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Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §485.623 Physical Plant and Environment was out of compliance.

C-0914 (b) The CAH has housekeeping and preventive maintenance programs to ensure that-
(1) All essential mechanical, electrical, and patient-care equipment is maintained in safe operating condition. Based on observations, interviews, and document review, the facility failed to ensure the physical plant and environment was maintained in good working condition to ensure patient safety. Specifically, the facility failed to ensure equipment was maintained according to the manufacturer's standards. (Cross-reference C-2523).

In addition, based on a concurrent Life Safety Code survey completed on 10/3/24, the facility failed to comply with the regulations set forth for Life Safety. Numerous violations in regards to fire prevention and mitigation were identified, and four immediate jeopardies were called under Life Safety Code tags K161, K341, K353, and K920. See survey event ID 8D9821 for full details of the cited deficiencies.

Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §485.627 Organizational Structure, was out of compliance.

C-0962 The CAH has a governing body or an individual that assumes full legal responsibility for determining, implementing and monitoring policies governing the CAH'S total operation and for ensuring that those policies are administered so as to provide quality health care in a safe environment. Based on document review and interviews, the facility failed to provide oversight of contracted services to ensure quality health care was provided in a safe environment.

Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §485.640 Infection Prevention and Control and Antibiotic Stewardship Programs was out of compliance.

C-1208 (a)(3) The infection prevention and control includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and that the program also addresses any infection control issues identified by public health authorities. Based on observations and interviews, the facility failed to implement infection control prevention and surveillance measures to avoid possible sources of infection.

Based on observations, interviews, and document review, the facility failed to ensure the physical plant and environment was maintained in good working condition to ensure patient safety. Specifically, the facility failed to ensure equipment was maintained according to the manufacturer's standards. (Cross-reference C-2523).

Findings include:

Reference:

The Anesthesia System instructions for use (IFU) read, the minimum frequency for periodic maintenance and gas bench calibration was annually.

1. The facility failed to maintain equipment to ensure a safe environment for patients.

A. Observations

i. Observations conducted on 9/26/24 in the operating room (OR) revealed the anesthesia cart performance maintenance (PM) tag to have expired in April of 2024. Facility staff used the anesthesia cart to administer anesthesia to surgical patients from 5/1/24 through 9/26/24 despite its expiration date.

This was in contrast to the anesthesia system IFU which read, the minimum frequency for periodic maintenance and gas bench calibration was annually.

B. Interviews

i. On 10/1/24 at 3:25 p.m., an interview was conducted with the maintenance director (Director) #4. Director #4 stated a contracted company did the PMs for patient equipment. Director #4 stated the anesthesia cart had an expired PM because the facility planned to purchase a new machine. Director #4 stated the vendor delayed the delivery of the machine so the facility decided to not complete the PM and waited for the vendor to deliver the new machine. Director #4 stated the facility did not want to spend the money on preventative maintenance on a machine they wanted to replace. Director #4 stated they did not know of any specific risks to patients for using a machine that had an expired PM but agreed the facility should have performed the PM for patient safety.

Based on observations, document review, and interviews, the facility failed to provide direct oversight of contracted services to ensure quality health care was provided in a safe environment.

Findings include:

Facility policy:

The Fire Protection Systems policy read, all facility fire protection systems shall be maintained in a serviceable state at all times through a proactive inspection, testing, and maintenance program that is designed to identify and repair any system deficiency or malfunction that could be a threat to the facility and its occupants. Inspection and testing tasks shall be performed by personnel who have developed competence through training and experience. Maintenance Staff shall complete the inspection on an annual basis and log the date on the Lincoln Health Fire Damper and heat tab Location and Functionality test log.

Reference:

The Bylaws of the Board of Trustees read, the term "Chief Executive Officer" or "CEO" shall mean the individual appointed by the Board to act in its behalf in the overall management and operation of the Hospital. The Board shall also have exclusive control of the construction or enlargement of any Hospital buildings; and the supervision, care and custody of the grounds, rooms or buildings purchased, constructed, leased or set apart for that purpose. The Board shall ensure the quality of care provided by the Hospital is consistent with the generally accepted standards of care and providers and staff are properly credentialed to provide such care. The CEO shall act as the duly authorized representative of the Board. In all matters in which the Board has not formally designated some other person to act. As such, they shall have the authority to sign appropriate contracts, including governmental and commercial payer contracts, on behalf of the Board, subject to any guidelines set forth by the Board. The CEO shall ensure that all departments are accountable for proper maintenance of all equipment and physical properties. The CEO shall be responsible for reviewing the Hospital's policies and contracts to ensure that the foregoing comply with all applicable laws and regulations and that the objectives and purposes of the Hospital are being served by the requirements of such documents and policies.

