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Based on a review of hospital policies and procedures and staff interview, it was determined the hospital failed to ensure there was an infection control nurse. This deficient practice poses the risk of not having an established infection control program, no one at the facility to track, control, and coordinate a response to infectious diseases within the facility, and an increased occurrence and transmission of infectious diseases.

Findings include:

Hospital policy titled "Infection Control," received on 01/31/2023, revealed: " ...Clinical personnel are provided with orientation to infection control principles, as well as ongoing inservice training and continuing education ...Report any new signs/symptoms of infection in a patient to your supervisor and/or the Infection Control Nurse ...."

Employee #1 confirmed in an interview on 01/31/2023, there is not currently an Infection Control Nurse.

Based on review of hospital policies and procedures, observation on tour, and staff interviews, it was determined that the hospital failed to require that medical supplies used for patient care were not expired. This deficient practice poses a potential risk for the health and safety of the patients, including risk for infection, negative outcomes, and or false laboratory testing when the hospital cannot ensure that expired supplies are being discarded, and are not being used for patient care.

Repeat deficiency - Event #93JH11, tag 1208, 01/11/2022

Findings Include:

Policy titled "Discarding of Expired Supplies," revealed: "...All dated materials will be checked for expired date when supplies are restocked on a weekly basis. If supplies are found to be expired they will be disposed of according to manufactures suggestion ...."

During hospital tours conducted on 02/01/2023 and 02/02/2023, the following expired supplies were found in the following areas:
1. In hospital storage room:
I-gel 30-60kg size 3 x4 exp.12/2022
Mallinckrodt 2.5 uncuffed tracheal tube x 3 04/27/2021
Mallinckrodt 3.0 uncuffed tracheal tube x2 04/04/2021
Mallinckrodt 3.5 uncuffed tracheal tube x 4 03/03/2021
Mallinckrodt 4.5 uncuffed tracheal tube x1 10/12/2020
Hudson RCI 4.5 cuffed endotracheal tube 03/2020
Smiths Medical Vibratory Pep Therapy System x 8 exp 01/03/2022
MedSource Suction catheter 10fr x17 exp 11/19/2022
MedSource Suction catheter 12 fr x 2 exp 03/14/2022
Phonfris Shiley inner cannula Size 8 x2 exp 07/12/2021
Ponfris Shiley inner cannula Size 6 x2 exp 05/10/2022
and
2. In CT scan room:
18G Insyte exp 8/31/22 x20

Employee #1 confirmed in an interview on 02/01/2023 that these supplies were expired.

Based on a review of hospital policy and procedure, documents, and interviews, it was determined the hospital failed to ensure the Infection Control Committee met, maintained meeting minutes, and discussed items identified as quality monitors. This deficient practice poses the potential risk of an ineffective infection control program, a higher risk of infection within the hospital, and infection control issues not being properly monitored in order to make recommendations and take actions to prevent the spread of infectious diseases.

Findings include:

Policy titled "Infection Control," received on 01/31/2023, revealed: "...To prevent or minimize the potential for transmission of infection to patients receiving clinical care, clinical personnel participate in infection monitoring, prevention, and control activities to reduce the risk of transmission of infections and promote patient and staff safety...."

Infection Control Meeting Minutes were requested for the fiscal year 2022 and none could be provided.

Employee #1 confirmed in an interview conducted on 02/01/2023, that infection control meeting minutes for fiscal year 2022 were not available.

Based on a review of hospital policy and procedure, documents, and interview, the Department determined the administrator failed to ensure there was documentation from the Quality Committee presented to the governing body to address concerns and improvements surrounding hospital care. This deficient practice poses the risk of the governing body being unaware of quality of care concerns to patients, visitors, and staff at the hospital, or how quality can be improved upon.

