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

During an observation and interview on 3/12/24 at 9:34 a.m., the Broselow pediatric emergency bag was observed to have the following expired items:

-Pink/Red Intubation Module, expiration 6/30/23,
-Purple Intubation Module, expiration 8/31/23,
-Yellow Intubation Module, expiration 7/31/23,
-White Intubation Module, expiration 8/31/23,
-Blue Intubation Module, expiration 8/31/23,
-Orange Intubation Module, expiration 8/31/23, and
-Green Intubation Module, expiration 8/31/23.

Staff member AA said nursing staff was responsible for checking for outdated medication and staff member BB was responsible for outdated medical supplies

During an interview on 3/12/24 at 11:38 a.m., staff member B said the department had a system in place for checking and replacing outdated supplies. Staff member B stated the night shift was responsible for checking the items. Staff member B said the items had been ordered and the items were on backorder. Staff member B did not know which items within the modules were outdated and had not attempted to order those items individually.

Record review of a facility provided purchase order showed the above items were ordered on 2/13/24 and were on backorder. No purchase orders were provided for the expired items prior to their expiration date.

Based on observation, interview, and record review, the facility failed to ensure all essential mechanical, electrical, and patient-care equipment was identified and included in an inventory list; and failed to ensure all essential medical equipment was identified and maintained through a facility established maintenance strategy. This deficient practice had the potential to affect all patients provided care services by the facility. Findings include:

1. During an interview on 3/12/24 at 11:40 a.m., staff member X stated he was responsible for the maintenance of the facility and the facilities equipment. Staff member X stated he did not have a master list of all the equipment requiring facility evaluation, but provided a list of all the equipment serviced by the bio-medical contractor. Staff member X stated he monitored the facilities mechanical lifts, beds, recliners, tub, and any other equipment that the bio-medical service contract did not service. Staff member X stated he did not have a way to identify critical care equipment, or regular use equipment. Staff member X stated, "I don't even know what critical equipment is."

A request for an inventory list including all equipment in the facility was requested and was not received prior to the end of the survey.

2. During an observation on 3/14/24, the following equipment was observed to not have a periodic maintenance sticker, which identified the equipment had an initial safety inspection prior to being used and/or had received periodic maintenance to ensure the equipment was inspected, tested, and maintained to ensure patient safety:

Located in the emergency department:

-one (1) Homemedic Thermometer, serial number A2309010AD03425,
-two (2) Welch Allyn otoscopes, serial number 71670,
-one (1) Welch Allyn charging stand, serial number 71140,
-one (1) Welch Allyn speculum light and charger, serial number 71040 and
-one (1) 3M surgical clipper and stand, serial number 9660.

Located in an alcove adjacent to the nurse's station:
-one (1) Manitowoc ice machine. No serial number accessible.

Located in patient care areas:
-twelve (12) electric recliners. No serial number accessible
-two (2) EZ way smart stand mechanical lifts, serial number 201643 and the other serial number was unreadable.

Review of a facility policy titled, "Emergency Medical Services: Supplies and Equipment," with an effective date of 10/1/19, showed:

" ... [Job title], or his/her designee shall see that such an inventory of supplies and equipment is stored in an orderly manner, periodically and regularly inspected, and tested, as appropriate and periodically and regularly reviewed for completeness."

A review of a facility policy titled, "Preventative Maintenance," with a revised date of 4/9/21, showed:

" ... equipment used in direct patient care is checked for electrical safety prior to use and than semi-annually. Tags are applied to each piece of equipment noting the date of the inspection ...
... The preventative maintenance program is provided by the maintenance department ..."[sic]

A review of the job description for staff member X showed:

"Duties and responsibilities:
... Drafts and implements preventative maintenance schedules for buildings and equipment. Following the manufacturers guidelines, state and federal life safety regulations, and environment of care regulations."

Based on interview and record review, the facility failed to provide periodic performance evaluations of mid-level providers by a doctor of medicine or osteopathy. This deficient practice had the potential to affect all patients receiving care at the facility. Findings include:

Record review of a credentialing file for staff member S did not contain a competency appraisal. Privileges were granted on 3/21/23.

Record review of a credentialling file for staff member T did not contain a competency appraisal. Privileges were granted on 10/26/22.

During an interview on 3/13/24 at 4:11 p.m., staff member Q said the facility did not have a written process in place for formal evaluations on the mid-level providers after the credentialing process.

