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Base on the onsite investigation, completed February 06, 2020, the facility failed to comply with the regulations set forth for Life Safety and, therefore, deficiencies were cited under Life Safety Code Tags K291, K293, K321, K355, K372, K712, K781 and K920.

Based review of personnel files, training records, observation, and interview, it was determined there was a potential for lack of coverage in the operating room (OR) if a trained Surgical Technologist (scrub-tech) was unavailable. This deficient practice had the potential to adversely affect all patients receiving services at the hospital.

Findings include:

1) During an observation of the operating room (OR), on 01/22/20 at 3:15 PM, the Central Supply Aide (CSA) said he had functioned as the scrub tech as recently as March of 2019 during a C-section [Caesarean section - an incision is made into the mother abdomen to deliver a baby.] The CSA said he learned the skill by watching, but the facility had not required completing any training or a return demonstration of his skills. The CSA said he was not a certified scrub tech. He said he only functioned as a scrub tech when someone else was sick.

Review of the CSA's personnel file on 01/24/20 at 9:30 AM, with the Human Resource Coordinator, showed the CSA did not hold a current BLS or CPR certification.

In an interview on 01/24/20 at 9:50 AM, the Co-Director of Nursing Services (DNS) #2 said, "[CSA's] BLS had expired and he is signed up for a BLS class next week." She said they had a new Human Resource Coordinator who they had been informed to alert them when a nurse's BLS was expiring, but since the CSA was not a nurse, they had not been notified of the expiration of his BLS certification.

In an interview on 01/24/20 at 12:00 PM, the Human Resource Manager said, "I cannot find a current BLS certificate or an expired BLS certificate for [CSA.]

In a phone call set up by the facility on 01/24/20 at 12:05 PM, The CSA said, "I was an EMT [emergency medical technician] back in the 90's and I haven't updated anything since then."

Review of the job description for "Surgical Technologist [scrub-tech]," which was not dated, provided by the facility showed under "Job Summary: The Surgical Technologist is responsible for maintaining the sterile field in the operating room, being constantly vigilant to see that proper aseptic techniques are utilized to prevent contamination and infection. Also, to assist the surgical team as the sterile member who passes instruments, sutures, and sponges during surgery. Knowledge/Skills Needed ... Current CPR [a part of BLS] certification required."

2) Review of the job description titled "Operating Room Job Descriptions/Director of Surgical Services," issued 10/06, showed, "Basic responsibilities: ... has knowledge of operating room, sterilizing and recovery room ..., and under Job Duties: Fulfills the role of scrub nurse ... "

In an interview on 01/22/20 at 4:15 PM, Co-DNS #1 said she was the Director of Surgical Services. She said she did not perform the duties of scrub tech [aka Surgical Technologist] and did not perform any duties in sterilization. She said she had not been trained in either of these duties.

In an interview on 01/22/20 at 4:15 PM, Co-DNS #2 said the CSA was there every day to cover the duties of scrub tech, sterilization, and sterilization of scopes. She said if the CSA was not there, no one would know how to run the sterilizer. She said in the OR there would not be an RN who could step in as the scrub tech, if the scrub tech or the scrub nurse were not there. Co-DNS #2 said, "During a C-section, at night, no one would be able to step in to scrub if the scrub tech was not available, because the RN [registered nurse] would be there to care for the baby. She said the CSA was the only staff who knew how to sterilize.

Based on observation, interview, record review, and review of facility documents, the facility failed to meet the Conditions of Participation for Clinical Records. The facility failed to ensure the electronic medical record system was maintained in a manner to access records promptly and retrieve records. In addition, the facility failed to ensure that all medical records were accurate and included required documentation to ensure the safe and accurate provision of health care.

