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Based on observations, interview, and record review, the hospital failed to ensure the Governing Body functioned effectively and held the ultimate responsibility for the hospital's compliance, not only with the specific standards of the Governing Body Condition of Participation (CoP), but also with all of the CoPs for the provision of services, as evidenced by:

1. Failed to ensure its Medical Staff's Bylaws were approved by the Governing Body. This failure had the potential for the hospital to not be compliant with current laws and may not reflect the organization's current practices.
(Cross Reference A-0048).

2. Failed to ensure one of three contracted services was evaluated to ensure the contracted off-site telemedicine service (Contractor 2) was provided in a safe and effective manner.
(Cross Reference A-0084).

3. Failed to maintain the list of all contracted services to include the scope and nature of services provided.
(Cross Reference A-0085).

4. Failed to ensure there was a hospital-wide Quality Assurance Performance Improvement (QAPI) program.
(Cross Reference A-0263, A-0273, A-0283, A-0297).

5. Failed to maintain the hospital facilities and equipment, to meet the needs of all patients, and adequately ensure life safety from fire requirements were met. [DUPLICATE - WRITTEN DIRECTLY BELOW AS WELL]
(Cross Reference A-0700, A-0701, A-0713).
Adequately ensure life safety from fire requirements are met.
(Cross Reference K161, K223, K293, K321, K324, K342, K345, K353, K355, K363, K712, K761, K781, K904, K918, K919, K920 and K923).

6. Failed to ensure Rehabilitation Services met the needs of all patients.
(Cross Reference A-1123, A-1124, A-1125, A-1134).

7. Failed to meet the needs of the patients who required Respiratory Care Services.
(Cross Reference A-1151, A-1154, A-1160, A-1164).

The cumulative effects of these systemic problems resulted in the hospital's inability to provide Rehabilitation Services in a safe and effective manner, in accordance with the statutorily-mandated Conditions of Participation for Rehabilitation Services; the hospital's inability to develop, implement and maintain an effective, ongoing, hospital-wide, data-driven Quality Assessment and Performance Improvement (QAPI) program, in accordance with the statutorily-mandated Conditions of Participation for Quality Assurance Performance Improvement; the hospital's inability to provide a safe environment, in accordance with statutorily-mandated Condition of Participation Physical Environment; and, the hospital's inability to provide well-organized Respiratory Services, with the statutorily-mandated Conditions of Participation Respiratory Services.

Based on interview, and document review, the hospital failed to ensure there was a hospital-wide Quality Assurance Performance Improvement (QAPI) program, as evidenced by:

1. The hospital failed to ensure an effective performance improvement program for identified hospital services, which accurately reflected the depth and scope of departmental operations, to ensure services furnished were evaluated on a routine basis, to identify quality and performance problems, implement appropriate corrective or improvement activities, and to ensure the monitoring and sustainability of those corrective or improvement activities.
(Cross Reference A 273).

2. The hospital failed to ensure an effective performance improvement program for identified hospital services, which accurately reflected the depth and scope of departmental operations, to ensure services furnished were reviewed on a routine basis, to identify quality and performance problems, implement appropriate corrective or improvement activities, and to ensure the monitoring and sustainability of those corrective or improvement activities.
(Cross Reference A 283).

3. The hospital failed to ensure that performance improvement activities: 1) fully evaluated the depth and scope of the department; and, 2) demonstrated opportunities for improvement. Performance improvement activities, limited to monitoring of quality indicators that demonstrated hospital compliance, resulted in missed opportunities to identify areas of improvement. (Cross Reference A 297).

The cumulative effect of these systemic problems resulted in the hospital's failure to meet statutorily-mandated compliance with the Condition of Participation for Quality Assurance Performance Improvement.

Based on interview and record review, the hospital failed to provide an organized Nursing
Service for one of 31 sampled patients (Patient 18) as evidenced by:

1. The hospital failed to have a staffing system in place based on the number and acuity of patients. Patients would not receive nursing care based on their individual, sudden or emergent nursing/medical needs. (Cross Reference A-0392).

The cumulative effect of these systemic problems resulted in the hospital's failure to meet statutorily-mandated compliance with the Condition of Participation for Nursing Services.

Based on observation, interview, and document review, the hospital failed to maintain the hospital facilities and equipment to meet the needs of all patients, as evidenced by failure to:

1. Adequately maintain the hospital's buildings and equipment (both facility equipment and patient care equipment).
(Cross Reference A-0701).

2. Properly store and dispose of trash.
(Cross Reference A-0713).

3. Adequately ensure life safety from fire requirements were met.
(Cross Reference K161, K223, K293, K321, K324, K342, K345, K353, K355, K363, K712, K761, K781, K904, K918, K919, K920 and K923).

The cumulative effect of these systemic problems resulted in the hospital's failure to meet statutorily-mandated compliance with the Condition of Participation for Physical Environment.

Based on observation, interview, and document review, the hospital failed to ensure Rehabilitation Services met the needs of all patients, as evidenced by failure to:

1. Adequately staff the Rehabilitation (Rehab) Services department, which resulted in missed sessions with occupational and physical therapists.
(Cross Reference A-1124).

