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Based on observation, record review, and interview the hospital failed to meet the Conditions of Participation (CoP) of Patient Rights. This deficient practice was evidenced by:
1) failure to promptly resolve 2 (#1, #2) of 2 (#1, #2) patient grievances reviewed (See Findings Tag A0118);
2) failure to review and resolve 2 (#1, #2) of 2 (#1, #2) patient grievances reviewed (See Findings Tag A0119);
3) failure to provide written notice to 2 (#1, #2) of 2 (#1, #2) patient grievances reviewed (See Findings Tag A0123);
4) failure to reveal documentation of the patient or the patient's representative participating in the development and implementation of his or her plan of care in 3 (#1 - #3) of 3 (#1 - #3) patient medical records reviewed (See Findings Tag A0130);
5) failure to include discharge planning in 1 (#2) of 3 (#1-#3) patient plan of cares reviewed for informed decisions (See Findings Tag A0131);
6) failure of the nurse call system to be functioning from the available nurse call button on the side railing of the patient beds in 3 ("a", "h", "l") of 17 ("a" - "q") rooms observed (See Findings Tag A0144); and
7) failure to provide the services necessary to avoid physical harm, mental anguish or mental illness to 2 (#1, #2) of 2 (#1, #2) patient grievance reports reviewed (See Findings Tag A0145).

Based on observation, policy review, record review and interview, the hospital failed to establish a process for prompt resolution of patient grievance. This deficient practice was evidenced by the failure to promptly resolve 2 (#1, #2) of 2 (#1, #2) patient grievances reviewed.
Findings:

A review of facility policy, "Patient Rights," Policy ID 16427107, last revised 10/2006 with GB approval 08/2024, revealed in part, Purpose: 2. Respect and Dignity: The patient has the right to considerate, respectful care at all times and under all circumstances, with recognition to his personal dignity. 4. Personal Safety: The patient has the right to expect reasonable safety in so far as the hospital practices and environment are concerned. A Patient's Bill of Rights: 24. The patient has the right to be cared for in a safe environment. 27. The patient has a right to voice a complaint/grievance to the hospital and/or the Department of Health and Hospitals and have that complaint/grievance investigate within a reasonable amount of time, usually five (5) days. This is to be followed by a letter to the patient or their representative identifying the results of the investigation and the corrective action that has been taken.

A review of facility policy, "Patient/Family Grievance" Policy ID 16427105, last revised 05/2024 and Governing Gody (GB) approval 08/2024, revealed in part, Procedure Grievances: 4. In cases of a grievance the Social Services/ case manager or the Director of Nursing will investigate the substance of the grievance, if resolution of the grievance cannot be achieved within 7 business days , the Director of Social Services or case manager will alert the Director of Nursing or Hospital Administrator to assist with resolution. 5. If by the 7th day the grievance still cannot be resolved, the patient and /or their representative will be sent a written letter informing them that the investigation is still underway and that a letter of resolution will be sent to them within 21 days by the Director of Social Services. 7. All Grievance will be entered into the grievance tracking database and the investigation documented on the Grievance Complaint Form. 8. A copy of all letters sent to patients will be maintained in Social Services/case manager's office.

A review of the hospital's Complaint Log revealed a complaint on 08/04/2024 at 7:00 a.m. by Patient #1 with a statement of complaint: "gnats biting forehead." Further review revealed a complaint on 08/07/2024 at 8:00 a.m. by Patient #2 with a statement of complaint: "gnats in food/room."

A review of a Patient Grievance Investigation Form from 08/04/2024 at 7:00 a.m. revealed Patient #1 filing a grievance on 08/04/2024. The form revealed, "Patient c/o gnats keep biting my forehead. Patient crying and states I can't move to get them off of me." The form also revealed the patient is a "Quad" and the patient suggested the facility obtain "gnat traps".