Based on observation, interview, and record review, the facility failed to complete a thorough investigation after controlled medication patches were not found on two separate patients (#s 27 and 33) of 3 sampled patients involving incident reports; failed to label medications with a use by date and an open date; and failed to complete a self-administration of medication assessment for 1 (#28) of 7 sampled patients during a medication pass. Findings include:

1. Review of a facility document titled, "Accident/Incident Report," dated 3/29/23, showed:

Patient #27's Fentanyl pain patch was unable to be located by staff. Staff placed a new Fentanyl patch on resident #27 per the MAR schedule. No vital signs assessed after the incident. No investigation or interventions were completed by the facility. The incident report was signed by staff member B on 3/30/23.

Review of a facility document titled, "Accident/Incident Report," dated 5/24/23, showed:

Resident #27 was due for a scheduled Fentanyl patch change, and the nurse could not locate the old Fentanyl patch. No vital signs assessed after the incident. Staff member B was notified. No investigation or interventions were completed by the facility. The incident report was signed by staff member B on 5/25/23.

Review of a facility document titled, "Accident/Incident Report," dated 7/15/23, showed:

Resident #33 was due for a scheduled Fentanyl patch change, and the nurse could not locate the old Fentanyl patch. No vital signs assessed after the incident. Staff member B was notified. No investigation or interventions were completed by the facility. The incident report was signed by staff member B on 7/15/23.

During an interview on 3/13/24 at 4:05 p.m., staff member B stated staff member Y investigated the incidents regarding the missing Fentanyl patches. Staff member B stated she was told by staff member Y, "There was no diversion on patient #27." Staff member B stated she did not know what happened to patient #33's Fentanyl patch because, "she is alert and oriented." Staff member B stated she did not do any follow up with the incident reports, but they were now using a different system for incidents.

During an interview on 3/13/24 at 4:20 p.m., staff member Y stated she had never received any incident reports from the facility regarding missing Fentanyl patches. Staff member Y stated, "The facility does not notify me of any incidents or issues that involve medications. I have met with staff member A about my concerns but that is as far as it went." Staff member Y stated she had not done any investigations into the missing Fentanyl patches because she had not been aware of them.

Review of a facility policy titled, "Incident Reporting," with an effective date of 10/1/20, showed:

" ...The purpose of incident reports is to identify safety hazards and develop interventions to mitigate these hazards in order to reduce harm in health care."

A review of a facility document titled, "Investigation of Missing Transdermal Patches from the Patient's body Following the Original Application," dated, March 2024, showed:

" ...C. If the patch is not found ...
1. The nurse first calls the provider ...
2. If the transdermal patch is not found on the patient's body, a new transdermal patch will be applied.
3. ...our pharmacists will be notified per phone or fax.
4. A thorough investigation continues followed by a written incident report. The DON is notified and reviews the incident report and nurse's findings. The DON will document a summary of the investigation.

2. During an observation on 3/13/23 at 8:00 a.m., the medication cart contained medications that did not contain an open date, or a use by date. Medications included:

- Acetaminophen 325 mg bottle,
- Tums bottle ¾ empty,
- 24-hour arthritis, 325 mg bottle,
- Ibuprofen 200 mg bottle,
- Acetaminophen Extra strength 500 mg bottle,
- one (1) tube Voltaren Gel,
- one (1) bottle debrox ear solution,
- one (1) Metamucil bottle,
- one bottle tobramycin eye drops,
- one (1) bottle Flurbiprofen sodium 0.03% eye drops,
- one (1) bottle Prednisone AC 1% eye drops,
- one (1) bottle Refresh 1.4/0.6% eye drops,
- one (1) bottle Fluticasone propinate nasal spray 50 mcg,
- one (1) bottle Systane eye drops, and
- one (1) tube of glucose tablets.

During an interview on 3/13/24 at 8:15 a.m., staff member G stated, "All medications were to be dated when they are opened, and it was the responsibility of nursing staff to make sure the medications were labeled."

Review of a facility policy titled, "Labeling of Medication Containers," undated, showed:

"All medications maintained in the facility shall be properly labeled in accordance with current state and federal regulations. ..."

3. During an observation and interview on 3/13/24 at 8:00 a.m., staff member G was doing the morning med pass in the dining room. Staff member G stated patient #29 was the only patient that was able to self-administer her medications.

During an interview 3/13/24 at 8:50 a.m., patient #29 stated the nurse gave her medications but she was able to take them on her own without the nurse watching her.