1. The facility failed to provide direct oversight of contracted services to ensure quality health care was provided in a safe environment.

A. Observations

i. On-site observations conducted during the complaint survey completed on 10/3/24 revealed the facility failed to comply with the regulations set forth for Life Safety. Numerous violations in regards to fire prevention and mitigation were identified, and four immediate jeopardies were called under Life Safety Code tag K161, K341, K353, and K920. See survey event ID 8D9821 for full details of the cited deficiencies.

This was in contrast to the Fire Protection Systems policy which read, all facility fire protection systems should be maintained in a serviceable state at all times through a proactive inspection, testing, and maintenance program that was designed to identify and repair any system deficiency or malfunction that was a threat to the facility and its occupants.

B. Document Review

i. Review of the contract between the external fire service company (Contractor) and the facility revealed the most recent contract for the fire sprinkler system inspection was entered into on 1/24/24. The contract was signed by the director of maintenance (Director #4). There was no evidence the contract was reviewed by the governing board or chief executive officer since its initiation. The contract read, the company shall visually inspect the fire sprinkler system one time per year. The inspection does not address the capability of the fire protection system to protect the building of its contents. It is not the role of the inspector to determine if changes have been made or the subsequent evaluation of the fire system. The responsibility for properly maintaining a water-based fire protection sprinkler system shall be that of the owner of the property.

C. Interviews

i. An interview was conducted on 10/2/24 at 9:02 a.m. with the director of maintenance (Director) #4. Director #4 stated they were not aware that the facility or the Contractor had installed a sprinkler head that was not connected to any water source. Director #4 stated the facility had been working with the Contractor for twelve years. Director #4 stated the Contractor was supposed to inspect the facility's suppression systems, maintain the alarm panels, and inspect the sprinkler system. Director #4 stated the Contractor was supposed to ensure each sprinkler head was up to date, not corroded, and not painted, however, these services were not completed by the Contractor. Director #4 stated that they never checked the logs of work from the Contractor with the sprinkler system, and relied on the Contractor to do the work because the Contractor had been used by the facility for so long. Director #4 stated it was important to have a system that addressed safety issues because if patients at the facility were not safe, they would not receive good care.

ii. An interview was conducted on 10/2/24 at 11:03 a.m. with the chief nursing officer (CNO) #5. CNO #5 stated the leadership team was responsible for overseeing contracts with external vendors and contractors and the facility. CNO #5 stated they were aware the facility had issues keeping a centralized list of contracts and had issues ensuring that contracted services were being performed according to agreements. CNO #5 stated the facility was implementing a system to centrally store contracts, but not all contracts were uploaded into the system at this time.

iii. An interview was conducted on 9/30/24 at 4:40 p.m. with chief executive officer (CEO) #6. CEO #6 stated the facility did not properly supervise the Contractor. CEO stated the facility was not as vigilant because they trusted the fire service contractor.

iv. An additional interview was conducted on 10/2/24 at 4:06 p.m. with CEO #6. CEO #6 stated their role was to oversee everything in the facility. CEO #6 stated the facility's process regarding entering contracts and monitoring contracts was not formal. CEO #6 stated department managers would often enter into a contract with an outside contractor because they needed to get something done. CEO #6 stated the facility needed to have a process for regular evaluation of contracted services. CEO #6 stated the facility had been instructed by their certification authority in 2021 to ensure all contracts were readily available, but the facility was still working on this process.

Based on observations and interviews, the facility failed to implement infection control prevention and surveillance measures to avoid possible sources of infection.

Findings include:

Facility policies:

The Infection Prevention Plan policy read, the infection prevention program addressed detection, prevention, and control of infections. Infection prevention included strategies to decrease risk and a surveillance plan. Infection prevention rounds are made to assess the level of quality provided and actions for improvement are taken as needed. Compliance with infection prevention practices is monitored and documented by staff evaluation and observation of practices. The infection preventionist and department managers review the compliance monitoring and initiate appropriate actions.

The Surveillance Infection Control policy read, nursing staff were responsible for functions essential to the prevention, recognition, and management of infections. Prevention of infection was the main goal of the staff. This was accomplished by practicing good aseptic techniques, observing infection control policies and procedures, and recognizing the potential risks associated with invasive procedures. Adherence to the practice of standard precautions was expected of all nursing staff. Nursing staff served as a role model for all healthcare workers in the adherence of established guidelines.

The Sink Storage policy read, there will be no supplies stored in cabinets underneath the sinks in patient care areas. Supplies will be stored meeting infection control guidelines in appropriate cabinets.

The Physical Environment Pest Control Program policy read, all policies and procedures specific to pest and rodent control were the responsibility of the maintenance department and appropriate contract services.