A review of a Patient Grievance Investigation Form from 08/07/2024 at 8:00 a.m. revealed Patient #2 filing a grievance on 08/07/2024. The form revealed, "Patient c/o excessive amount of gnats in his room. Patient state gnats are always flying in his food trays and on his face and body. Patient states it is disgusting." Further the form revealed in part, nursing staff observed the flying gnats around the patients diaper and seen inside the diaper during diaper change and sacrum wound care.

Documentation related to a resolution, an investigation or the results of an investigation to these grievances was requested and was not provided. There was no documentation related to a follow-up letter being sent to the patients or the patient's representative communicating an investigation was still underway and a resolution letter would be sent to them within 21 days. Of note, it has been approximately 37 days since the initial grievance had been reported.

An observation on 09/09/2024 at 11:45 a.m. revealed a black, tiny insect flying around Patient #1's room.

In an interview on 09/09/2024 at 11:45 a.m. Patient #1 confirmed the presence of black, tiny insects flying in his room. He indicated the insects were "gnats." He confirmed they fly around his face and he was defenseless against these insects because he cannot move.

In an interview on 09/09/2024 and present during the interview with Patient #1, S1RNHM confirmed the presence of the gnat in Patient #1's room.

In an interview on 09/09/2024 at 1:30 p.m. S1RNHM confirmed the the above mentioned findings.

In an interview on 09/10/2024 at 9:00 a.m. S2LPN confirmed she was the case manager and received the grievances, however there had not been a follow up to the grievances and she was unaware the hospital was still having issues with these flying insects.

Based on policy review, record review and interview, the hospital's Governing Body (GB) failed to establish a grievance process that effectively reviews and resolves grievances. This deficient process was evidence by the failure to review and resolve 2 (#1, #2) of 2 (#1, #2) patient grievances reviewed.
Findings:

A review of facility policy, "Patient Rights," Policy ID 16427107, last revised 10/2006 with GB approval 08/2024, revealed in part, Purpose: 2. Respect and Dignity: The patient has the right to considerate, respectful care at all times and under all circumstances, with recognition to his personal dignity. A Patient's Bill of Rights: 27. The patient has a right to voice a complaint/grievance to the hospital and/or the Department of Health and Hospitals and have that complaint/grievance investigate within a reasonable amount of time, usually five (5) days. This is to be followed by a letter to the patient or their representative identifying the results of the investigation and the corrective action that has been taken.

A review of facility policy, "Patient/Family Grievance" Policy ID 16427105, last revised 05/2024 and GB approval 08/2024, revealed in part, Policy: The GB has delegated the responsibility for review, investigation, and resolution of the grievances to the Patient Safety Committee. Patient Safety Committee: The Committee consist of Quality/Risk Management, Hospital Administrator, Director of Nursing (DON), and Social Worker/Case Manager.

A review of a Patient Grievance Investigation Form from 08/04/2024 at 7:00 a.m. revealed Patient #1 filing a grievance on 08/04/2024. The form revealed, "Patient c/o gnats keep biting my forehead. Patient crying and states I can't move to get them off of me." The form also revealed the patient is a "Quad" and the patient suggested the facility obtain "gnat traps".

A review of a Patient Grievance Investigation Form from 08/07/2024 at 8:00 a.m. revealed Patient #2 filing a grievance on 08/07/2024. The form revealed, "Patient c/o excessive amount of gnats in his room. Patient state gnats are always flying in his food trays and on his face and body. Patient states it is disgusting." Further the form revealed in part, nursing staff observed the flying gnats around the patients diaper and seen inside the diaper during diaper change and sacrum wound care.

Documentation related to a resolution, an investigation or the results of an investigation to these grievances was requested and was not provided. There was no documentation related to a follow-up letter being sent to the patients or the patient's representative communicating an investigation was still underway and a resolution letter would be sent to them within 21 days. Of note, it has been approximately 37 days since the initial grievance had been reported.

A review of the hospital's Quality Assurance Performance Improvement (QAPI) Dashboard for 2024 year to date did not reveal the above mentioned grievances on the provided report.

In an interview on 09/09/2024 at 1:30 p.m. S1RNHM confirmed the above mentioned findings and further confirmed the facility had recently changed DONs and was unaware if this DON had knowledge of these grievances.