During an inteveiw on 3/13/24 at 2:30 p.m., staff member B stated there were no patients in the facility that self-administer medications.

A review of patient #29 electronic medical record did not show a self-administration of medications assessment had been completed.

A request was made for patient #29's self-administration of medications assessment and was not received prior to the end of the survey.

A review of a facility document titled, "Self-Administration of Medications," with an effective date of November 2014, showed:

"A. If a resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team..."

Based on interview and record review, the facility failed to develop individualized therapeutic diets based on patient needs and preferences. This deficient practice had the potential to affect all patients/residents in the facility with specific dietary requirements. Findings include:

On 3/11/24, a request was made for a copy of all therapeutic diets offered within the facility. A handwritten note was received with a list of residents requiring a therapeutic diet for textures.

During an interview on 3/11/24 at 1:50 p.m., staff member V said the facility had switched vendors for their meal planning and was now using USDA. The USDA meal rotation did not provide alternate therapeutic diets. Staff member W said the facility provided the different textures for patients, but the providers only ordered regular diets for the patients. If a patient requests or requires a substitute item, the facility would provide the item requested by the patient.

During an interview on 3/13/24 at 11:06 a.m., staff member V said the facility did not have prescription diets at this time. Staff member V stated the new system required each individual patient to be built, to include their dietary needs and preferences. The system will print out a meal ticket for their meal. Staff member V said she has been provided training on the system, but had not had time to build each patient into the system. She stated all patients receive regular diets currently.

During an interview on 3/13/24 at 1:33 p.m., staff member S said she only orders regular diets for swing bed patients. Staff member S said she has ordered sodium restricted diets for inpatients. Staff member S said she was not aware the facility did not have therapeutic diets available.

During an interview on 3/13/24 at 1:50 p.m., staff member Z stated she was contracted by the facility for nutritional assessments and dietary management. She stated she visits the facility once a month. Staff member Z said she was not aware the facility no longer had therapeutic diets available, as they had therapeutic diets with the previous vendor. Staff member Z said she was not familiar with the USDA system and did not know a diet needed to be built individually for every resident/patient.

During an interview on 3/14/24 at 9:02 a.m., staff member A said he thought the dietary program was switched to USDA 6 months ago. Staff member A stated he was not aware of the change in menus, or change in the process for therapeutic diets.

Based on interview and record review, the facility failed to have a process in place to verify the completeness of medical records for 4 (#s 2, 4, 14, and 19) of 27 sampled patients. This deficient practice had the potential to affect all medical records for patients receiving care at the facility. Findings include:

A review of patient #2's EMR, with an admission date of 1/4/23, showed a nutritional assessment on 12/12/23 that was not entered into the medical record until 1/24/24. Nutritional information was not available for patient #2, within the EMR, until 6 weeks after the assessment was completed.

A review of patient #4's EMR, with an admission date of 5/6/23, failed to include a history and physical.

A review of patient #14's EMR, with an admission date of 9/23/23, failed to include a consent for inpatient treatment.

A review of patient #19's EMR, with an admission date of 10/22/23, failed to include a consent for inpatient treatment.

During an interview on 3/12/24 at 2:56 p.m., staff member C stated nursing staff should have obtained a separate consent to treat when a patient changed from ER status to inpatient status.

During an interview on 3/14/24 at 10:00 a.m., staff member C stated she scanned documents into the patient's medical records and checked to make sure the scan was completed. She stated she was not aware of a process to verify patient medical records were completed. Staff member C stated she did not know who would be responsible for checking the EMR for complete record entries. Staff member C said she would assume nursing staff was responsible for making sure all orders and entries were completed.

Due to the manner and degree of the deficient practice, the facility failed to meet the Condition of Participation for Infection Prevention and Control.

Based on interview and record review the facility failed to:

- Ensure the individual employed as the primary Infection Preventionist and Control Specialist was qualified through training, experience, and/or certification in infection prevention and control practices. (see C1204)

-Ensure all Healthcare Associated Infections, Antibiotic Stewardship and other infectious diseases were integrated and followed though the facilities QAPI leadership and program. (see C1229)

- Ensure the Infection Preventionist was involved in the development and implementation of the infection prevention, control, and surveillance policies and procedures. (see C1231)

- Provide education to all staff related to infection prevention and control practices in the facility. (see C1237)

- Establish methods used by the Infection Preventionist to review all Healthcare Associated Infections and ensure all staff are following infection control practices. (see C1240)

- Ensure the Antibiotic Stewardship Program was based on nationally recognized guidelines for improvement and monitoring the use of Antibiotic use in the facility. (see C1244)

Based on interview and record review, the facility failed to ensure the individual employed as the primary Infection Preventionist and Control Specialist was qualified through 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 3/13/24 at 8:30 a.m., staff member D stated he assisted with Infection Prevention, but staff member S was appointed by the governing board as the Infection Preventionist. Staff member D stated he had not received any education on Infection Prevention, and he had not taken any Infection Prevention classes or seminars. Staff member D stated, "What I have learned, I have learned off of the APIC website."

