date of 9/5/24. No acknowledgement of the patient rights for care in a safe setting, to include abuse and harassment, was in the medical record.

Review of patient #11's EMR showed an ER admission date of 4/27/24. No acknowledgement of the patient rights for care in a safe setting, to include abuse and harassment, was in the medical record.

Review of patient #12's EMR showed an ER admission date of 5/12/24. No acknowledgement of the patient rights for care in a safe setting, to include abuse and harassment, was in the medical record.

Review of patient #13's EMR showed an ER admission date of 6/6/24. No acknowledgement of the patient rights for care in a safe setting, to include abuse and harassment, was in the medical record.

Review of patient #14's EMR showed an ER admission date of 7/1/24. No acknowledgement of the patient rights for care in a safe setting, to include abuse and harassment, was in the medical record.

Review of patient #15's EMR showed an ER admission date of 8/28/24. No acknowledgement of the patient rights for care in a safe setting, to include abuse and harassment, was in the medical record.

Review of patient #16's EMR showed an ER admission date of 8/5/24. No acknowledgement of the patient rights for care in a safe setting, to include abuse and harassment, was in the medical record.

Review of patient #18's EMR showed an outpatient date of 9/10/24. No acknowledgement of the patient rights for care in a safe setting, to include abuse and harassment, was in the medical record.

Review of patient #19's EMR showed an admission date of 9/9/24. No acknowledgement of the patient rights for care in a safe setting, to include abuse and harassment, was in the medical record.

Review of patient #20's EMR showed an outpatient date of 9/11/24. No acknowledgement of the patient rights for care in a safe setting, to include abuse and harassment, was in the medical record.

Review of patient #21's EMR showed an admission date of 8/22/24. No acknowledgement of the patient rights for care in a safe setting, to include abuse and harassment, was in the medical record.

Review of patient #23's EMR showed an admission date of 9/10/22. No acknowledgement of the patient rights for care in a safe setting, to include abuse and harassment, was in the medical record.

During an interview on 9/11/24 at 4:40 p.m., staff members A and B stated they had not been providing patients in the ER or outpatient setting with any notification of patient rights. Staff member A stated he was not aware they needed to be provided in the ER or outpatient setting.


47752