In an interview on 09/09/2024 at 4:00 pm, S3Adm confirmed the facility had been having problems with the flying insects (gnats), she was unaware of the continued problem.

In an interview on 09/10/2024 at 9:00 a.m. S2LPN confirmed she was the case manager and received the grievances, however there had been no follow up to the grievances and she was unaware the hospital was still having issues with these flying insects (gnats). She further confirmed the hospitals QAPI Dashboard was not up to date.

Based on policy review, record review and interview, the hospital failed to provide the patient with a written notice of its decision regarding the resolution of a grievance that contained the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and the date of completion. This deficient practice was evidenced by the failure to provide written notice to 2 (#1, #2) of 2 (#1, #2) patient grievances reviewed.
Findings:

A review of facility policy, "Patient Rights," Policy ID 16427107, last revised 10/2006 with GB approval 08/2024, revealed in part, Purpose: 2. Respect and Dignity: The patient has the right to considerate, respectful care at all times and under all circumstances, with recognition to his personal dignity. 27. The patient has a right to voice a complaint/grievance to the hospital and/or the Department of Health and Hospitals and have that complaint/grievance investigate within a reasonable amount of time, usually five (5) days. This is to be followed by a letter to the patient or their representative identifying the results of the investigation and the corrective action that has been taken.

A review of facility policy, "Patient/Family Grievance" Policy ID 16427105, last revised 05/2024 and GB approval 08/2024, revealed in part, Procedure Grievances: 4. In cases of a grievance the Social Services/ case manager or the Director of Nursing will investigate the substance of the grievance, if resolution of the grievance cannot be achieved within 7 business days , the Director of Social Services or case manager will alert the Director of Nursing or Hospital Administrator to assist with resolution. 5. If by the 7th day the grievance still cannot be resolved, the patient and /or their representative will be sent a written letter informing them that the investigation is still underway and that a letter of resolution will be sent to them within 21 days by the Director of Social Services. 7. All Grievance will be entered into the grievance tracking database and the investigation documented on the Grievance Complaint Form. 8. A copy of all letters sent to patients will be maintained in Social Services/case manager's office.

A review of a Patient Grievance Investigation Form from 08/04/2024 at 7:00 a.m. revealed Patient #1 filing a grievance on 08/04/2024. The form revealed, "Patient c/o gnats keep biting my forehead. Patient crying and states I can't move to get them off of me." The form also revealed the patient is a "Quad" and the patient suggested the facility obtain "gnat traps".

A review of a Patient Grievance Investigation Form from 08/07/2024 at 8:00 a.m. revealed Patient #2 filing a grievance on 08/07/2024. The form revealed, "Patient c/o excessive amount of gnats in his room. Patient state gnats are always flying in his food trays and on his face and body. Patient states it is disgusting." Further the form revealed in part, nursing staff observed the flying gnats around the patients diaper and seen inside the diaper during diaper change and sacrum wound care.

Documentation related to a resolution, an investigation or the results of an investigation to these grievances was requested and was not provided. There was no documentation related to a follow-up letter being sent to the patients or the patient's representative communicating an investigation was still underway and a resolution letter would be sent to them within 21 days. Of note, it has been approximately 37 days since the initial grievance had been reported.

In an interview on 09/09/2024 at 1:30 p.m. S1RNHM confirmed the above mentioned findings.

In an interview on 09/10/2024 at 9:00 a.m. S2LPN confirmed she was the case manager and received the grievance, however there had been no follow up to the grievances and she was unaware the hospital was still having issues with the flying insects (gnats).

Based on policy review, record review and interview, the hospital failed to include the right of the patient to participate in the development and implementation of his or her plan of care. This deficient practice was evidenced by the failure to reveal documentation of the patient or the patient's representative participating in the development and implementation of his or her plan of care in 3 (#1 - #3) of 3 (#1 - #3) patient medical records reviewed.
Findings:

A review of facility policy, "Patient Rights," Policy ID 16427107, last revised 10/2006 with GB approval 08/2024, revealed in part, Purpose: 6. Information: The patient has a right to obtain, from the practitioner responsible for coordinating his care, complete and current information concerning his diagnosis, treatment, and any known prognosis. A Patient's Bill of Rights: 20. The patient has the right to assist in the development and implementation of their plan of care.