During an interview on 3/13/24 at 10:35 a.m., staff member B stated she used to be the Infection Preventionist and held an APIC certificate. Staff member B stated, "I have too much on my plate, so I am not the infection Preventionist currently, but I do help with Infection Prevention."

During an interview on 3/13/24 at 10:50 a.m., staff member S stated she was who the governing board appointed as the Infection Prevention provider. Staff member S stated she was appointed because she happened to attend that particular board meeting. Staff member S stated she does not have any Infection Prevention certificates or extra training. Staff member S stated, "I am a PA so that is what education I have had."

A review of a facility document titled, "[Facility] Board of Directors Meeting," dated 2/16/23, showed:

" ...CMS requires a practitioner to be approved by the board for infection control in the facility. It was recommended that [Staff member S's Name] be approved." The motion was seconded and "staff member S was approved as the infection control practitioner."

Based on interview and record review, the facility failed to ensure all Healthcare Associated Infections, Antibiotic Stewardship, and other infectious diseases were integrated and followed though the facilities QAPI leadership and program. This deficient practice had the potential to affect all patients recieving care at the facility. Findings include:

During an interview on 3/13/24 at 8:30 a.m., staff member D could not verbalize how HAI's, Antibiotic Stewardship, and other infections were addressed with QAPI leadership or the QAPI program. Staff member D stated, "I just print off a report and give it to staff member A."

During an interview on 3/13/24 at 10:35 a.m., staff member B stated the only people who look at HAI's, Antibiotic Stewardship, and other infections are herself and staff member D.

During an Interview on 3/13/24 at 10:50 a.m., staff member S stated, "I don't know how staff members B and D handle that." Staff member S stated she did not attend any QAPI meetings and was unsure what QAPI was.

A review of a facility document titled, "Antibiotic Stewardship-Staff and Clinician Training and Roles," undated, showed:

" ... 4. The IP will report to the Pharmacy Review and the QAPI committee ...".

Based on interview and record review, the facility failed to ensure the Infection Preventionist was involved in the development and implementation of the infection prevention, control and surveillance 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 3/13/24 at 8:30 a.m., staff member D stated, "I write all the policies and procedures for Infection Prevention. Staff member B looks at them and staff member S signs off on them."

During an interview on 3/13/24 at 10:35 a.m., staff member B stated, "As a clinical person, I get the clinical policies implemented."

During an interview on 3/13/24 at 10:50 a.m., staff member S stated, "I do not have a role in the development and implementation of policy and procedure for Infection Prevention. I just review the minutes from the infection control committee."

A review of a facility document titled, "Infection Prevention and Control Program," undated, showed:

" ... C. The program is under the direction of the Infection Preventionist (IP) assigned by administration and the Board of Directors, to provide oversight ..."

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 3/13/24 at 8:30 a.m., staff member D stated he was responsible for the education of facility staff. Staff member D stated he assigns videos for staff and all department heads are responsible for doing audits to ensure completion. Staff member D stated he had never done any education with the providers.

During an interview on 3/13/24 at 10:35 a.m., staff member B stated staff member D was primarily responsible for staff education.

During an interview on 3/13/24 at 10:50 a.m., staff member S stated she had not had any training related to infection prevention.

During an interview on 3/13/24 at 3:12 p.m., staff member G stated she had not had any recent education on infection prevention.

A review of a facility document titled, "Infection Control Committee," undated, showed:

" The infection control committee shall oversee training programs for all employees ...

A. Infection Prevention and Control in-service training records, indicating the dates of the training sessions, the content of those training sessions along with the names of all persons conducting the training, and the names of all those receiving the training. ..."

A request was made for Infection Prevention training and a folder was brought to the surveyor. Review of the folder failed to include documentation of any Infection Prevention education and/or in-services provided to staff.