The Sanitation and Infection Control Pest Control policy read, if a pest situation was reported, the contractor was notified and requested to make an unscheduled visit to address concerns.

1. The facility failed to implement a process that identified areas of infection risk throughout the facility and mitigate possible sources of infection in the emergency department (ED), surgical services areas, procedural areas, magnetic resonance imaging (MRI) trailer, and inpatient care unit.

A. Observations

i. Observations were conducted on 9/26/24 at 9:00 a.m. in the ED. In the ED treatment room where staff cared for patients, observations revealed staff stored a bottle of sterile water and a bottle of normal saline, both used in patient care, under the sink in a plastic patient care bucket.

This was in contrast to the facility's sink storage policy which read, there will be no supplies stored in cabinets underneath the sinks in patient care areas and stored to meet infection control guidelines in appropriate cabinets.

Further observations in the ED revealed an unknown soiled substance on the bottom shelf of the cupboard. Additional observations in the ED revealed an exposed cement floor in a patient supply storage room which produced dust and loose cement particles on the floor.

ii. Observations conducted in the inpatient care unit nurses' station revealed a large area of exposed, broken drywall under a window near medications and patient care items. Additional observations in patient care room #10 revealed a bottle of cleaning solution in disrepair with the instructions for use peeled and flaked off.

iii. Observations conducted in the operating room (OR) revealed rust on top of a stand used to hold patient suction tubing during procedures. Further observations revealed staff had covered two sterile supply cabinets in the OR room with a thin sheet of plastic and used plastic tape to secure the plastic wrap in anticipation of construction in the OR. Observations revealed the tape did not secure or seal the plastic completely and left gaps for dust to reach the sterile supplies in both cabinets.

iv. Observations conducted in the endoscopy and colonoscopy procedure room revealed a layer of dust on the air vent on the endoscopy computer tower. Further observations revealed the air return vent was also covered in dust. Additionally, there were crumbled cement and dust particles on the floor where staff stored supplies for scope procedures.

These observations were in contrast to the facility's Surveillance Infection Control policy which read, nursing staff were responsible for functions essential to the prevention, recognition, and management of infections. Staff accomplished this through the recognition of the potential risks associated with invasive procedures.

v. Observations conducted in the OR supply room revealed a dead bug in the bottom of the cart used for patient supplies. Additional observations in the MRI trailer revealed dead moths in a plastic bin covered in dust used for storage of MRI equipment.

vi. Observations in the magnetic resonance imaging (MRI) trailer revealed bottles of solution used for the MRI machine were stacked directly on the floor of the trailer. Multiple cardboard boxes and plastic air-filled bubble wraps stacked on top of the bottles of solution and leaned against an electrical panel. Further observations revealed a plastic tote filled with MRI equipment, dust, dirt, and dead moths.

This was in contrast to the facility's physical environment Pest Control Program policy which read, the maintenance department and appropriate contract services had the responsibility specific to pest and rodent control.

B. Interviews

i. On 10/1/24 at 1:49 p.m., an interview was conducted with registered nurse (RN) #1. RN #1 stated staff completed infection prevention modules through online training. RN #1 stated the modules included hand hygiene, isolation precautions, and personal protective equipment. RN #1 stated she did not know the frequency of the modules. RN #1 stated they checked patient care rooms prior to patient placement because the building was old and bugs got into the rooms. RN#1 stated they did not know of any infection prevention surveillance conducted by any team or leadership. RN #1 stated it was important to keep the environment clean to decrease the risk of patient exposure to infectious matter.

ii. On 10/1/24 at 2:33 p.m., an interview was conducted with the director of inpatient services and infection control (Director) #3. Director #3 stated their biggest priority for the infection prevention program was to keep the patients safe from hospital-associated infections (HAIs). Director #3 stated the infection control plan ensured that staff mitigated risks and provided a safe and clean environment for patients. Director #3 stated they followed the direction of their accreditation agency and tracked patient infections. Director #3 stated their primary focus was not the environmental areas, but instead, the bacterial and viral pathogens with which the patients entered the hospital.

Director #3 stated they did not have a specific team that performed infection prevention surveillance nor utilized a formatted checklist. Director #3 stated instead, staff looked for imminent threats to patients while providing care. Director #3 stated they had a difficult time maintaining the environment of the building because the building was old, however, staff ensured each room they entered was as good as it could be. Director #3 stated it was important to have a clean hospital environment and risked patient contamination and infection if staff did not clean the environment.

