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Based on record review and interview, the hospital's Governing Body failed to ensure the QAPI program reflected the complexity of the hospital's services as evidenced by failing to include all hospital services in the QAPI program. This deficient practice was evident by failing to include the following contracted services: linen service, medical transcription service, outpatient dialysis service, dietary service, record storage service, and waste management service.
Findings:

Review of the QAPI Plan failed to reveal the following contracted services were included: linen service, medical transcription service, outpatient dialysis service, dietary service, record storage service, and waste management service.

Review of the list of contracted services provided by S1ADM confirmed the linen service, medical transcription service, outpatient dialysis service, dietary service, record storage service, and waste management service were contracted.

In an interview on 01/18/23 at 2:00 p.m. S1ADM verified the above were contracted services and not included in the QAPI Plan.

Based on record review and interview, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care of each patient as evidenced by 1) failing to assess a pressure sore wound for seven days (since admit) for 1 sampled patient (Patient #17) and 2) failing to ensure that a nurse timely notified EMS and the physician when 1 sampled patient was unresponsive for 14 minutes (Patient #18).
Findings:

1) Failing to assess a pressure sore wound for seven days (since admit) for 1 sampled patient (Patient #17)

Review of the medical record for Patient #17 revealed an admit date of 01/11/23 with diagnoses including anterior right ankle pressure ulcer and subarachnoid hemorrhage.

Physician admission orders dated 01/11/23 revealed daily wet to dry dressing changes to the right inner ankle pressure sore.

Review of the Photographic Wound Documentation form dated 01/11/23 revealed a photo of the right inner ankle pressure sore and nurses notes stating the pressure sore measured 6cm x 6cm x 0.1cm. The notes further stated there was a small amount of purulent exudate and a foul odor. There was no documented staging of the pressure sore.

Review of the physician orders revealed Keflex (antibiotic) was ordered for seven days due to the infected pressure sore.

Review of the medical record, including nurses notes from 01/12/23 until 01/18/23 revealed no documented evidence of any further assessment of the pressure sore.

On 01/18/23 at 10:00 a.m., interview with S2DON confirmed that the nurses should have been documenting in the nurses notes an assessment of Patient #17's pressure sore at least daily when they performed dressing changes. S2DON further stated that he was unable to locate a policy regarding timeframes for assessing pressure sores or a procedure for completing the assessments.

2) Failing to ensure that a nurse timely notified EMS and the physician when 1 sampled patient was unresponsive for 16 minutes (Patient #18).

Review of the medical record for Patient #18 revealed an admit date of 11/02/22 with diagnoses including debility, aftercare from CVA and seizure disorder.

Review of the History and Physical dated 11/02/22 revealed under the plan, the physician had documented "Seizure disorder - Treat".

Review of the medical record revealed the patient was prescribed no medication for seizures.

Review of the nurses notes dated 11/10/22 at 2:50 a.m. revealed nurse went to the patient's room and "found patient unresponsive with tonic clonic hard grand mal seizure. Safety provided for patient's airway. Suctioned. Pulse weak, thready and irregular from 140's to 160's. Sat down to 91%. Snoring/agonal respirations. Diaphoretic."

The next nurses note was dated 11/10/22 at 3:04 a.m. (14 minutes later) and revealed the physician was called while at bedside with patient. Continues to seize. Irregular heart rate, diaphoretic and snoring respirations. Instructed to call EMS and transfer patient to hospital.

The nurses note dated 11/10/22 at 3:06 a.m. revealed the nurse notified EMS (16 minutes after the patient had been found unresponsive).

On 01/18/23 at 1:05 p.m., S2DON reviewed the patient's medical record with the surveyor. S2DON stated that the hospital has no emergency department and that the physician and EMS should have been immediately notified and the nurse should not have waited for 16 minutes to notify EMS of an unresponsive patient. Further interview with S2DON confirmed that the hospital had no policy and procedure addressing patients with seizures/seizure precautions.

25119

Based on record review and interview, the hospital failed to ensure the nursing staff developed and kept current individualized and comprehensive nursing care plans. This deficient practice was evidenced by failure of the nursing staff to include all identified medical diagnoses and failure to include nursing interventions for 3 (Patient #1, 3, 18) of 9 (#1-9) current sampled patients reviewed for care plans of a total sample of 20.
Findings:

Review of the hospital policy titled Plan Care Plan Reassessment, Policy Number N2.058, revealed in part: To provide appropriate and consistent individualized patient care on an ongoing basis and as needed between the interdisciplinary departments. 1. Patients care plans are initiated within 24 hours of admission.