Based on interview and record review, the facility failed to establish methods used by the Infection Preventionist to review all Healthcare Associated Infections and ensure all staff were following infection control practices. This deficient practice had the potential to affect all patients who received care in the facility and all staff providing care in the facility. Findings include:

During an interview on 3/13/24 at 8:30 a.m., staff member D was unable to verbalize what methods were used to review HAI's and ensure staff were following the infection control practices.

During an interview on 3/13/24 at 10:35 a.m., staff member B stated, "We just add more infection control audits if needed."

During an interview on 3/13/24 at 10:50 a.m., staff member S was unable to verbalize what methods were used to review HAI's and ensure staff were following the infection control practices. Staff member S stated, "I don't know."

Review of a facility document titled, "Monitoring Compliance with Infection Control," undated, showed:

"[Facility Name] will conduct routine monitoring and surveillance of the workplace to determine compliance with infection prevention and control policies and practices.

A. The Infection Preventionist or designee monitors the effectiveness of out infection prevention and control work practices. ..."

Based on interview and record review, the facility failed to ensure the Antibiotic Stewardship Program was based on nationally recognized guidelines for improvement and monitoring the use of antibiotics in the facility. This deficient practice had the potential to affect all patients receiving care in the facility. Findings include:

During an interview on 3/13/24 at 8:30 a.m., staff member D stated, "I don't know if the Antibiotic Stewardship program is based on any national guidelines."

During an interview on 3/13/24 at 10:35 a.m., staff member B stated, "We are looking into that. We have an ICAR scheduled to try and help us."

During an interview on 3/13/24 at 10:50 a.m., staff member S stated, "I am not sure, I just use my clinical judgement as a PA."

A review of a facility document titled, "Antibiotic Stewardship," undated, showed:

"Antibiotics will be prescribed and administered under the guidance of [Facility Name] Antibiotic Stewardship Program."

Due to the manner and degree of the deficient practice, the facility failed to meet the Conditions of Participation for Quality Assessment and Performance Improvement.

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

- Implement a QAPI program that represents the services it provided. (See C1302)

- Maintain an ongoing QAPI program. (See C1306)

- Develop a QAPI program that used objective measures to evaluate the facilities processes, functions, and services. (See C1309)

- Appoint qualified leadership to provide oversight and direction in maintaining a comprehensive, ongoing, inclusive, and data driven QAPI program. (See C1313)

Based on interview and record review, the facility failed to implement a QAPI program that represents the services it provided. This deficient practice had the potential to affect all areas providing services to patients receiving care. Findings include:

During an interview on 3/12/24 at 1:52 p.m., staff member A said he had completed a facility quality assurance review on 6/30/22. Staff member A stated he had not completed the review annually because he was told it only needed to be performed every two years.

During an interview on 3/14/24 at 9:02 a.m., staff member A said he was responsible for the QAPI program and had limited experience in QAPI program oversight. Staff member A said he had been "limping along" with the program and had just hired a new staff member to help the facility with their QAPI program.

Review of a facility provided document, "[Facility Name] Critical Access hospital Annual Evaluation," dated 6/30/22, representing July 2021 through June 2022, showed:

" ...Periodic Evaluation and Quality Assurance Review- [Facility Name] continues to meet the requirements of this section, which generally describes the requirement of the organization to perform a review of operations at least annually. ..."

A request for policies and procedures for the facility QAPI program was made on 3/11/24 and 3/13/24. No policies or procedures were provided by the facility prior to the end of the survey.

Based on interview and record review, the facility failed to maintain an ongoing QAPI program. This deficient practice had the potential to affect all areas of the facility providing patient care. Findings include:

A review of the facility QAPI notebook, containing multiple years of QAPI projects for individual departments, showed current process improvement projects for each department. Nursing, Education, and Social Services were the only departments indicating current process improvement projects, which were initiated in 2023. No process improvement projects were identified as implemented in 2024.

A review of the facility QAPI meeting minutes for 1/24/24 showed, no QAPI updates were provided for Medical Records, Dietary, Maintenance, Nursing, Medical Staff, Organ Procurement, or Human Resources. Education provided an update, "continued improvement on obtaining general orientation checklist. No exact numbers at this time, but certainly an improvement." No QAPI projects were discussed with possible project development, parameters, or adjustments made for compliance.