Director #3 stated CNO #5 and the director of maintenance (Director) #4 completed an infection control risk assessment (ICRA) which was reviewed and signed off by Director #3 when a larger construction project happened. Director #3 stated they directed staff to wrap the supply cabinets in the OR in anticipation of electrical work but had not been able to evaluate the wrapping done in the OR or sign off on it.

iii. On 10/1/24 at 2:51 p.m., an interview was conducted with the director of housekeeping (Director) #2. Director #2 stated the housekeeping department cleaned all areas of the hospital daily except for the OR. Director #2 stated the OR was cleaned by OR staff. Director #2 stated the OR staff cleaned the OR because housekeeping did not have enough staff to clean that area. Director #2 stated they walked through the building daily, but not with a team of people as a formal surveillance. Director #2 stated staff encountered issues with multiple bugs due to the age of the building. Director #2 stated staff swept bugs away during the cleaning process and did not call pest control for additional pest control treatment. Director #2 stated staff had to do additional cleaning in the ED storage room with the broken cement floor due to the additional dust it produced. Director #2 stated patients deserved a clean environment to improve their health and risked infections when the environment was not clean.

iv. On 10/2/24 at 9:02 a.m., an interview was conducted with the director of maintenance (Director) #4. Director #4 stated they did not have a current work order for the drywall in the inpatient unit nurses' station and were unaware of the condition of disrepair of the wall. Director #4 stated the floor in the ED needed repair but they did not have an estimated time of completion. Director #4 stated they concentrated on direct patient care areas first for repairs. Director #4 agreed the drywall and cement deterioration posed a concern for infection control. Director #4 stated they did not participate in infection control surveillance and stated a plan needed to be in place for patient safety and good care so patients did not experience harm.

v. On 10/2/24 at 12:59 p.m., an interview was conducted with chief nursing officer (CNO) #5. CNO #5 stated Director #3's status as a medical doctor made them qualified as an infection preventionist. CNO #5 stated Director #3 brought infection prevention concerns to the quality meeting for review, but the facility did not have a formal surveillance process dedicated to infection control. CNO #5 stated if the facility did not practice a process for infection control issues throughout the facility environment, it placed the patients at risk for poor outcomes or complications of care.

These interviews were in contrast to the facility's infection prevention plan which read, infection prevention included strategies to decrease risk and a surveillance plan. Infection prevention rounds assessed the level of quality provided. The facility monitored compliance with infection prevention practices and documented staff evaluation and observation of practices. The infection preventionist and department managers then reviewed the compliance monitoring and initiated appropriate actions.

Additionally, these interviews were in contrast to the facility's sanitation and infection control pest control policy which read, when the facility reported a pest situation, the facility notified the contractor and requested an unscheduled visit to address concerns.

Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §485.641, Quality Assessment and Performance Improvement Program, was out of compliance.

C-1306 The CAH's QAPI program must be ongoing and comprehensive. Involve all departments of the CAH and services (including those services furnished under contract or arrangement). Based on interviews and document review, the facility failed to ensure the quality assessment and performance improvement (QAPI) program identified and implemented performance improvement activities, including high-risk, problem-prone areas. This failure affected patient rights, infection control, and physical plant and environment. (Cross-reference C-1208, C-0914, and C-2523)

Based on interviews and document review, the facility failed to ensure the quality assessment and performance improvement (QAPI) program identified and implemented performance improvement activities, including high-risk, problem-prone areas. This failure affected patient rights, infection control, and physical plant and environment. (Cross-reference C-1208, C-0914, and C-2523)

Findings include:

Facility policies:

The Fire Protection Systems policy read, all facility fire protection systems shall be maintained in a serviceable state at all times through a proactive inspection, testing, and maintenance program that is designed to identify and repair any system deficiency or malfunction that could be a threat to the facility and its occupants. Fire/smoke damper inspection to be completed at least every 6 years by technicians. Nebraska Safety & Fire has been asked to complete the inspection every 3 years. Maintenance staff will complete the inspection on an annual basis and log the date on the Lincoln Health Fire Damper and heat tab Location and Functionality test log.

The Electrical Power Strips policy read, it is the policy that electrical power strips can be used as long as no electric extension cords are plugged into it before or after the power strip (piggy backing / daisy chaining). No electrical power strips can be used on medical equipment. No personal devices can be plugged into an electrical power strip.

The Infection Prevention Plan policy read, the infection prevention program addressed detection, prevention and control of infections. Infection prevention included strategies to decrease risk and a surveillance plan. Infection prevention rounds are made to assess the level of quality provided and actions for improvement are taken as needed. Compliance with infection prevention practices is monitored and documented by staff evaluation and observation of practices. The infection preventionist and department managers review the compliance monitoring and initiate appropriate actions.

The Infection Control-Maintenance policy read, the department will do on-going monitoring of the facility for areas needing repair. Leaks and areas of moisture shall be fixed promptly and drywall, ceiling tiles, and other materials shall be replaced.

