HospitalInspections.org

It was determined the Conditions of Participation for Nursing Services was not met as evidenced by.

Based on interview and record review the facility failed to provide organized nursing services to ensure safe care to patients in that there was no organized system to ensure all nursing and patient care technicians held current licensure, certifications and competencies as required by their job description.

1. The facility failed to ensure a license registered nurses who provided direct patient care held a current certification in Advanced Cardiopulmonary Life Support (ACLS).

2. The facility failed to ensure a non-licensed patient care tech who provided direct patient care held a current certification in Basic Life Support (BLS).

Cross Refer Tag A0397

It was determined the Conditions of Precipitation for Physical Environment was not met as evidenced by.
Based on interview and record review the facility failed to ensure the facility was maintained to ensure the safety of patients, staff, and visitors.

Findings included:

1. Record review of Fire Door Annual report, FD12525, dated 03/28/2022 indicated 76% (29 out of 38) of the fire doors were non-compliant. The facility was unable to provide an annual fire door inspection for 2023.

2. The facility failed to ensure staff conducted fire watch rounding every hour, 24 hours a day and failed to demonstrate staff competencies as indicated in the facilities Fire Watch Rounding policy.

3. The facility failed to ensure fire drills were conducted once per shift per quarter (12 per year).

Cross Refer Tag 0701

Based on interview and record review, the hospital failed to ensure the registered nurse and patient care technician assigned to provide direct patient care held current specialized qualifications and competencies as required by hospital job description.
1.Personnel #10, a registered nurse, worked 35 shifts providing direct patient care with an expired Advanced Cardiac Life Support certification.
2.A non-licensed technician in direct patient care worked at least six shifts without current Basic Life Support certification.

Findings included:

1. The facility failed to ensure all registered nurses who provide direct patient care held a current certification in Advanced Cardiopulmonary Life Support (ACLS).

Record Review of personnel #10 employee file on 07/20/2023 indicated Advanced Cardiac Life Support (ACLS) expired on 04/30/2023. Personnel #10 worked 05/02/2023, 05/04/2023, 05/06/2023, 05/08/2023, 05/09/2023, 05/11/2023, 05/14/2023, 05/17/2023, 05/18/2023, 05/22/2023, 05/24/2023, 05/26/2023, 05/28/2023, 05/31/2023, 06/01/2023, 06/06/2023, 06/07/2023, 06/10/2023, 06/13/2023, 06/14/2023, 06/16/2023, 06/18/2023, 06/20/2023, 06/21/2023, 06/24/2023, 06/27/2023, 06/28/2023, 06/30/2023, 07/04/2023, 07/05/2023, 07/08/2023, 07/11/2023, 07/12/2023, 07/15/2023, 07/19/2023, a total of 35 shifts with an expired ACLS certification.

Personnel #10 Signed Registered Nurse Job Description on 10/10/2022 states ..."All Registered Nurses must maintain current licensure, BLS and ACLS certification while employed with LifeCare Hospitals.

2. The facility failed to ensure a non-license patient care tech who provided direct patient care held a current certification in Basic Life Support (BLS). Review of personnel file #11 on 07/20/2023 indicated Basic Life Support (BLS) expired on 06/30/2023. Personnel #11 worked 07/03/2023, 07/04/2023, 07/05/2023, 07/07/2023, 07/10/2023, 07/11/2023 with no current BLS certification.

Personnel #11 Signed Patient Care Technician Job Description on 08/16/2022 states," ...All (Patient Care Technicians) PCT's must maintain current ...BLS certification while employed at LifeCare Hospitals."

During an interview with Personnel #5 on 07/20/2023 confirmed the above findings.

During an interview with Personnel #3 on 07/20/2023 stated "Personnel #10 ACLS was noted last week to have expired on 04/30/2023 and Personnel #10 has continued to work."

Based on interview and record review the facility failed to ensure the facility was maintained to assure the safety of patients, staff, and visitors. The facility failed to provide a fire door inspection for year 2023. The fire door inspection dated 3-28-2022 had 76% of the doors as non-compliant, fire watch rounding was not completed every hour, 24 hours a day, staff did not have competencies for performing fire watch rounding, fire drills were not performed every shift every quarter.

Findings Included:

Record review of Fire Door Annual report, FD12525, dated 03/28/2022 indicated 76% (29 out of 38) of the fire doors were non-compliant. There was no record of an annual fire door inspection for year 2023.

Policy & procedure titled "Life Safety Management Plan" Policy # LS.031, reviewed on 03/23/2022 ...Inspecting, Testing and Maintaining Fire Protection and Life Safety Systems ...Door assemblies-annul inspection and testing. Annual inspections shall be documented. The inspection shall be performed by an individual knowledgeable of the operating components of the door (s) being tested. Pre-visual inspection shall be performed. Testing shall include both sides of the opening ...Documentation of maintenance, testing and inspection of above activities, including, activity name, inventory of equipment, devices or other items, the activities required frequency, name of person performing the activity, including affiliation and contract information, related NFPA standard(s), activity results.

Record review of the facilities "Fire Watch Logs" on 07/20/2023 indicated no fire watch was performed on 07/11/2023 during the hours of 7:00 PM to 6:00 AM, 07/12/2023 during the hours of 7:00 PM to 6:00 AM, 07/16/2023 during the hours of 7:00 PM to 6:00 AM , 07/18/2023 during the hours of 7:00 PM to 6:00 AM.

Record review of the facilities "Fire Watch Log" does not identify the location of the fire watch as indicated in the facility policy.

Policy & Procedure title "Life Safety-Fire Watch" ...C. Documentation: A fire watch tour is a periodic walking tour of all Life Care rooms and areas by one or more assigned and trained staff. The tour monitors Life Care facility areas through direct observation of all rooms for possible signs of fire. Each tour is recorded with findings noting date time and staff initials. This documentation is part of the facility safety rounds process. D.6. The fire watch procedure shall designate facility tours designating wing, floor, or building identifier ...7. Fire watch tour shall occur at ¼ hour intervals, 24 hours a day. Fire watch shall be performed by personnel solely dedicated to the fire watch and no other facility related activities or events.

Record review indicated no Fire Watch Staff Competencies were completed.

Record review of Fire Drill Reports indicated fire drills were conducted on
1. 07/28/2022 at 5:30 PM (2nd shift)
2. 10/21/2022 at 9:45 AM (1st shift)
3. 01/17/2023 at 2:27 PM (1st shift)
4. 04/21/2023 at 4:23 PM (2nd shift)

Policy & Procedure titled "Life Safety management Plan, LS.031, reviewed on 03/23/2022 ..."Fire Drills shall be conducted once per shift per quarter in each building defined as a healthcare occupancy by the Life Safety Code."

During an interview with Personnel # 4 on 07/24/2023 at 10:45 AM stated our fire drills are done quarterly, and we do one shift per quarter. We do four fire drills per year. You will see a first shift fire drill done one quarter and then the second shift will be done on the next quarter.

During an interview with Personnel # 4 and #5 on 07/24/2023 at 1:30 PM confirmed the above findings.