During an interview on 3/14/24 at 9:02 a.m., staff member A said the facility did not include Pharmacy in the QAPI program because it was a contracted service. Staff member A said he was not aware of any safety, medication therapy, or infection control process improvement projects. Staff member A stated each service area was currently working to update policies and procedures. Staff member A said each service area was responsible for identifying, monitoring, and reporting current projects.




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During an interview on 3/11/24 at 2:35 p.m., staff member B stated, " I do not believe it (organ procurement) is being followed in QAPI."

During an interview on 3/12/24 at 9:55 a.m., staff member C stated, OPO is not being followed in QAPI.

A review of the facilities QAPI minutes showed no documentation for the inclusion of the OPO program.

Based on interview and record review, the facility failed to develop a QAPI program that used objective measures to evaluate the facilities processes, functions, and services. This deficient practice had to potential to affect the facilities performance based on national standards. Findings include:

During an interview on 3/13/24 at 11:40 a.m., staff member B said she had not received any training on development of a process improvement project, and she used the forms provided by the facility. Staff member B states she was currently working on a falls project but had not set parameters for the project.

During an interview on 3/14/24 at 9:02 a.m., staff member A said he was responsible for the QAPI program and had limited experience in QAPI program oversight. Staff member A said he had been "limping along" with the program and had just hired a new staff member to help the facility with their QAPI program. Staff member A said he did not feel he had the medical background required for QAPI oversight.

A request for policies and procedures for the facility QAPI program was made on 3/11/24 and 3/13/24. No policies or procedures were provided by the facility prior to the end of the survey.

Based on interview and record review, the facility's governing board failed to appoint qualified leadership to provide oversight and direction in maintaining a comprehensive, ongoing, inclusive, and data driven QAPI program. This deficient practice had the potential to affect all care provided to patients by all departments within the facility. Findings include:

During an interview on 3/14/24 at 9:02 a.m., staff member A said he was responsible for the QAPI program and had limited experience in QAPI program oversight. Staff member A said he had been "limping along" with the program and had just hired a new staff member to help the facility with their QAPI program. Staff member A said he did not feel he had the medical background required for QAPI oversight.

A request for policies and procedures for the facility QAPI program was made on 3/11/24 and 3/13/24. No policies or procedures were provided by the facility prior to end of the survey.

Based on interview and record review, the facility failed to notify the OPO (Organ Procurement Organization) upon the death of 2 (#s 12 and 27) of 5 sampled patients who expired in the facility; and failed to ensure their organ, tissue, and eye donation program (OPO) was integrated into their QAPI (Quality Assurance and Performance Improvement) program. This deficient practice had the potential to affect all patients with a requested organ donor and imminent death. Findings include:

Review of patient #12's electronic medical record, dated 7/18/23 to 7/24/23, showed the patient expired in the facility on 7/24/23. The electronic medical record showed the OPO was not notified of the patient's death.

Review of patient #27's electronic medical record, dated 7/8/19 to 7/14/23, showed the patient expired in the facility on 7/14/23. The electronic medical record showed the OPO was not notified of the patient's death.

During an interview on 3/12/24 at 10:30 a.m., staff member C stated the facility was not aware of having to notify the OPO of the death of hospice patients. Staff member C stated, "We were under the understanding that hospice called the OPO."

Review of a facility policy titled, "Organ, Tissue, and Eye Donation," with an effective date of 10/1/2019, showed:

" ... 1. [Facility] will notify LifeCenter Northwest (LCNW) as soon as possible of every death and imminent deaths in the critical access hospital or emergency room."

During an interview on 3/11/24 at 2:35 p.m., staff member B stated, "I do not believe it (organ procurement) is being followed in QAPI."

During an interview on 3/12/24 at 9:55 a.m., staff member C stated, OPO is not being followed in QAPI.

A review of the facilities QAPI minutes showed no documentation for the inclusion of the OPO program.

Based on interview and record review, the facility failed to inform all patients whom to contact to file a grievance for 26 (#s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, and 27) of 27 sampled patients. This deficient practice had the potential to limit a patient's right to submit a grievance to the facility. Findings include:

A review of resident #1's EMR, with an admission date of 7/14/21, showed no information was provided to the patient or the patient's representative about filing a grievance.

A review of resident #2's EMR, with an admission date of 11/4/22 and 1/4/23 showed no information was provided to the patient of patient's representative about filing a grievance.

A review of resident #3's EMR, with an admission date of 6/26/20, showed no information was provided to the patient of patient's representative about filing a grievance.

A review of resident #4's EMR, with an admission date of 5/6/23, showed no information was provided to the patient or the patient's representative about filing a grievance.