Findings include:

1. The facility failed to ensure medical records for all patients previously admitted were accessible from 01/13/20 to 01/24/20. or (Refer to C-1102)
2. The facility failed to ensure medical records were accurate and included required documentation. (Refer to C-1104 and C-1110)
3. The facility failed to ensure orders and progress notes written by a physician were timed. (Refer to C-1118)

Based on medical record review, policy review, and interview the facility failed to ensure medical records could be promptly retrieved and accessible for 22 0f 26 patient (P)2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, P14, P15, P16, P17, P18, P19, P20, P23, P24, and P25). This failure had the potential to negatively impact the quality of care and safety of patients receiving care in the facility.

Findings include:

On 01/22/20 at 9:30 AM, The Chief Executive Officer (CEO) of the facility stated the electronic health record (EHR) system was not accessible due to a computer virus found by the information technology (IT) vendor. The CEO stated the IT vendor informed the hospital the computer virus would require the vendor to rebuild the system to bring the EHR system back online. The CEO further stated the EHR system had been disabled since 01/13/20 and the facility reverted to paper charting since that time. Closed records were not accessible.

On 01/23/20 at 2:00 PM the facility stated the system was back on-line and access to the remainder of the requested records was available.

On 01/24/20 copies of documents from the EHR were requested including nursing notes, nursing assessments, and physician progress notes for two patients (P6 and P7). During an interview at 4:30 PM, the Quality Assurance Manager stated the facility was experiencing limited access to the EHR and would not be able to provide the documents due to current limitations of the system since it had come back on-line on 01/23/20

A review of a facility policy titled, "Contingency Plan," with the last review or revision date of 05/10/04, revealed the facility had a policy to respond to emergencies such as, "fire, vandalism, system failure and natural disasters." The policy stated, "The Contingency Plan serves as the master plan for responding to system emergencies in order to ensure continuity of operation during an emergency and recovering from a disaster." However, the policy did not contain any references to reverting to and maintaining paper medical records in the event of a system failure.

Based on record review and interview, the facility failed to provide medical record documentation of physician ordered treatment and medical evaluations that were complete and accurate for two of 26 patients (P)6 and P7.

Findings include:

Review of the electronic health record (EHR) on 01/24/19 revealed, in the section titled "Orders," that P6 was admitted on 12/03/19 and that on 12/03/19 at 6:34 PM, physician #1, wrote an order for P6 to receive "methylprednisolone [a medication used to treat inflammatory disorders] 4mg [milligram] tablets (oral), once daily for 8 days, 8 tabs on day 1 then decrease daily, decrease dose by 1 tab daily; (36 tabs over 8 days)." The order was noted by the nurse on 12/04/19 at 5:16 AM. No documentation was present to demonstrate if P6 had received the ordered medication. Documentation indicated P6 was discharged from inpatient status to swing bed status on 12/04/19.

Review of the EHR on 01/24/20 revealed, in the "profile" section, that P7 was admitted to on 11/26/19. In the section titled "Orders," on 11/26/19 at 12:56 PM, Nurse Practitioner (NP) #1 order an "IP [in patient] Cardiac Monitor ... every 12 hours for 7 days." The order was not noted (activated) in the EHR. Review of the nurse progress/assessment notes between 11/26/19 and 11/28/19 showed that a cardiac monitor was in place. Review of the Physician progress notes between 11/26/19 and 11/28/19 failed to address the cardiac monitor results. Review of the EHR did not show any results documented from the cardiac monitoring.

In an interview on 01/24/20 at 4:06 PM, Co-DNS #2 said the facility did not have a policy that detailed the completeness and documentation of orders.

In an interview on 01/24/19 at 4:20 PM regarding P6, the Quality Assurance Manager said P6 had been transferred to swing bed status the next day, on 12/04/19, after the order had been written. She said the medication order had not been discontinued while P6 was in an inpatient status, but the medication had not been reordered when he had moved on to swing-patient status. The Quality Assurance Manager also said the facility would not be able to provide copies of requested nursing notes, nursing assessments, or the requested physician progress notes for two residents, Patient #6 and Patient #7, due to "current limitations of the EHR," related to "limited access."