Patient #1
Review of Patient #1's medical record revealed an admission date of 01/16/23 with an admitting diagnosis of critical illness myopathy, S/P COVID, hypertension, seizure disorder, aftercare CVA with paresis, BPH, insomnia, hyperlipidemia, incontinence, and history of falls. Further review revealed a physician order for flush PICC line every shift and change PICC dressing every 4 days per protocol and PRN.

Review of the care plan for Patient #1 revealed no documentation for interventions for PICC line care.

In an interview on 01/17/23 at 3:15 p.m. S2DON verified patient #1's care plan was not comprehensive to his care and did not include interventions for PICC line.

Patient #3
Review of Patient #3's medical record revealed an admission date of 01/09/23 with admitting diagnosis of Myopathy, Pneumonia, HTN, Respiratory Failure, CAD, and Hypernatremia. Further review revealed Physicians orders for Foley catheter to change every month and catheter care every shift, PICC line dressing change every 4 days and flush every shift.

Review of the care plan for patient #3 dated 01/09/23 revealed interventions for Impaired Gas Exchange, Activity Intolerance, and Decreased Cardiac Output. There was no documentation for interventions for Foley catheter care or PICC line.

Interview on 01/17/23 at 2:20 p.m. with S2DON confirmed patient #3's care plan was not comprehensive to her care and did not include interventions for Foley catheter and PICC line.

Patient #18
Review of the medical record for Patient #18 revealed an admit date of 11/02/22 with diagnoses including debility, aftercare from CVA and seizure disorder.

Review of the patient's care plan revealed that seizures were not addressed.

Review of the nurses notes dated 11/10/22 revealed that the patient had a seizure and was transferred to the hospital.

On 01/18/23 at 1:05 p.m., S2DON reviewed the patient's care plan and confirmed that seizures was not addressed.




44763

Based on record review and interview, the hospital failed to ensure that all orders, including verbal orders, must be dated, timed and authenticated promptly by the ordering practitioner as stated in medical staff bylaws for 3 of 3 patient records reviewed for verbal orders (Patient #13, 14, 18).
Findings:

Review of the Medical Staff Bylaws - Responsibilities of the Membership revealed that all orders, including verbal orders, must be dated, timed and authenticated promptly by the ordering practitioner.

Patient #13
Review of the medical record revealed a physician telephone order dated 01/14/23 for a medication order. Further review revealed a physician signature under the telephone order with a date and time noted in a different pen color and hand writing.

Patient #14
Review of the medical record revealed a physician telephone order dated 12/02/22 for discharge orders. Further review revealed a physician signature under the telephone order with a date and time noted in a different pen color and hand writing.

Review of the medical record revealed a physician telephone order dated 11/23/22 for therapy orders. Further review revealed a physician signature under the telephone order with a date and time noted in a different pen color and hand writing.

Patient #18
Review of the medical record revealed a physician telephone order dated 11/03/22 for a medication order. Further review revealed a physician signature under the telephone order with a date and time noted in a different pen color and hand writing.

On 01/18/23 at 2:15 p.m., S2DON reviewed the above records and confirmed that the dates/times were not of the same writing as the physicians. S2DON further stated that the physicians should be dating and timing their signatures.

Based on record review and interview, the hospital failed to ensure each patient had a completed medical H&P examination documented no more than 30 days before or 24 hours after admission as evidenced by having incomplete H&Ps for 3 (Patient #1, 3, 7) of 9 (#1-9) current sampled patients charts reviewed for completion in a total sample of 20.
Findings:

Review of the hospital policy titled Documentation, Policy Number HIM 5.003, revealed in part: Documentation in the patient's medical record will include: 1. History and Physical within 24 hours.

Review of the Medical Staff Rules and Regulations revealed a history and physical shall be completed within 24 hours of admission.

Patient #1
Review of Patient #1's medical record revealed an admission date of 01/16/23 with admitting diagnoses including S/P COVID, hypertension, seizure disorder and aftercare CVA with paresis. Further review of the record revealed a History and Physical Exam dated 01/16/23 with documentation stating the patient's history/chief complaint was "see PAA" (Pre-Admission Assessment). The H & P further revealed history of present illness as "see PAA". Further review of the H & P revealed there were no documented vital signs or current medications listed.