A review of facility policy, "Individual Plan of Care," Policy ID 15957970, last revised with GB Approval 08/2024, revealed in part, Policy: All patients will have an individualized plan of care that is individually tailored, integrated and coordinated by competent professional through licensure, training and experience. Procedure: 1. Each patient has a care plan developed based on the initial assessment. 2. The individual care plan includes the following information: b. The patient's stated goals and nursing goals are included in the care plan.

A review of facility policy, "Plan of Care" Policy ID 15674247, last revised with GB Approval 05/2024, revealed in part, Policy: B. All disciplines involved in the care of a patient collaborate to develop a patient's plan. C. The patient/family/caregiver is included in the development, implementation, maintenance and evaluation of the care provided.

A review of Patients #1 - #3's medical record failed to reveal documentation of the patient or the patient's representative participating in the development and implementation of his or her plan of care.

In an interview on 09/09/2024 at 2:30 p.m. S2LPN confirmed the above mentioned findings.

In an interview on 09/10/2024 at 11:00 a.m. S1RNHM confirmed the above mentioned findings.

Based on policy review, record review and interview, the hospital failed the patient's right to make informed decisions regarding his or her care which included being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This deficient practice was evidenced by the failure to include discharge planning in 1 (#2) of 3 (#1-#3) patient plan of cares reviewed for informed decisions.
Findings:

A review of facility policy, "Patient Discharge Planning," Policy ID 1566777, last revised and GB approval 05/2024, revealed in part, 1. Discharge planning will begin at the time that the initial psychosocial assessment is completed ... 2. Discharge planning decisions shall be assessed on an ongoing basis during each patient's stay ... 3. Discharge planning options are to be provided to the patient/family during the initial assessment and at any other time that the discharge plan is being re-assessed.

A review of facility policy, "Patient Rights," Policy ID 16427107, last revised 10/2006 with GB approval 08/2024, revealed in part, Purpose: 2. Respect and Dignity: The patient has the right to considerate, respectful care at all times and under all circumstances, with recognition to his personal dignity. 8. Consent: The patient has the right to reasonable informed participation in decisions involving his health care. A Patient's Bill of Rights: 3. The patient has the right to received form his physician information necessary to give informed consent prior to the stat of any procedure and/or treatment.

A review of Patient #2 revealed an admission date of 07/19/2024 and discharge on 08/13/2024. A review of the Finalized Plan of Care failed to reveal documentation related to discharge planning problems, interventions, and goals. Further, the Finalized Plan of Care failed to reveal documentation related to Case Management or Discharge Planning involvement.

In an interview on 09/10/2024 at 11:00 a.m. S1RNHM confirmed the above mentioned findings.

Based on observation, policy review and interview, the hospital failed the patient's right to receive care in a safe setting. This deficient practice was evidenced by the failure of the nurse call system to be functioning from the available nurse call button on the side railing of the patient beds in 3 ("a", "h", "l") of 17 ("a" - "q") rooms observed.
Findings:

A review of facility policy, "Patient Rights," Policy ID 16427107, last revised 10/2006 with GB approval 08/2024, revealed in part, Purpose: 2. Respect and Dignity: The patient has the right to considerate, respectful care at all times and under all circumstances, with recognition to his personal dignity. 4. Personal Safety: The patient has the right to expect reasonable safety in so far as the hospital practices and environment are concerned. A Patient's Bill of Rights: 24. The patient has the right to be cared for in a safe environment.

A tour of the facility on 09/09/2024 from 10:30 am to 11:45 am revealed the presence of the nurse call system to be non-functioning from the available nurse call button on the side railing of the patient beds located in Rooms "a", "h" and "l".

