HospitalInspections.org

Based on interview and record review, the facility failed to follow the Medical Staff ByLaws, to ensure the governing board reviewed a new medical staff member for appointment, based on the recommendations of the medical staff. Findings include:

A review of the facility's Medical Staff ByLaws, last updated 12/19/17, showed:

- "...6.4-5 BOARD ACTION

- A. On Favorable Medical Staff Recommendations: The board shall, in whole or in part, adopt or reject a favorable recommendation of the medical staff..."

During an interview and record review on 5/25/22 at 8:25 a.m., staff member A stated staff member M had not been approved by the governing board upon hire. A review of staff member M's credentialing file showed a recommendation for appointment by the medical staff, but no review had been completed for the appointment by the governing board.

Based on observation, interview, and record review, the facility failed to develop and implement policies and procedures to include identifying hazardous radiation areas; and failed to ensure clear signage was posted in the X-Ray machine location, identifying a hazardous radiation area. This deficient practice had the potential to affect all patients and staff utilizing the radiation services. Findings include:

A review of the facility's policy and procedure titled, X-Ray Department Safety Precautions, last revised 10/1/13, showed, "Purpose: To inform X-ray personnel of the X-ray Department Safety Precautions. Policy: The Board of Directors has adopted the following safety precautions for the X-ray Department of [facility]..." The policy and procedure did not address signage to be posted, identifying hazardous radiation areas.

During an observation and interview on 5/24/22 at 7:53 a.m., the entrance door to the X-Ray room displayed a sign which showed, "X-Ray Do Not Enter." Staff member E stated no signage had been posted on the door showing a hazardous radiation area. She stated the policy and procedure had recently been updated but did not include posting signage identifying a hazardous radiation area.

Based on observation, interview, and record review, the facility failed to follow their established policies and procedures on COVID-19 vaccination requirements for staff members granted a vaccine exemption. This deficient practice had the potential to increase the risk of COVID-19 transmission to patients, employees, volunteers, and visitors. Findings include:

A review of the facility's COVID-19 staff vaccination record, which included contracted staff, showed 49% of the staff had received either a medical or religious exemption to the vaccine. Staff members A, L, N, O, and P had been granted a vaccine exemption.

A review of the facility's policies and procedures titled COVID-19 Vaccination Requirement, effective 2/14/22, showed:

- ..."Accommodations:
- ...These will be the accommodations but are not limited to:
- A. All employees vaccinated or unvaccinated must at a minimum always wear a surgical mask while delivering direct patient care or when there is an outbreak of Covid-19 N95 masks are required.
- a. However, all unvaccinated employees will be required to test weekly if the county transmission rate is above low. The Director of Nursing will be in contact with [health department] for the counties transmission rate.
- b. Unvaccinated employees will be required to wear masks at all times..."[sic]

During an observation on 5/24/22 at 11:55 a.m., staff member N was seated behind the nurses' station desk with a surgical mask on, pulled down below her chin.

During an observation on 5/24/22 at 3:32 p.m., staff member N was seated behind the nurses' station desk with a surgical mask on, pulled down below her chin. Staff member P was standing next to the nurses' station desk with a surgical mask on, pulled down below her chin.

During an observation on 5/24/22 at 3:33 p.m., staff member O was seated in her office, with the door open, and was not wearing a surgical mask. Staff member A was seated in her office, with the door open, and was not wearing a surgical mask.

During an interview on 5/24/22 at 3:45 p.m., staff member P stated she thought the policy regarding mask requirements was to wear them when around patients.

During an interview on 5/24/22 at 3:46 p.m., staff member N stated she should wear a surgical face mask at all times and was aware she had not followed the guideline.

During an interview on 5/24/22 at 3:48 p.m., staff member O stated the policy for staff with a vaccine exemption was to wear masks, but if she was alone in her office, she did not need to wear a mask.

During an interview on 5/24/22 at 3:50 p.m., staff member A stated she was required to wear a mask at all times.

During an observation and interview on 5/24/22 at 2:30 p.m., staff member L was in the kitchen preparing potato soup. Staff member L was not wearing a mask. The kitchen doors were open. The dining room doors were closed but unlocked. Staff member L stated he was not vaccinated for Covid-19, he was afraid of shots and was claustrophobic, when wearing a mask. Staff member L stated the management told him he did not have to wear a mask if he stayed in the kitchen and was not around the patients.

During an interview on 5/25/22 at 8:45 a.m., staff member B stated staff member L was claustrophobic and could not wear a mask. Management had made a decision that staff member L did not have to wear a mask but had to remain in the kitchen and not be out where patients were located.

During an interview on 5/25/22 at 1:00 p.m., staff member G stated she could not provide documentation of training to staff members on the established policies and procedures for COVID-19 Vaccination Requirement.

Based on interview and record review, the facility failed to follow their established policies and procedures to provide on-going training to their employees on the prohibition and prevention of patient abuse. Findings include:

A review of the facility's policies and procedures, titled Resident/Patient Abuse, effective date of 3/14/03, showed: ..."Train employees, through orientation and on-going sessions on issues relate to abuse prohibition practices such as: Appropriate interventions to deal with aggressive and/or catastrophic reactions of residents; How staff should report their knowledge related to allegation without fear of reprisal. How to recognize signs of burnout, frustration and stress that may lead to abuse; and what constitutes abuse, neglect and misappropriation of resident property. Staff will receive one in-service annually and one other educational session on abuse..." [sic]

A review of the facility's employee personnel files for staff members B, E, F, G, I, L, and N showed no evidence of annual or additional sessions on abuse training.

During an interview on 5/25/22 at 11:15 a.m., staff member A stated she was unable to find recent training information on abuse and neglect completed by the requested employees sampled.