A review of resident #5's EMR, with an admission date of 3/8/24, showed no information was provided to the patient or the patient's representative about filing a grievance.

A review of resident #6's electronic medical record, with an admission date of 3/5/24, failed to show documentation the patient or the patient's representative was provided information about how to file a grievance or who to file a grievance with at the facility.

A review of resident #7's electronic medical record, with an admission date of 12/15/21, failed to show documentation the patient or the patient's representative was provided information about how to file a grievance or who to file a grievance with at the facility.

A review of resident #8's electronic medical record, with an admission date of 11/9/22, failed to show documentation the patient or the patient's representative was provided information about how to file a grievance or who to file a grievance with at the facility.

A review of resident #9's electronic medical record, with an admission date of 10/3/23, failed to show documentation the patient or the patient's representative was provided information about how to file a grievance or who to file a grievance with at the facility.

A review of resident #10's electronic medical record, with an admission date 4/21/22, failed to show documentation the patient or the patient's representative was provided information about how to file a grievance or who to file a grievance with at the facility.

A review of resident #11's electronic medical record, with an admission date of 11/5/23, failed to show documentation the patient or the patient's representative was provided information about how to file a grievance or who to file a grievance with at the facility.

A review of resident #12's electronic medical record, with an admission date 4/21/22, failed to show documentation the patient or the patient's representative was provided information about how to file a grievance or who to file a grievance with at the facility.

A review of resident #13's EMR, with an admission date of 9/12/23, showed no information was provided to the patient or the patient's representative about filing a grievance.

A review of resident #14's EMR, with an admission date of 9/22/23, showed no information was provided to the patient or the patient's representative about filing a grievance.

A review of resident #16's EMR, with an admission date of 12/26/23, showed no information was provided to the patient or the patient's representative about filing a grievance.

A review of resident #17's EMR, with an admission date of 12/29/23, showed no information was provided to the patient or the patient's representative about filing a grievance.

A review of resident #18's EMR, with an admission date of 9/30/23, showed no information was provided to the patient or the patient's representative about filing a grievance.

A review of resident #19's EMR, with an admission date of 10/21/23, showed no information was provided to the patient or the patient's representative about filing a grievance.

A review of resident #20's EMR, with an admission date of 12/28/23, showed no information was provided to the patient or the patient's representative about filing a grievance.

A review of resident #21's EMR, with an admission date of 9/5/23, showed no information was provided to the patient or the patient's representative about filing a grievance.

A review of resident #22's EMR, with an admission date of 10/28/23, showed no information was provided to the patient or the patient's representative about filing a grievance.

A review of resident #23's EMR, with an admission date of 12/1/23, showed no information was provided to the patient or the patient's representative about filing a grievance.

A review of resident #24's EMR, with an admission date of 1/13/24, showed no information was provided to the patient or the patient's representative about filing a grievance.

A review of resident #25's EMR, with an admission date of 2/20/24, showed no information was provied to the patient or the patient's representative about filing a grievance.

A review of resident #26's EMR, with an admission date of 3/6/24, showed no information was provided to the patient or the patient's representative about filing a grievance.


47752



A review of resident #27's electronic medical record, with an admission date 7/8/19, failed to show documentation the patient or the patient's representative was provided information about how to file a grievance or who to file a grievance with at the facility.

Review of a facility policy, "Grievances/Complaints, Filing," revision dated 4/2017, showed:

" ...4. Upon admission, residents are provided with written information on how to file a grievance or complaint. A copy of our grievance/complaint procedure is posted on the resident bulletin board. ..."

During an interview on 3/13/24 at 11:38 a.m., staff member B said grievance information for patients would be provided under the patients' rights area of the medical chart. Staff member B stated she did not believe the information for filing of grievances was provided to patients.

During an observation on 3/14/24 at 7:37 a.m., the resident information board was viewed and no listing of grievance policy or process was posted.

Based on interview and record review, the facility failed to establish a process which explained how to submit a verbal or written grievance to the facility for 26 (#s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, and 27) of 27 sampled residents. This deficient practice had the potential to affect all patients who were provided care by the facility. Findings include:

A review of resident #1's EMR, with an admission date of 7/14/21, failed to show documentation the patient or the patient's representative was provided information about how to file a verbal or written grievance with the facility.

A review of resident #2's EMR, with an admission date of 11/4/22 and 1/4/23, failed to show documentation the patient or the patient's representative was provided information about how to file a verbal or written grievance with the facility.