The Physical Environment Pest Control Program policy read, all policies and procedures specific to pest and rodent control were the responsibility of the maintenance department and appropriate contract services. Departments responsibilities were to report all pest problems to maintenance. Maintenance services receive all phone calls on pest problems and forward information to outside pest management contractor or corrective action.

The Sanitation and Infection Control Pest Control policy read, if a pest situation was reported, the contractor was notified and requested to make an unscheduled visit to address concerns.

The Incident-Variance Reporting policy read, this was mechanism for handling reportable incidents must be established in an effort to ensure proper management of incidents, and to enhance the quality of care to our patients by identifying problem areas in an effort to prevent the occurrence of future incidents. It is also done to document threatening incidents to staff so that potential safety hazards can be addressed. All reportable incidents associated with facility property, personnel, patients, or the public will be immediately documented and reported to the appropriate department manager. A written incident report will be submitted to the Compliance Office within twenty-four hours (forty-eight hours on weekends) following the actual occurrence. General incidents include any unusual or unexpected occurrence. Examples of incidents include: abuse, adverse cardiac or respiratory arrest, adverse reaction, complaints, complications, death, drug reactions, elopement, equipment or medical device malfunction, exposures, falls, injuries, and medication errors.

References:

The 2024 Quality Improvement Plan read, all services supported by the facility on a contracted basis will be evaluated on an as needed basis. The leadership team is responsible for: reporting to the management team on work plan results, selected outcome measures, program evaluation efforts, QI projects, patient satisfaction evaluation, state standard gaps, and QI Training needed by staff; assuring implementation of QI projects; and assuring continue identification and investigation of QI filters as they arise.

The Bylaws of the Board of Trustees read, the CEO shall ensure that all departments are accountable for proper maintenance of all equipment and physical properties. The CEO shall be responsible for reviewing the Hospital's policies and contracts to ensure that the foregoing comply with all applicable laws and regulations and that the objectives and purposes of the Hospital are being served by the requirements of such documents and policies.

1. The facility failed to ensure the QAPI program identified and implemented performance improvement activities, including in high-risk, problem-prone areas.

A. Observations

i. On-site observations conducted during the complaint survey completed on 10/3/24 revealed the facility failed to comply with the regulations set forth for Life Safety. Numerous violations in regards to fire prevention and mitigation were identified, and four immediate jeopardies were called under Life Safety Code tags K161, K341, K353, and K920. See survey event ID 8D9821 for full details of the cited deficiencies.

ii. Observations conducted on 9/26/24 in the OR supply room revealed surgical supplies stacked on the top shelves of the storage area within the 18-inch sprinkler head clearance. This obstructed the sprinkler head from operation in the event of a fire. Additionally, observations also included surgical supplies on top of a radiator.

iii. Observations conducted on 9/26/24 in the endoscopy procedure room revealed medical equipment plugged into extension cords and extension cords plugged into other power strips to increase the length of the extension cord.

This was in contrast to the use of electrical power strips policy which read, staff should not use electrical extension cords when plugged into electrical power strips and should not use them for medical equipment.

iv. Observations were conducted on 9/26/24 at 9:00 a.m. in the ED. In the ED treatment room where staff cared for patients, observations revealed staff stored a bottle of sterile water and a bottle of normal saline, both used in patient care, under the sink in a plastic patient care bucket. Further observations revealed an unknown soiled substance on the bottom shelf of the cupboard. Additional observations in the ED revealed an exposed cement floor in a patient supply storage room which produced dust and loose cement particles on the floor.

This was in contrast to the facility's sink storage policy which read, there will be no supplies stored in cabinets underneath the sinks in patient care areas and stored to meet infection control guidelines in appropriate cabinets.

v. Observations conducted in the inpatient care unit nurses' station revealed a large area of exposed, broken drywall under a window near medications and patient care items. Additional observations in patient care room #10 revealed a bottle of cleaning solution in disrepair with the instructions for use peeled and flaked off.

vi. Observations conducted in the operating room (OR) revealed a stand with patient care suction tubing taped to the top of a metal plate with significant rust on the metal plate. Further observations revealed staff had covered the sterile supply cabinets in the OR room with a thin sheet of plastic and used plastic tape to secure the plastic wrap in anticipation of construction in the OR. Observations revealed the tape did not secure or seal the plastic completely and left gaps for dust to reach the sterile supplies in both cabinets.

vii. Observations conducted in the endoscopy and colonoscopy procedure room revealed a thick layer of dust on the air vent on the endoscopy computer tower. Further observations revealed the air return vent also was covered in dust. Additionally, observations revealed the cement floor between the patient procedure room and the scope reprocessing room where staff stored scope supplies had crumbed cement which produced dust and cement particles.