In an interview and present during the tour on 09/09/2024, S1RNHM confirmed the above mentioned findings.

Based on observation, policy review, record review, and interview, the hospital failed the patient's right to be free from all forms of abuse or harassment. This deficient practice was evidenced by the failure to provide the services necessary to avoid physical harm, mental anguish or mental illness to 2 (#1, #2) of 2 (#1, #2) patient grievance reports reviewed.
Findings:

A review of facility policy, "Patient Rights," Policy ID 16427107, last revised 10/2006 with GB approval 08/2024, revealed in part, Purpose: 2. Respect and Dignity: The patient has the right to considerate, respectful care at all times and under all circumstances, with recognition to his personal dignity. 4. Personal Safety: The patient has the right to expect reasonable safety in so far as the hospital practices and environment are concerned. A Patient's Bill of Rights: 1. The patient has a right to considerate and respectful care. 23. The patient has a right to be free from all forms of abuse and/or harassment during their hospital stay. 24. The patient has the right to be cared for in a safe environment. 27. The patient has a right to voice a complaint/grievance to the hospital and/or the Department of Health and Hospitals and have that complaint/grievance investigate within a reasonable amount of time, usually five (5) days. This is to be followed by a letter to the patient or their representative identifying the results of the investigation and the corrective action that has been taken.

A review of facility policy, "Abuse and Neglect: Identification, Assessment, Response, and Reporting," Policy ID 16427103, last revise with GB approval 08/2024, revealed in part, Purpose: To provide guidance on identifying and addressing circumstances in which a patient is suspected of having been subject to physical or emotional abuse and/or neglect ... Definitions: Neglect: for the purpose of this requirement, is considered a form of abuse and is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Policy: The hospital will ensure patients are free from all forms of abuse, neglect or harassment. III. Identify: a. Staff shall be informed of what constitutes abuse and how to identify events for reporting suspected abuse. i. Neglect: Failure of the facility, its employees or service providers to provide goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. v. Protect: a. The facility will make efforts to ensure patients are protected from abuse during the investigation of any allegations of abuse, neglect, or harassment. v. Investigate: a. An immediate investigation is warranted when suspicion of abuse, neglect, or harassment, or reports of abuse, neglect or harassment occurs. vii. Report/Respond: a. The hospital will report and respond to any incidents of abuse, neglect or harassment and analyze, and the appropriate corrective, remedial or disciplinary action occurs ... g. Defining how care provision will be changed and/or improved to protect patients receiving services.

A review of a Patient Grievance Investigation Form from 08/04/2024 at 7:00 a.m. revealed Patient #1 filing a grievance on 08/04/2024. The form revealed, "Patient c/o gnats keep biting my forehead. Patient crying and states I can't move to get them off of me." The form also revealed the patient is a "Quad" and the patient suggested the facility obtain "gnat traps".

A review of a Patient Grievance Investigation Form from 08/07/2024 at 8:00 a.m. revealed Patient #2 filing a grievance on 08/07/2024. The form revealed, "Patient c/o excessive amount of gnats in his room. Patient state gnats are always flying in his food trays and on his face and body. Patient states it is disgusting." Further the form revealed in part, nursing staff observed the flying gnats around the patients diaper and seen inside the diaper during diaper change and sacrum wound care.

Documentation related to a resolution, an investigation or the results of an investigation to these grievances was requested and was not provided. Of note, it has been approximately 37 days since the initial grievance had been reported.

An observation on 09/09/2024 at 11:45 a.m. revealed a black, tiny insect flying around Patient #1's room.

In an interview on 09/09/2024 at 11:45 a.m. Patient #1 confirmed the presence of black, tiny insects flying in his room. He indicated the insects were "gnats." He confirmed they fly around his face and he was defenseless against these insects because he cannot move.

In an interview on 09/09/2024 and present during the interview with Patient #1, S1RNHM confirmed the presence of the flying insect ("gnat") in Patient #1's room.