In an interview on 01/24/20 at 5:05 PM regarding P7, the Quality Assurance Manager said if something came up on the telemetry [cardiac monitor] a screen shot would have been taken and entered in the medical record. She said there was nothing noted in the record other than in the nurse's assessments and that no results from the cardiac monitor were entered.

In an interview on 01/24/20 at 5:05 PM, Co-DNS #2 said "It [the cardiac monitor order] is not activated." She said that usually every shift took a screen shot of the telemetry [cardiac monitoring] and scanned the screen shot into the medical record. She said no actual results were found in the EHR for the telemetry which was in place.

Based on record review, interview, and review of facility documentation, the facility failed to ensure the medical record contained a history and physical (H&P), physician's notes, and a discharge summary for one of 26 sampled patients (P8).

Findings Include:

A review of P8's electronic health record (EHR) revealed the patient was admitted on 11/24/19 for end of life care due to a diagnosis of gastrointestinal (GI) bleeding, lung cancer, and liver cancer. In addition, record indicated P8 expired on 11/24/19 after admission to the facility. Further review of P8's EHR revealed the record did not contain a H&P, notes from the physician, or a discharge summary.

On 01/24/20 at 1:00 PM, an interview was conducted with the Chief Medical Officer (CMO). The CMO stated the policy of the facility required medical staff of the facility to properly document all medical records by including a H&P, physician's notes and a discharge summary. In addition, the CMO confirmed P8's record did not contain a H&P, physician's notes or a discharge summary.

On 01/24/20 at 5:00 PM, an interview was conducted with the Director of Nursing Services (DNS)2. DNS2 reviewed P8's medical record and confirmed the record did not contain a H&P, physician's notes or a discharge summary, but DNS2 could not provide an explanation for why the record was incomplete.

Review of the facility document titled, "Medical Staff Rules and Regulations," dated approved 07/30/02, revealed medical staff were required to document a H&P, physician's notes and a discharge summary. In the section of the document titled, "Addendum A, Medical Record Directives," the document stated, "the attending practitioner shall be responsible for the preparation of a complete and legible medical record for each patient." The document further stated, "this record shall include ...e. history of present illness, f. physical examination ...r. progress notes, s. final diagnosis ...x. discharge summary ..." In addition, the document stated, "a discharge summary shall be written or dictated in a timely manner on all medical records of patients hospitalized over 48 hours or under 48 hours if a transfer or death."

Based on medical record review and interview, the facility failed to ensure that all physician entries were timed and authenticated for one of six patients (patient (P)21) whose medical record was reviewed in paper format due to the electronic health record being inaccessible from 01/13/20 to 01/24/20. Not timing or authenticating orders has the potential to impact patient safety and quality of care.

Findings include:

Review of the paper medical record on 01/23/20 for P21 revealed the following:

P21's admission history and physical (H&P) was documented by the physician on a form titled "Physician's Orders." The document was signed and dated but did not include the time it was completed.

A telephone order to admit P21 for observation was written on 01/21/20 and included all admission orders. The telephone order was dated and countersigned by the physician but did not include the time of the order.

An order on a form titled "Radiology Requisition," dated 01/21/20, did not show the time of the order and was not countersigned by the physician.

A form titled "Physician's Order Sheet and Progress Notes," which held two separate physician notes contained the date and signature of the physician but did not include the time of the note.

In an interview on 01/23/20 at 4:06 PM, Co-DNS #2 said the facility did not have a policy that detailed the components required in physician orders or progress notes.

Based on observation, interview, record review, and review of facility documents, the facility failed to meet the Conditions of Participation for Infection Prevention and Control and Antibiotic Stewardship Programs by failing to ensure appropriate infection control practices were followed. The deficient practice had the potential to adversely affect all patients receiving care and services in the facility and increased the potential for hospital acquired infection (HAI). (Refer toC-1208)

Findings include:

The facility failed to ensure infection prevention measures were implemented for one of one patient (P) #4 receiving medication and blood glucose testing and the facility failed to ensure the terminal cleaning was conducted in the Operating Room (OR) on a consistent basis. (Refer to C-1208)

Based on observation, interview, and record review the facility failed to ensure infection prevention measures were implemented for one of one patient (P)4 receiving medication and blood glucose testing and failed to ensure terminal cleaning had been conducted in the operating room (OR) on a consistent basis. This deficient practice had the potential to adversely affect all patients receiving medications and blood glucose monitoring and increased the potential for infection in patients receiving services in the OR.