These observations were in contrast to the facility's surveillance infection control policy which read, nursing staff were responsible for functions essential to the prevention, recognition, and management of infections. Staff accomplished this through the recognition of the potential risks associated with invasive procedures.

viii. Observations conducted in the operating room (OR) supply room revealed a dead bug in the bottom of the carts used for patient supplies while in the OR. Additional observations in the MRI trailer revealed dead moths in a plastic bin used for storage of MRI equipment.

This was in contrast to the facility's physical environment pest control program policy which read, the maintenance department and appropriate contract services had the responsibility specific to pest and rodent control. Departments' responsibilities were to report all pest problems to maintenance. Maintenance services were to receive all phone calls on pest problems and forward information to outside pest management contractor or corrective action.

B. Interviews

i. An interview was conducted with registered nurse (RN) #1. RN #1 stated they worked in the emergency department and the medical-surgical unit. RN #1 stated if there were an incident that needed to be reported they would fill out a paper sheet and give the sheet to the chief nursing officer. RN #1 stated that medication errors and falls should be reported as incidents. RN #1 stated it was important to practice good infection control to help keep patients safe. RN #1 stated patients preferred to be treated in a clean facility, and to not be exposed to anything. RN #1 stated the risk of not practicing infection control would be a patient acquiring a new infection.

ii. An interview was conducted with the director of specialty services (Director) #7. Director #7 stated they helped oversee the operating room. Director #7 stated safety was their number one concern, and this was heightened due to the small size of the operating room. Director #7 stated they were not aware of any particular rounding process to identify infection control concerns. Director #7 stated their mindset around utilizing incident reports was to take care of any identified concerns and not file an incident report. Director #7 stated they did not provide education to their staff about filing reports, but thought someone from risk addressed this with staff. Director #7 stated the criteria to file a report was vague, but reports should have been filed for patient safety issues or injuries to patients. Director #7 stated it was important to have a process in place to identify patient safety issues so all staff were utilizing the same approach and standards to more easily identify issues. Director #7 stated the risk of not identifying or addressing safety issues would be patient harm or risk of harm.

This was in contrast to the Incident-Variance Reporting policy which read, a mechanism for handling reportable incidents must be established in an effort to ensure proper management of incidents,, and to enhance the quality of care to patients by identifying problem areas in an effort to prevent the occurrence of future incidents. It was also done to document threatening incidents to staff so that potential safety hazards can be addressed. All reportable incidents associated with facility property, personnel, patients, or the public were to be immediately documented and reported to the appropriate department manager. A written incident report would be submitted to the Compliance Office within twenty-four hours (forty-eight hours on weekends) following the actual occurrence.

iii. An interview was conducted with the director of maintenance (Director) #4. Director #4 stated areas of cement deterioration in the building and disintegration of floor tiles could have been an infection control concern. Director #4 stated the facility had been working with a fire service contractor (Contractor) for twelve years, but they were now aware that the Contractor was not completing the contracted work to maintain the facility's fire suppression and alarm systems. Director #4 stated it was important to have a system for the facility to address safety issues to ensure that patients and staff were kept safe. Director #4 stated there was a risk of harm if the facility was not identifying safety issues and improving them.

iv. An interview was conducted with the director of risk management (Director) #8. Director #8 stated they managed the facility's incident reports. Director #8 stated the process to file an incident report was electronic, and staff could utilize the process from computers at the facility. Director #8 stated another team member would combine all the incident reports to provide quarterly reports for the board. Director #8 stated incident reports were to be filed by any staff at the facility if something occurred outside of the ordinary or was outside of policies or procedures. Director #8 stated many staff were not reporting incidents, and that the staff in the emergency department and inpatient unit did not use the facility's electronic system and instead used paper forms. Director #8 stated these paper forms were kept with the department manager, and were not always received in a timely manner to ensure they were included in data for tracking and trending. Director #8 stated it was important to have a standardized system for monitoring incidents because the facility would not be aware of issues or be able to receive information from front line staff. Director #8 stated if the system used to identify issues was not used as intended there was a risk that the facility would miss large opportunities to correct issues and it could lead to something catastrophic. Director #8 stated there was a disconnect between the facility actively seeking out opportunities for safety improvement and a missing connection between the facility's risk assessment team and quality improvement. Director #8 stated resources and staff were barriers to identifying issues, especially with respect to the physical environment of the facility.

v. An interview was conducted with the director of inpatient services (Director) #3. Director #3 stated they oversaw the facility's infection control program. Director #3 stated their biggest priority was to keep patients safe from hospital acquired infections. Director #3 stated this included mitigating risks for patients at the facility by maintaining a safe environment, and ensuring any construction on the building utilized methods that minimized risk of infection. Director #3 stated they would round on patients, and observe for any imminent environmental threats to patients during that time. Director #3 stated it was important to maintain a clean environment at the facility because patients may have a bacteria or virus, and these should not be transmitted to other patients seeking care at the facility. Director #3 stated there was a risk if certain areas were not cleaned at all or not cleaned appropriately. Director #3 stated they followed the direction of the facility's accrediting agency to determine any infection control quality improvement projects. Director #3 stated they followed what the facility's accrediting agency dictated rather than setting their own priorities for quality improvement. Director #3 stated they were focused on preventing the spread of catheter (a thin, flexible tube that's inserted into the body to transfer liquids out) associated urinary tract infections and respiratory infections while patients were hospitalized.