In an interview 09/09/2024 at 3:54 p.m., S4Maint confirmed she has been treating the hospital for these flying insects. She further confirmed the hospital does not have a pest control contract with a professional control company and a professional pest control company has not been contacted to assist with the remediation of these flying insects.

In an interview on 09/09/2024 at 4:00 p.m. S3Adm confirmed it has been approximately 37 days since the initial grievance was filed, the hospital does not have a pest control contract with a professional pest control company and the hospital has not sought professional assistance with this remediation. She further confirmed she was unaware the flying insects remained a nuisance in the hospital.

Based on policy review, record review and interview the hospital failed to measure, analyze and track all adverse patient events and the hospital's administrative officials failed to ensure there were clear expectations for safety. This deficient practice was evidenced by: 1) failure to analyze and track identified grievances; and 2) failure of the administrative officials to be responsible and accountable to ensure clear expectations for patient safety were established.
Findings:

A review of facility policy, "Performance Improvement Plan," Policy ID 14968871, last revised with GB approval 03/2024, revealed in part, Purpose: The Performance Improvement Plan of the hospital is designed to provide a systematic and organized program for the promotion of safe and quality patient care and services ... patient care and processes that affect patient care outcomes shall be continuously monitored and evaluated to promote optional achievements ... Policy: The mission of the hospital will be based upon a comprehensive system that allows for the implementation of continuous quality improvement through the following: ... assessment of the effectiveness of action taken by initiation and ongoing monitoring ... A. Goals: The goals of the program are as follows: 1. To improve patient care safety, quality and services by measuring, assessing and improving ... support processes that most affect patient outcomes. 2. To improve patient care processes and outcomes, and to promote patient safety. F. Administration: The leadership of the hospital through the CEO with his/her Senior Management Staff and QAPI Committee, assumes the responsibility for the quality and safety of care and performance of non-physician professional and technical staff. I. Quality and risk Management Integration: It is essential and part of the Performance Improvement Plan that the Performance Improvement and Risk Management programs are integrated to assure the flow of information to the appropriate areas and up to the department and committee level for review, action, and/or follow-up.

1) Failure to analyze and track identified grievances

A review of the hospital's Complaint Log revealed a complaint on 08/04/2024 at 7:00 a.m. by Patient #1 with a statement of complaint: "gnats biting forehead." Further review revealed a complaint on 08/07/2024 at 8:00 a.m. by Patient #2 with a statement of complaint: "gnats in food/room."

A review of Patient Grievance Investigation Forms revealed the above two patient's complaints being reported as grievances. Documentation related to a resolution, an investigation or the results of an investigation to these grievances was requested and was not provided. Of note, it had been approximately 37 days since the initial grievance had been reported.

A review of the hospital's Quality Assurance Performance Improvement Dashboard for 2024 year to date did not reveal the above mentioned grievances on the provided report.

In an interview on 09/09/2024 at 1:30 p.m. S1RNHM confirmed the above mentioned information.

In an interview on 09/10/2024 at 9:00 a.m. S2LPN confirmed the above mentioned information.

2) Failure of the administrative officials to be responsible and accountable to ensure clear expectations for patient safety are established

A review of the hospital's Complaint Log revealed a complaint on 08/04/2024 at 7:00 a.m. by Patient #1 with a statement of complaint: "gnats biting forehead." Further review revealed a complaint on 08/07/2024 at 8:00 a.m. by Patient #2 with a statement of complaint: "gnats in food/room."

A review of Patient Grievance Investigation Forms revealed the above two patient's complaints being reported as grievances. Documentation related to a resolution, an investigation or the results of an investigation to these grievances was requested and was not provided. Of note, it had been approximately 37 days since the initial grievance had been reported.

A review of the hospital's Quality Assurance Performance Improvement Dashboard for 2024 year to date did not reveal the above mentioned grievances on the provided report.

In an interview on 09/09/2024 at 4:00 p.m. S3Adm confirmed the above mentioned information and further confirmed she was unaware the "gnats" were still a problem in the hospital.