Findings include:

1) During an observation on 01/22/29 at 3:15 PM of the OR with the Central Supply Aide (CSA), the CSA said he also had the responsibility of cleaning the OR between patients and providing the terminal cleaning of the OR on a regular basis. He said he conducted terminal cleaning of the OR on a monthly basis. The CSA said that the terminal cleaning included the regular cleaning of surfaces plus washing the walls.

In an interview on 01/23/20 at 11:10 AM, Co- Director of Nursing (DNS) 1, who was also the Director of Surgical Services, said the terminal cleaning of the operating room should be conducted on a monthly basis. She said the facility did not currently conduct active surveillance of the operating room, or the surgical services in general, and said the facility hadn't conducted the surveillance due to staff issues. She said last year the facility had one obstetric C-section infection [Caesarean section - an incision is made into the mother abdomen to deliver a baby.]

Review of the policy titled "OR Infection Control-Sanitation," showed, " ... D. Terminal Cleaning of the OR: i. Floors are mopped daily in OR M-F; ii. Trash and laundry are emptied daily and as needed; iii. Equipment and table are cleaned daily M-F; iv. Walls are washed monthly; v. Other areas: vi. Sink, shower, toilet, and fixtures are cleaned daily. Walls in bathroom are cleaned once a year; vii. Other furniture in area outside of OR is cleaned monthly or as needed; viii. PACU [post anesthesia care unit]/Endoscopy lab is cleaned weekly."

Review of a check list provided by the facility as the documentation of terminal cleaning of the OR, titled "[hospital] County Health Center Cleaning Checklist," showed during 2019 there was no documentation of terminal cleaning during January, February, March, May, and June.

Review of information provided by the facility of surgeries conducted in the facility from 01/01/19 to 01/13/20 showed surgeries had been conducted in the OR during this time period with the exception of the months of May June, and October.

2) During an observation of medication administration and blood glucose monitoring on 01/24/29 at 11:15 AM, Registered Nurse (RN)1 retrieved potassium chloride 20 milliequivalents, two tablets, which she attempted to pour into the bottle lid and then into a white paper souffle cup. In the process one of the pills dropped onto the flat surface of the Pixis machine. RN #1 picked up the pill with her bare hand and placed it into the souffle cup to be delivered and administered to P4. RN1 gathered a plastic container that contained the blood glucose meter, lancets, 2 x 2 gauze dressings, and alcohol prep pads. After entering P4's room she administered the two potassium tablets and began the blood glucose testing process. After collecting the sample, she disposed of the testing strip, removed her gloves and placed the glucose testing meter back into the plastic bin without cleaning the meter. She returned the plastic bin to the nurse's station.

In an interview on 01/24/20 at 11:25 AM, RN1 said, "If it [medication] falls on the floor I put it in the trash and get a new one. If it falls on the Pixis, I pick it up. She then said, "We don't clean the glucose meter," and "We use the glucose meter on everyone." She affirmed there was only one glucose meter being used on the floor and the meter would be used on all patients being administered glucose monitoring. RN1 said, "Today we just have [P4] using the meter. She indicated the Lab was responsible for calibrating and cleaning the meter each morning.

In an interview on 01/24/20 at 11:26 AM, DNS 2 said the medication should have been tossed and a new medication pulled and said the facility did not have a policy regarding how to handle dropped medications. DNS2 said the blood glucose meter should have been cleaned after use.

In an interview on 01/24/20 at 11:30 AM, the Lab Manager/Infection Preventionist said, "The policy says the meter should be cleaned after each use."