This interview was in contrast to the facility's infection prevention plan which read, infection prevention included strategies to decrease risk and a surveillance plan. Infection prevention rounds assessed the level of quality provided. The facility monitored compliance with infection prevention practices and documented by staff evaluation and observation of practices. The infection preventionist and department managers then reviewed the compliance monitoring and initiated appropriate actions.

This was also in contrast to the facility's 2024 Quality Improvement Plan which read, quality improvement efforts included review and improvement of all programs and processes that had a direct influence on the quality of health services provided. Program managers were responsible for initiating problem solving processes and quality improvement projects. Leadership was responsible for assuring continual identification and investigation of quality improvement filters as they arose.

vi. An interview was conducted on 10/2/24 at 11:03 a.m. with the chief nursing officer (CNO) #5. CNO #5 stated they were also the director of quality. CNO #5 stated it was important to help the facility and staff understand the impact of systems improvement. CNO #5 stated the QAPI plan should evaluate the facility from a 10,000 foot view. CNO #5 stated their responsibility for quality only covered the emergency department and the inpatient unit, with other managers responsible for monitoring and determining quality projects in their areas. CNO #5 stated they were instructed by their accrediting agency to use other departments to help evaluate the process in the emergency department. CNO #5 stated to ensure quality was not approached in a narrow manner, all quality issues were presented to the governing board. CNO #5 stated they were not involved with the infection control program but would listen to presentations to the board by the provider overseeing infection control. CNO #5 stated they were not aware of what different directors' quality projects were.

CNO #5 stated the leadership team oversaw contracts and was aware that a central list of contracts should have been kept in place to help monitor them. CNO #5 stated if the facility relied on the expertise of contractors, the facility needed to ensure the contracts were followed. CNO #5 stated they were aware of issues with the Contractor since 2020. CNO #5 stated it was important to have a comprehensive quality process that identified concerns because this allowed all staff to be successful with a proper system in place. CNO #5 stated the risk of not having a comprehensive approach to Quality would be a bad outcome, such as a bad patient outcome.

This interview was in contrast to the 2024 Quality Improvement Plan which read, all services supported by the facility on a contracted basis would be evaluated on an as needed basis. The leadership team was responsible for: reporting to the management team on work plan results, selected outcome measures, program evaluation efforts, QI projects, patient satisfaction evaluation, state standard gaps, and QI Training needed by staff; assuring implementation of QI projects; and assuring continue identification and investigation of QI filters as they arose.

vii. An interview was conducted on 10/2/24 at 4:06 p.m. with the chief executive officer (CEO) #6. CEO #6 stated their role was to oversee everything in the facility. CEO #6 stated it was key to have a QAPI program that worked on meaningful measures. CEO #6 stated they attended quality sub-committee meetings, and all departments had different improvement projects. CEO #6 stated it was important to oversee all departments with respect to quality, and to ensure systems issues were identified. CEO #6 stated there was not a formal process to enter contracts with vendors, and the facility needed to work on a more structured process to oversee contracted services.

Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §485.614 Patient Rights was out of compliance.

C-2523 (c)(2) The patient has the right to receive care in a safe setting. Based on observations, document review, and interviews, the facility failed to protect the patient's right to receive care in a safe setting. Specifically, the facility failed to have a functional fire suppression system and failed to implement a plan to mitigate the safety risk of fire throughout the entire facility. (Cross-reference C-0914)

Based on observations, document review, and interviews, the facility failed to protect the patient's right to receive care in a safe setting. Specifically, the facility failed to have a functional fire suppression system and failed to implement a plan to mitigate the safety risk of fire throughout the entire facility. (Cross-reference C-0914)

Findings include:

Facility policies:

The Fire Protection System Impairments policy read, to assure that unauthorized persons and/or outside contractors do not cause impairment to a fire protection system, the impairment process will occur prior to any outage. Inspection and testing tasks shall be performed by personnel who have developed competence through training and experience. System malfunctions shall receive immediate attention and repairs and if required, shall receive the highest priority to return the system(s) to full operation as quickly as possible. For shutdowns exceeding four hours within a 24-hour period, a fire watch will be implemented.