Based on observation, record review and interview, the hospital failed to develop and maintain the condition of the physical plant and the overall hospital environment in such a manner that the safety and well-being of patients were assured. The deficient practice was evidenced by failure to remediate flying insects within the hospital in a timely manner.
Findings:
An observation on 09/09/2024 at 11:45 a.m. revealed a black, tiny insect flying around Patient #1's room.

In an interview on 09/09/2024 at 11:45 a.m. Patient #1 confirmed the presence of black, tiny insects flying in his room. He indicated the insects were "gnats." He confirmed they fly around his face and he was defenseless against these insects because he cannot move.

In an interview on 09/09/2024 and present during the interview with Patient #1, S1RNHM confirmed the presence of the gnat in Patient #1's room.

An observation on 09/09/2024 at 1:30 p.m. revealed a black, tiny insect flying around the surveyor's face while reviewing documents in the hospital's conference room.

In an interview on 09/09/2024 at 1:30 p.m. S1RNHM confirmed the presence of flying insect.

A review of a Patient Grievance Investigation Form from 08/04/2024 at 7:00 a.m. revealed Patient #1 filing a grievance on 08/04/2024. The form revealed, "Patient c/o gnats keep biting my forehead. Patient crying and states I can't move to get them off of me." The form also revealed the patient is a "Quad" and the patient suggested the facility obtain "gnat traps".

A review of a Patient Grievance Investigation Form from 08/07/2024 at 8:00 a.m. revealed Patient #2 filing a grievance on 08/07/2024. The form revealed, "Patient c/o excessive amount of gnats in his room. Patient state gnats are always flying in his food trays and on his face and body. Patient states it is disgusting." Further the form revealed in part, nursing staff observed the flying gnats around the patients diaper and seen inside the diaper during diaper change and sacrum wound care.

It has been approximately 37 days since the initial grievance had been reported and these flying insect remain in the facility.

In an interview 09/09/2024 at 3:54 p.m., S4Maint confirmed she has been treating the hospital for these flying insects. She further confirmed the hospital does not have a pest control contract with a professional control company and a professional pest control company has not been contacted to assist with the remediation of these flying insects.

In an interview on 09/09/2024 at 4:00 p.m. S3Adm confirmed the above mentioned findings and further confirmed she was unaware the flying insects remained a nuisance in the hospital.

Based on record review and interview, the facility failed to ensure infection control standards were maintained. The deficient practice is evidenced by failure of the facility to maintain separate storage for clean and dirty items.
Findings:

A review of facility policy, "Infection Control Program and Plan," Policy ID 14966839, last revised and GB approval 03/2024, revealed in part, Program Goals: 8. Provide the policies, tools and education necessary for staff and physicians to limit the transmission of infections associated with the use of medical equipment, devices and supplies. Observation and Evaluation: Environmental Considerations: Inspect the environment on rounds and observe personnel activities for the purpose of detecting infection hazards. Surveillance: Standard Precautions: Environmental cleaning and disinfection shall be performed according to facility policy. All staff have responsibilities related to the cleanliness of the facility, and are to report problems outside of their scope to the appropriate department. Equipment Protocol: All reusable items and equipment requiring special cleaning, disinfection, or sterilization shall be cleaned in accordance with our current procedures governing the cleaning and sterilization of soiled or contaminated equipment.

An observation during a facility tour on 09/09/2024 from 10:30 a.m. to 11:45 a.m. revealed an equipment closet containing 10 wheelchairs, 3 walkers, 3 sets of crutches, an electric floor buffer containing a buffing pad that appeared to be used, an electric floor scrubber, a 5 gallon container of High Gloss Floor Finisher, a gallon container of Pioneer Products Floor Cleaner and an empty mop bucket stored atop a wheelchair. None of the patient care equipment was covered or had any indication that it had been sanitized prior to storage. The contents of this equipment closet should not be comingled due to the risk of the transmission of HAIs from floor cleaning equipment to patient equipment.

In an interview and present on the facility tour on 09/09/2024, S1RNHM confirmed the above mentioned findings and indicated the equipment should have been covered once it was sanitized and prior to storing.