Findings include:

Policy titled "Continuous Quality Improvement," received on 01/31/2023, identified: " ...Departments within WCH and areas within the departments will continuously evaluate areas of opportunity for process improvement, develop a process to audit, engage staff in the evaluation, education, and plan to make improvements in the process. As described by CMS Quality Improvement is a framework used to systematically improve care, standardize processes and advance knowledge of professionals ...."

Quality Meeting Minutes for 2022 were requested on entrance, and a document titled "Quality Council Quarterly Meeting--- Feb 2, 2022," and one titled "2022 Quality Metrics-2nd Quarter," were provided on 02/01/2023.

Documents titled "Governing Board Meeting Minutes," were provided for each quarter in 2022. There were no Quality Meeting Reports presented to the Governing Board.

Employee #1 confirmed in an interview on 02/01/2023, that each department has quality projects that are worked on independently, but not reported to the Governing Body for examination, monitoring, approval, or recommendation. Employee #1 also confirmed in an interview on 02/01/2023, that Quality Meeting Minutes or Quality Metrics were not available for use by each Department.

Based on review of policies and procedures, documents, medical records, and interview, it was determined the hospital failed to ensure that hospital policies and procedures related to complaints and grievances were followed. This deficient practice poses a risk to the health and safety of patients when potential system or individual performance problems may not be addressed.

Repeat deficiency - Event #93JH11, Tag #Y-1302, 01/11/2022

Findings include:

Hospital policy titled "Patient Concern, Complaint and Grievance Resolution Process," received on 02/01/2023, revealed: " ...Complaint Process ...Patients or representatives, family members or visitors may voice a complaint at any time. Verbal concerns that are unable to be resolved by staff present and require the intervention of a departmental supervisor/manager or director will be documented in Quality Calendar ...the Quality/Risk Manager will forward the complaint on to the Patient Experience Coordinator, Supervisor, or Manager, as appropriate for investigation. (Within 24 hours from the time the event was logged in) ... B. Written complaints will be required to be entered into Quality Calendar ...then forwarded on to the Quality/Risk Manager within 24 hours. The Quality/Risk Manager will forward the written complaint event to the Patient Experience Coordinator, departmental supervisor or manager for investigation and resolution. The supervisor or manager has 72 hours in which to conduct an investigation and attempt to resolve the complaint. Grievance Process: A. Written grievances will be required to be entered into Quality Calendar by the person receiving the written grievance, then forwarded on to the Quality/Risk Manager within 24 hours ...The supervisor or manager has 72 hours in which to conduct an investigation and attempt to resolve the complaint. B. For ALL Patients, an acknowledgement letter ...is generated by the director or chief officer within 7 business days of the grievance being filed by the patient or representative.. The letter states the grievance has been received, is being investigated ...The director or chief officer will provide ongoing contact to the patient or representative as needed during the investigation process until the grievance is resolved. D. The grievance, its investigation and proposed resolution will need to be completed within 5 business days ...F. When a resolution is reached by WCH Patient Relations Committee, the disposition of the matter by the committee is communicated to the complainant in written form ...G. For CMS complaints and grievances, the patient or representative will be notified with an Acknowledgement Letter ...within 7 business days of receiving the complaint/grievance. The final grievance resolution must occur within ninety (90) days of the grievance being received by the manager/director or chief officer in writing (Closure Letter ...)...."

The hospital Quality Calendar was reviewed and seven complaints and/or grievances for the hospital were identified between 10/01/2022, and 12/21/2022:

One out of seven patients (Patient #10), received an acknowledgement letter.

Zero out of seven patient complaints were investigated with a proposed resolution within five business days.

Two out of seven patient complaints were closed (Patient #11 did not want to speak with the hospital; Patient #12 had a note s/he was contacted, with no further notes. This grievance was re-opened by Employee #1 at the time of review).

Zero out of seven patients received written notice of a resolution being reached.

Employee #1 confirmed in an interview on 02/01/2023, that these complaints and grievances were not resolved, nor had letters been sent to the patients, within the policy stated timeframe.