In an interview on 01/24/20 at 12:40 PM, DNS1 said cleaning of the blood glucose meter was a training reviewed when a nurse first oriented and also a subject that was reviewed each year, "It's part of the annual education."

In an interview on 01/24/20 at 12:40 PM, DNS2 said, "It [cleaning glucose meters] is an item we need to train more on and what to do if medications are dropped."

In an interview on 01/24/20 at 1:15 PM, DNS2 showed documentation that RN1 had been assigned training on glucose meters and cleaning after use. DNS2 said disposing of a medication that had been dropped was a "basic nursing practice," and said, "The pill should have been thrown out, that is our practice."

Review of the facility policy titled, "Point-Of-Care Blood Glucose Testing," last revised 06/26/14 showed " ... Procedure ... 17. The meter must be cleaned after each use."

Review of the blood glucose monitor [Contour] users guide, provided by the Lab Manager/Infection Preventionist, showed, "The exterior of the meter can be cleaned using a moist (not wet) lint-free tissue with a mild detergent or disinfectant solution ... "

Based on interview, review of the facility's "Safety Plan," and other documentation provided, the facility failed to meet the Conditions of Participation for development of a comprehensive Emergency Preparedness Program (EPP.) This failure has the potential to impact the facility's ability to respond to emergency situations.

Findings include:

Review of the components of the facility's EPP, identified as the "Safety Plan," reveal the facility did not address the following regulatory components required in the EPP.

1. The facility failed to develop policies and procedures that address the provision of medical and pharmaceutical supplies in the event of an emergency. (Refer to E0015)

3. The facility failed to develop policies and procedures that address that address a process for tracking patients and staff in an emergent situation. (Refer to E0018)

4. The facility failed to develop policies and procedures that address a system of alternate communication in the event of an emergency. (Refer to E0020)

5. The facility failed to develop policies and procedures for the use of volunteers during an emergency. (Refer to E0024)

6. The facility failed to develop a communication plan that included names and contact information from all required staff, entities providing services under arrangement, patients' physicians, other facilities, and volunteers. (See E0030)

7. The facility failed to develop a communication plan that included contact information for federal, state, tribal, regional, and local emergency preparedness staff. (Refer to E0031)

8. The facility failed to develop a communication plan that included primary and alternate means of communicating with staff, federal, state, tribal, regional, and local emergency management agencies. (Refer to E0032)

9. The facility failed to have a system for sharing information and medical documentation for patients under their care in the emergency communication plan component of the EPP. (Refer to E0033)

Based on interview, and review of information provided as a part of the facilities emergency preparedness program (EPP), the facility failed to address policies and procedures for the provision of medical and pharmaceutical supplies in the event of an emergency and failed to incorporate a subsistence plan for staff and patients. This failure had the potential to affect all of the patients who received emergency and outpatient services at the facility, and any staff on duty.

Findings include:

In an interview on 01/23/20 at 12:50 PM, the Co-Director of Nursing Services (DNS)2, in charge of the EPP, said the facility did not have policies and procedures incorporated into one plan., She said the facility did not have a concrete plan to provide for food and water other than to rely on the nursing home. DNS2 said there would be about two days of food available from the nursing home. DNS2 said she was not aware of some of the elements that were required.

The facility had no further evidence to demonstrate that it had developed policies and procedures that address the provision of food, water, medical and pharmaceutical supplies or that addressed alternate sources of power in the event of an emergency in which staff, patient, and visitors must shelter in place or evacuate.

Based on interview, and review of the facility's Safety Plan, the facility failed to ensure the policies and procedures included a process for tracking staff in an emergency situation. This failure had the potential to affect all of the patients who received emergency and outpatient services at the facility, and any staff on duty.

Findings include:

A review of the facility's Safety Plan revealed the policies and procedures did not include a process for tracking staff in the event of an emergency.

In an interview on 01/23/20 at 12:50 PM, the Co-Director of Nursing Services (DNS)2, in charge of the Safety Plan, said the facility did not have a plan to track staff. They have worked with ESF8 [emergency services functions] on a program that tracked patients that have been transferred. DNS2 said tracking of staff was not a policy the facility had included in the emergency plan.