The Fire Watch policy read, the fire protection system impairment policy will be implemented in the event the fire alarm system or sprinkler system must be shut down or is out of service. This was to provide a mechanism for monitoring a building or portions of a building for potential or actual fire smoke conditions during the fire protection system shutdown or operational failure. Upon notification of a system outage that is anticipated to last more than four hours in a 24-hour period, maintenance will initiate a fire watch.

The Use of Electrical Power Strips policy read, electrical power strips can be used as long as no electric extension cords are plugged into it before or after the power strip. No electrical power strips can be used on medical equipment. No personal devices can be plugged into an electrical power strip.

1. The facility failed to implement a plan to mitigate the safety risk caused by a failed fire suppression system.

A. Observations conducted during the complaint survey completed on 10/3/24 revealed the facility failed to comply with the regulations set forth for Life Safety. Numerous violations in regards to fire prevention and mitigation were identified, and four immediate jeopardies were called under Life Safety Code tags K161, K341, K353, and K920. See survey event ID 8D9821 for full details of the cited deficiencies.

i. Observations conducted on 9/26/24 in the operating room (OR) supply room revealed surgical supplies stacked on the top shelves of the storage area within the 18-inch sprinkler head clearance. This obstructed the sprinkler head from operation in the event of a fire. Additionally, observations included surgical supplies on top of a radiator.

ii. Observations in the endoscopy procedure room revealed medical equipment plugged into extension cords and extension cords plugged into other power strips to increase the length of the extension cord.

This was in contrast to the Use of Electrical Power Strips policy which read, staff should not use electrical extension cords when plugged into electrical power strips and should not use them for medical equipment.

iii. Observations in a hallway near the sterile processing department (SPD) revealed a closet door unable to shut due to the amount of patient care equipment (bedside commodes, walkers, oxygen concentrators) stacked to the ceiling of the closet.

B. Interviews

i. On 10/1/24 at 3:25 p.m., an interview was conducted with the maintenance director (Director) #4. Director #4 stated staff moved objects that obstructed sprinkler heads when staff identified issues. Director #4 stated maintenance staff rounded through the facility daily but the checklist did not include a check for supplies to be below 18 inches from the ceiling and stated staff likely did not do the checks for supplies around the sprinkler heads. Director #4 state supplies stacked within 18 inches of the ceiling created an obstruction for the sprinkler heads.

This was in contrast to the document review of the rounding checklists kept by the facility which revealed maintenance staff completed the rounds three days each week, not daily, and primarily focused on mechanical equipment under the direction of the plant operations department.

ii. An interview was conducted on 10/2/24 at 9:02 a.m. with Director #4. Director #4 stated a contracted vendor started in 2012 and inspected the fire suppression sprinkler system four times a year. Director #4 stated the contracted vendor's responsibilities included suppression inspections, extinguisher inspections, maintenance on the kitchen hood, maintenance of alarm panels, strobes, horns, and ensured the sprinkler heads worked. Director #4 stated they accompanied and helped the contracted vendor with the water system. Director #4 stated they received reports of the deficiencies found with each quarterly inspection. Director #4 stated the reports all showed zero deficiencies except the report created after the inspection done in the presence of state life safety code surveyors. Director #4 stated that report had 17 deficiencies.

Director #4 stated they did not check the contracted vendor's logs against all the facility sprinkler system areas. Director #4 stated they assumed the contracted vendor did the work and showed the fire suppression system worked. Director #4 learned the system did not work properly at the time the state life safety code inspection started. The fire watch did not start until three days after they learned the fire suppression system did not work.

This was in contrast to the fire protection system impairments policy which read, personnel who developed competence through training and experience would perform the inspection and testing of the fire protection system. For shutdowns which exceeded four hours within a 24-hour period, the facility implemented a fire watch. Additionally, it was in contrast to the fire watch policy which read, the facility implemented the fire protection impairment policy, which included the initiation of a fire watch in the event the fire alarm system or sprinkler system shut down or experienced operational failure.

C. Document Review

i. The fire sprinkler system inspection reports supplied to the facility by the contracted vendor were reviewed. The review included inspections performed by the contracted vendor on 12/5/22, 3/8/23, 6/22/23, 9/12/23, 12/13/23, 8/29/23, and 9/27/24. The review revealed all reports through 8/29/23 read, there were no reported deficiencies for the report submission to the facility. The review of two reports provided for the inspection on 9/27/24, completed at the request and in the presence of life safety surveyors, revealed a total of 17 deficiencies noted in the inspection reports. The deficiencies included critical severity levels of deficient findings. The inspection report read the main shutoff valve did not shut off completely and the sprinkler system did not have a necessary backflow assembly on the sprinkler system or the antifreeze system. The inspection report read the test valve in a stairwell was clogged with debris and there were improperly labeled forward flow test valves for the sprinkler system.