A review of resident #3's EMR, with an admission date of 6/26/20, failed to show documentation the patient or the patient's representative was provided information about how to file a verbal or written grievance with the facility.

A review of resident #4's EMR, with an admission date of 5/6/23, failed to show documentation the patient or the patient's representative was provided information about how to file a verbal or written grievance with the facility.

A review of resident #5's EMR, with an admission date of 3/8/24, failed to show documentation the patient or the patient's representative was provided information about how to file a verbal or written grievance with the facility.

A review of resident #6's electronic medical record, with an admission date of 3/5/24, failed to show documentation the patient or the patient's representative was provided information about how to file a verbal or written grievance with the facility.

A review of resident #7's electronic medical record, with an admission date of 12/15/21, failed to show documentation the patient or the patient's representative was provided information about how to file a verbal or written grievance with the facility.

A review of resident #8's electronic medical record, with an admission date of 11/9/22, failed to show documentation the patient or the patient's representative was provided information about how to file a verbal or written grievance with the facility.

A review of resident #9's electronic medical record, with an admission date of 10/3/23, failed to show documentation the patient or the patient's representative was provided information about how to file a verbal or written grievance with the facility.

A review of resident #10's electronic medical record, with an admission date 4/21/22, failed to show documentation the patient or the patient's representative was provided information about how to file a verbal or written grievance with the facility.

A review of resident #11's electronic medical record, with an admission date of 11/5/23, failed to show documentation the patient or the patient's representative was provided information about how to file a verbal or written grievance with the facility.

A review of resident #12's electronic medical record, with an admission date 4/21/22, failed to show documentation the patient or the patient's representative was provided information about how to file a verbal or written grievance with the facility.

A review of resident #13's EMR, with an admission date of 9/12/23, failed to show documentation the patient or the patient's representative was provided information about how to file a verbal or written grievance with the facility.

A review of resident #14's EMR, with an admission date of 9/22/23, failed to show documentation the patient or the patient's representative was provided information about how to file a verbal or written grievance with the facility.

A review of resident #16's EMR, with an admission date of 12/26/23, failed to show documentation the patient or the patient's representative was provided information about how to file a verbal or written grievance with the facility.

A review of resident #17's EMR, with an admission date of 12/29/23, failed to show documentation the patient or the patient's representative was provided information about how to file a verbal or written grievance with the facility.

A review of resident #18's EMR, with an admission date of 9/30/23, failed to show documentation the patient or the patient's representative was provided information about how to file a verbal or written grievance with the facility.

A review of resident #19's EMR, with an admission date of 10/21/23, failed to show documentation the patient or the patient's representative was provided information about how to file a verbal or written grievance with the facility.

A review of resident #20's EMR, with an admission date of 12/28/23, failed to show documentation the patient or the patient's representative was provided information about how to file a verbal or written grievance with the facility.

A review of resident #21's EMR, with an admission date of 9/5/23, failed to show documentation the patient or the patient's representative was provided information about how to file a verbal or written grievance with the facility.

A review of resident #22's EMR, with an admission date of 10/28/23, failed to show documentation the patient or the patient's representative was provided information about how to file a verbal or written grievance with the facility.

A review of resident #23's EMR, with an admission date of 12/1/23, failed to show documentation the patient or the patient's representative was provided information about how to file a verbal or written grievance with the facility.

A review of resident #24's EMR, with an admission date of 1/13/24, failed to show documentation the patient or the patient's representative was provided information about how to file a verbal or written grievance with the facility.

A review of resident #25's EMR, with an admission date of 2/20/24, failed to show documentation the patient or the patients representative was provided information about how to file a verbal or written grievance with the facility.

A resview of resident #26's EMR, with an admission date of 3/6/24, failed to show documentation the patient or the patients representitive was provided information about how to file a verbal or written grievance with the facility.




47752


A review of resident #27's electronic medical record, with an admission date 7/8/19, failed to show documentation the patient or the patient's representative was provided information about how to file a verbal or written grievance with the facility.

During an interview on 3/11/24 at 3:00 p.m., patient #3 said she had not been given any information on how to file a grievance with the facility. Patient #3 said she had not seen any information posted within the facility or grievance forms available for patients to file a complaint.

During an interview on 3/14/24 at 8:28 a.m., staff member A said he was responsible for the investigation of grievances. He was not aware the patients were not provided information for filing a grievance within the facility.