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Based on observation and interview, it was determined for 2 of 2 airway boxes and 1 of 1 intraosseous box in the emergency department, the hospital failed to ensure the boxes were maintained and monitored. This has the potential to affect all patients who receive care in the emergency department.

Findings include:

1. During a tour of the emergency department on 4/25/23 at approximately 12:00 PM, 1 intraosseous box and 1 airway box in room #3 and 1 airway box in room #4 were observed to lack documentation of monitoring.

3. During an interview on 4/25/23 at approximately 12:00 PM, E#9 (Manager of Acute Care Services and the Emergency Department) stated the airway boxes and the intraosseous box had not been monitored monthly. E#9 stated the boxes should have been checked each month when the crash cart check was checked.

Based on direct observations during the survey walk-through, staff interviews and document reviews during the life safety code portion of a recertification survey conducted on May 4, 2023 the surveyors find the facility does not comply with the applicable provisions of the 2012 Edition of NFPA 101 Life Safety Code therefore the requirements of 42 CFR Subpart 485.625, Physical Plant and Environment are NOT MET.

See the life safety code deficiencies on the associated K-tags

Based on direct observations during the survey walk-through, staff interviews and document reviews during the life safety code portion of a recertification survey conducted on May 4, 2023 the surveyors find the facility does not comply with the applicable provisions of the 2012 Edition of NFPA 101 Life Safety Code.

See the life safety code deficiencies on the associated K-tags.

Rutherford, Donna J.
Based on document review and staff interview, it was determined in 1 of 1 Emergency Department Registered Nurse who required conscious sedation training, The hospital failed to ensure training was conducted as required. This has the potential to affect all patients who require conscious sedation in the emergency department.

Findings include:

1. The personnel files were reviewed on 4/27/23. The ED Registered Nurse (E#10), date of hire 4/12/07, file lacked current training for conscious sedation (last training 1/26/21).

2. During an interview on 4/27/23, E#3 (Manager of Quality) stated "The Hospitals practice is for the ED RN's to have conscious sedation training at least yearly."

Based on document review and staff interview, it was determined in 2 of 4 (Pt #3, Pt #13) blood transfusion records reviewed, the registered nurse failed to follow the blood transfusion per policy. This has the potential to affect all patients who receive blood by the hospital.

Findings include:

1. The policy titled "Transfusion of Blood and Blood Products" was reviewed on 4/26/23. The policy noted "Policy:...4. Blood and Blood products are administered according to licensed provider order..."

2. Pt#3 was admitted to the hospital for blood transfusion on 4/11/23 with a diagnosis of acute myeloblastic leukemia. The MD ordered 2 units of packed blood cells to be transfused, each unit over 3 hours. The first unit of packed blood cells was started at 9:48 AM and ended 12:05 PM (2 hours 17 minutes). The second unit of packed cells was started at 12:07 PM and ended 2:23 PM (2 hours and 16 minutes).

3. Pt#13 was admitted to the hospital on 4/17/23 with a diagnoses of anasarca (generalized swelling) and vascular access problem. The MD ordered 1 unit of packed blood cells to be transfused over 4 hours. The first unit was started at 11:03 PM and ended 2:15 AM (3 hours and 12 minutes).

4. During an interview on 4/28/23 at approximately 9:00 AM, E#3 (the Manager of Quality/ Safety) verbally agreed the blood wasn't given in the time it was ordered for.

Based on document review and interview, it was determined for 11 of 15 patient record reviewed who presented to the Emergency Department alert and oriented, the hospital failed to ensure a consent for treatment (Authorization/Release/Agreement and Contract to Pay) was provided and signed by the patient or patient's guardian. This has the potential to affect all patients who receive treatment by the hospital.

Findings include:

1. The "Authorization/Release/Agreement and Contract to Pay" was reviewed on 4/27/23. The agreement noted "This agreement is effective as of the date of my signature... I will need to sign this Agreement upon each visit... emergency department visits... If the undersigned is not the Patient the undersigned represents and warrants the s/he has full legal authority to sign Agreement on behalf of the Patient. I acknowledge and certify that all my questions were answered to my satisfaction and that I was given the opportunity to receive a copy of the Agreement... I ACKNOWLEDGE AND CERTIFY I HAVE READ AND UNDERSTAND THIS CONTRACT."

2. The "Consent to Treat - Minor" (effective 7/21/21) was reviewed on 4/27/23. The policy noted "1. Consent from the patient or parent/guardian is needed prior to provision of care, ... 2. Written or verbal consent from parent/guardian is necessary to provide care to a minor... 3. The Authorization/Release/Agreement to Pay (ARA) is valid for the following timeframes: ... except ED..."

3. The following records were reviewed throughout the survey and lacked documentation of a signed consent or ARA:
a) Pt #3, DOS: 4/11/23
b) Pt #8, DOS: 2/7/23
c) Pt #11, DOS: 7/31/22
d) Pt #12, DOS: 12/27/22
e) Pt #13, DOS: 4/11/23
f) Pt #14, DOS: 3/6/23
g) Pt #15, DOS: 3/31/23
h) Pt #19, DOS: 3/27/23
i) Pt #20, DOS: 3/27/23
j) Pt #21, DOS: 3/27/23
k) Pt #22, DOS: 3/27/23

4. On 4/27/23 at approximately 2:30 PM, E#5 (Regulatory Coordinator) demonstrated in the electronic medical record under the "Registration" tab, a line item that read "ARA verbal". The tab lacked documentation of who gave verbal consent or that a copy the ARA was offered.