Patient #3
Review of Patient #3's medical record revealed an admission date of 01/09/23 with admitting diagnoses including pneumonia and respiratory failure. Further review of the record revealed a History and Physical Exam dated 01/09/23 with documentation stating the patient's history/chief complaint was "see PAA" (Pre-Admission Assessment). The H & P further revealed a history of present illness as "see PAA". There was no family history, vital signs, current medications list, or assessment/diagnosis/plan documented on the H & P.

Patient #7
Review of Patient #7's medical record revealed an admission date of 01/11/23 with admitting diagnoses including encephalopathy, tachycardia and bilateral lower lung infiltrates. Further review of the record revealed a History and Physical Exam dated 01/11/23 with documentation stating the patient's history/chief complaint was "see PAA" (Pre-Admission Assessment). The H & P further revealed a history of present illness as "see PAA". There was no documented vital signs, current medications list, or assessment/diagnosis/plan.

Interview on 01/17/23 at 2:15 p.m. with S5RN revealed that the physicians document on the History and Physical to reference the "PAA". S5RN further stated that the documentation on the PAA is obtained from the referral source documentation prior to the patient's admission, and it does not always reflect patient's current findings.



44763

Based on observation and interview, the hospital failed to ensure outdated, mislabeled, or otherwise unusable drugs and biologicals were not available for patient use as evidenced by:
1) failing to remove expired emergency medications in the crash cart; and
2) failing to remove expired medications from the central supply room.
Findings:

1) Failing to remove expired emergency medications in the crash cart.

Review of the policy titled Pharmacy, Policy Number 2.05, revealed in part: Mabile's Pharmacy will maintain the medication trays that go into the crash carts.

Observation 01/17/23 at 11:15 a.m. of the emergency crash cart in the nurses station contained two Adenosine 6mg/2ml with manufacturer expiration date of 11/2022.

Interview on 01/17/23 at 11:20 a.m. with S4RN stated that the pharmacist checks the medications for expiration monthly.

Review of the Crash Cart Drug List and Expiration Drug Check Sheet revealed documentation that the crash cart was checked 12/18/22 and noted Adenosine expiration date of 11/2022.

2) Failing to remove expired medications from the central supply room.

Review of the hospital's policy titled Infection Control, Policy Number IC 5.005, revealed in part: Sterile supplies are rotated as new stock arrives to prevent use of an expired item. At that time, expiration dates are checked.

Observation on 01/17/23 at 11:20 a.m. of the central supply room revealed:
3 of 5 5% dextrose and 0.45% Sodium Chloride Injection 1000mL bags with an expiration date of 12/2022.

In an interview on 01/17/23 at 11:31 a.m. S7HK verified the above IV fluids to be expired.




44763

Based on observation and interview, the hospital failed to ensure all equipment was maintained in a manner to ensure an acceptable level of safety and/or quality as evidenced by failing to ensure the functionality of a nurse call button located on the handrails of 12 of 12 inpatient beds.
Findings:

On 01/17/23 at 10:45 a.m., observation of unoccupied inpatient rooms (a, b, c) revealed the patient beds had non-functional nurse call buttons on the side rails of the beds. The nurse call button on the beds were pressed by the surveyor during the observations and no alert of any type was generated when it was pressed.

On 01/17/23 at 10:50 a.m., S1ADM confirmed that the nurse call buttons on all current 12 inpatient beds were not functional.



17450

Based on observation and interview, the hospital failed to ensure the infection prevention and control program included maintaining a clean and sanitary environment to avoid sources and transmission of infection. This deficient practice was evidenced by failing to maintain a sanitary environment where the clean linen and equipment was stored.
Findings:

In an observation on 01/17/23 at 11:45 a.m. of the portable storage building where the clean linen and equipment were stored revealed multiple clean linen packages opened exposing patient blankets, sheets, and gowns. Further observations revealed several beetle looking insects crawling on the exposed patient blankets, by the window and flying throughout the portable storage building. There were also several spider nests/eggs located on the walls. There was also clean equipment used in patient care stored in this same portable building that was not covered.

In an interview during this observation, S1ADM verified this was where the clean linen and equipment was stored. She stated the beetle looking insects were "Japanese Beetles".