Based on interview, and review of the facility's Safety Plan, the facility failed to develop policies and procedure for the evacuation plan to include a primary and alternate means of communication with external sources of assistance. This failure had the potential to affect all of the patients that receive emergency and outpatients' services at the facility and any staff on duty.

Finding include:

A review of the facility's Safety Plan revealed the evacuation plan component did not include a process for primary and alternate communication with external sources for assistance.

In an interview on 01/23/20 at 12:50 PM, the Co-Director of Nursing Services (DNS)2, in charge of the Safety Plan, said the evacuation policies and procedures did not include a primary and alternate means of communication. She said she was not aware of some of the elements that was required. DNS2 said the policies did not include the use of the 800 mHz radios the facility had acquired.

Based on interview, and review of the facility's Safety Plan, the facility failed to include develop policies and procedures for the use of volunteers or other emergency staffing strategies in the event of an emergency.

Findings include:

A review of the facility's Safety Plan include any policy's or procedures for the use of volunteer staff or the integrate state and federal health care professionals.

In an interview on 01/23/20 at 12:50 PM, the Co-Director of Nursing Services (DNS)2, in charge of the Safety Plan, said the facility did not have a policy that addressed this. She said the plan did not include all of the comprehensive elements required in the Emergency Preparedness regulations. She said she was not aware of some of the elements that are required.

Based on interview, and review of the facility's Communication Plan, the facility failed to develop a comprehensive communication plan that included contact information for staff and entities providing services under arrangement.

Findings include:

A review of the facility's Communication Plan revealed the communication plan lacked comprehensive contact information for staff and entities providing services under agreement.

In an interview on 01/23/20 at 12:50 PM, the Co-Director of Nursing (DNS)2, in charge of the emergency preparedness rogram (EPP), said the facility had developed a list of physicians, but had not included staff or other entities. The DNS2 said the plan did not include all of the comprehensive elements required in the EPP. She said she was not aware of some of the elements that are required.

Based on interview, and review of the facility's Communication Plan, the facility failed to develop a Communication Plan that included contact information for Federal, State, tribal, regional, local emergency preparedness staff, or other sources of assistance.

Findings include:

In an interview on 01/23/20 at 12:50 PM, the Co-Director of Nursing Services (DNS), in charge of the emergency preparedness plan, said the facility had been working on the "Safety Plan," which had been reviewed in 2019, but the plan did not include all of the required contact information necessary, such as contact information for the State, tribal, regional, local emergency preparedness staff, or other resources of assistance. The plan did include information for ambulances and other health care facilities.

Based on interview, and review of the facility's Communication Plan, the facility failed to include a primary and alternate means for communicating with facility staff, Federal, State, tribal, regional, and local emergency management agencies.

Findings include:

In an interview on 01/23/20 at 12:50 PM, the Co-Director of Nursing Services (DNS)2, in charge of the emergency preparedness program (EPP), said the facility had not established primary and alternate methods of communication in order to contact staff or emergency management agencies in the event of an emergency in the area.

Based on interview, and review of the facility's Communication Plan, the facility failed to develop a communication plan that included a method for sharing information or medical documentation regarding patients under the facility's care with other health providers if the need arose in the event of an emergency. The facility also failed identify methods to release patient information, to include condition or location, in the event of an emergency. This failure could impact continuity of care.

Findings include:

A review of the facility's Communication Plan, revealed the facility had worked with the community group ESF8 [emergency services functions] to develop a plan to communicate transfer of patients to other facilities, but did not have a specific plan for sharing information and medical documentation for patients, or a means to release patient information.

In an interview on 01/23/20 at 12:50 PM, the Co-Director of Nursing Services (DNS) 2, in charge of the facilities "Safety Plan", said the facility had been working on a transfer plan, but said the plan did not include all of the comprehensive elements required in the regulation.