5. During an interview on 4/27/23 at approximately 1:00 PM, E#1 (Manager of Quality and Safety) stated "We have one staff member at the registration desk in the ED. That person cannot always leave the desk, so she calls the patient or guardian in the room and verbalizes the consent to them."

Based on document review, observation and interview, it was determined for 1 of 2 (E#8) Certified Registered Nurse Anesthetist observed, the hospital failed to ensure infection prevention measures where implemented per policy. This has the potential to affect all patients who receive anesthesia by the hospital.

Findings include:

1. The policy titled "Skills: Medication Administration: Intravenous Bolus" (no date) was reviewed on 4/28/23. The policy noted "6. Disinfect vials by cleansing the access diaphragm using friction and sterile 70% isopropyl alcohol... and allow it to dry for 10 seconds."

2. During a tour on 4/27/23 at 9:50 AM, E#8 was observed to open 4 vials of medication and inserted the needle into the diaphragm without cleaning the septum.

3. During an interview on 4/28/23 at approximately 10:00 AM, E#3 (Manager of Quality and Safety) agreed the septum of the vials should have been cleaned prior to inserting the needle.

Based on document review and interview, it was determined for 3 of 8 (MD#2, MD#3, MD#4) physician files reviewed, the hospital failed to ensure the physicians received education on infection prevention measures per policy. This has the potential to affect all patients who receive care by the hospital.

Findings include:

1. The "Bylaws, Rules and Regulations" (effective 8/21/20) were reviewed on 4/28/23. The Bylaws noted on page 61 "8.3.6 Completion of required training... training in the use of HOSPITAL's electronic medical records system..."

2. The physician files were reviewed on 4/27/23. MD#2, MD#3 and MD#4 lacked documentation infection prevention education had been assigned or completed.

3. During an interview on 4/27/23 at approximately 1:30 PM, E#1 (Manager of Quality and Safety) stated all physicians should be assigned infection prevention training in the electronic medical records system and a completion date. E#1 agreed MD#2, MD#3 and MD#4 had not been assigned or completed infection prevention training.

A. Based on document review and interview, it was determined for 1 of 1 (Pt #10) patient record reviewed for violent restraints, the hospital failed to ensure documentation of a one-hour face to face evaluation was completed, as required. This has the potential to affect all patients placed in violent restraints.

Findings include:

1. The policy titled "Restraint and Seclusion Management" (approved 12/19/2022 was reviewed on 4/27/23. The policy noted "... Process: 2. Ensure face- to- face evaluation is performed within one hour of initiation of a restraint for violent and/or self destructive behavior..."

2. Pt #10 was admitted to the hospital on 10/4/22 with the diagnosis of Psychosis. The Emergency Medicine note dated 10/4/22 at 10:52 AM noted "Violent Restraints and/or Face to Face... Pt has exhibited some dangerous potentially self injurious behavior (jumping out of a moving car) and impulsive aggressive behavior. The record noted Pt #10 was placed in violent restraints on 10/4/22 at 7:35 PM to 10/5/22 at 3:30 PM. The record lacked a face to face assessment during the violent restraint application.

3. During an interview on 4/27/23, E#3 (Manager of Quality and Regulatory) reviewed Pt #10's record and verbally agreed a face to face had not been completed during the violent restraint application.

B. Based on document review and interview, it was determined for 1 of 2 (Pt #10) patients records reviewed with an acute psychiatric diagnosis, the hospital failed to ensure the patients received care and staff worked in a safe environment. This has the potential to affect all patients who receive care in the emergency department and staff employed in the emergency department.

Findings include:

1. Pt #10 was admitted to the hospital on 10/4/22 with the diagnosis of Psychosis. The Emergency Medicine note dated 10/4/22 at 10:52 AM noted "Violent Restraints and/or Face to Face... Pt has exhibited some dangerous potentially self injurious behavior (jumping out of a moving car) and impulsive aggressive behavior." The nurse's note dated 10/4/22 at 11:30 AM noted "... patient was walking in the halls and asked to return to room which he/she did but when ER doors opened patient exited... Patient ran across parking lot and hi-way ... Patient asked to return and started running again going down Harlem ave." The nurse's note dated 10/4/22 at 5:30 PM noted "Patient approached nurses station and asked for... clothes... swung with closed fist hitting this nurse in the back of the head and knocking... to the ground... went for the doctor... and began hitting... around the head multiple times." The record lacked documentation measures to protect patients, staff and the patient were implemented. The Physician's note dated 10/4/22 at 7:32 PM noted "Pt will be placed in 4 point restraints for the protection of the staff as we have no security and the police have left the premises." The record noted Pt #10 was placed in violent restraints on 10/4/22 at 7:35 PM to 10/5/22 at 3:30 PM and was monitored by camera only.

2. During an interview on 4/27/23, E#3 reviewed Pt #10's record and verbally agreed measures to protect patients, staff and the patient were not implemented.




32189

Based on document review and interview, it was determined for 3 of 9 (MD#1, MD#2, MD#3) physician files reviewed, the hospital failed to ensure Emergency Preparedness training was completed. This has the potential to affect all staff and patients who receive care by the hospital.

Findings include:

1. The following physician files lacked documentation of emergency preparedness training:
a) MD#2, last credentialed on 08/2021;
b) MD#3, last credentialed on 04/2023;
c) MD#4, last credentialed on 05/2022.

2. During an interview on on 04/27/23 at approximately 3:00 PM, E#3 (Manager of Quality and Safety) reviewed MD#2, MD#3 and MD#4's file and verbally agreed the physicians had not been assigned or completed the emergency preparedness training.