2. Ensure the Rehab Services department had the oversight of a Director of Rehab Services.
(Cross Reference A-1125).

3. Develop treatment plans for patients receiving Rehab Services which included a documented frequency and duration for receiving occupational therapy sessions.
(Cross Reference A-1134).

The cumulative effect of these systemic problems resulted in the hospital's failure to meet statutorily-mandated compliance with the Condition of Participation for Rehabilitation Services.

Based on interview, and document review, the hospital failed to meet the needs of the patients who required Respiratory Care Services, as evidenced by:

1. The hospital failed to ensure there were two licensed respiratory practitioners on duty at all times.
(Cross Reference A-1154).

2. The hospital failed to ensure patients received the prescribed respiratory treatments, as ordered.
(Cross Reference A-1154).

3. The hospital failed to ensure the recommended preventive maintenance schedule was developed and implemented, per manufacturer's recommendations.
(Cross Reference A-1160).

4. The hospital failed to ensure an effective performance improvement program to analyze staffing, missed treatments and preventative maintenance schedules, in accordance with acceptable standards.
(Cross Reference A-1151 and A-0263).

The cumulative effect of these systemic problems resulted in the hospital's failure to meet statutorily-mandated compliance with the Condition of Participation for Respiratory Services.

Based on interview and document review, the hospital failed to ensure the Medical Staff's Bylaws were approved by the Governing Body. This failure had the potential for the hospital to not be compliant with current laws and may not reflect the organization's current practices.

Findings:

During a concurrent interview and document review on 8/18/22 at 1:50 p.m., Administrative Staff I confirmed the hospital's Medical Staff's Bylaws were approved 8/24/21.

Review of the Governing Body Meeting Minutes, dated 6/30/22 and 3/29/22, the Medical Staff Medical Executive Meeting/Governing Body Minutes, dated 1/18/22, and Medical Staff Governing Body Meeting Minutes, dated 12/16/21, did not document the Governing Body had approved the medical staff bylaws before the bylaws would be considered effective.

Based on interview, and administrative record review, the hospital failed to ensure one of three contracted services were evaluated to ensure the contracted off-site telemedicine service (Contractor 2) was provided in a safe and effective manner. The hospital did not implement a Quality Assessment and Performance Improvement program (QAPI), to ensure services, furnished under contract, were reviewed on a routine basis to identify quality and performance problems, implement appropriate corrective or improvement activities, and to ensure the monitoring and sustainability of those corrective or improvement activities. This failure resulted in the potential patient care service areas would be accessed by unauthorized persons.

Findings:

During an interview, on 8/27/33 at 9:30 a.m., Administrative Staff B and Administrative Staff E provided the requested contractor review documents. Administrative Staff E confirmed the Contract Review Sheet, used by the hospital to evaluate contracted services, was incomplete. Contractor 2 provided telemedicine services for the hospital.

During an administrative record review of the, "Vendor Contract Review 2022," included the list of 67 vendors, the nature and scope of services was not provided. The list of contracted services did not include services provided by Contractor 2 (telemedicine services).

Review of the, "CONTRACT REVIEW SHEET," dated 3/20/22, did not include the name/title of the reviewer, did not include whether or not the contractor met or did not meet applicable evaluation criteria, did not include department manager/reviewer information, and did not include whether the hospital would renew the contract.

Based on interview and document review, the hospital failed to maintain the list of all contracted services to include the scope and nature of services provided. This failure could result in services performed under a contract to be provided in a safe and effective manner.

Findings:

During a concurrent interview and document review on 8/17/22 at 9:30 a.m., with Administrative Staff B and Administrative Staff D, the vendor contract list was requested and provided. Review of the, "Vendor Contract Review 2022," indicted three columns, Department/Vendor Name, Date Last Reviewed and To Be Reviewed. The vendor contract list did not provide the delineation of contractor responsibility.

The, "Vendor Contract Review 2022," list did not contain the name of Contractor 1. Administrative Staff B and Administrative Staff D confirmed Contractor 1 had been in place for the past two to four months. Review of Contractor 1's contract, revealed it was last reviewed on 2/17/21 and was signed by the Governing Body President on 9/29/21.

Based on administrative staff interview, and document review, the hospital failed to ensure an effective performance improvement program, for identified hospital services, which accurately reflected the depth and scope of departmental operations, to ensure services furnished were evaluated on a routine basis to identify quality and performance problems, implement appropriate corrective or improvement activities, and to ensure the monitoring and sustainability of those corrective or improvement activities.

Failure to develop a comprehensive program that identified opportunities for improvement, may result in compromised patient outcomes in relationship to the patience care services provided.

Findings:

On 8/23/22 at 1:40 p.m., the hospital's performance improvement plan was reviewed with Administrative Staff E. He described a program that was implemented by the Performance Improvement Committee. It was noted the program was limited to evaluating Rapid Response (change in condition), grievances/complaints, transfers, the results of resuscitation (code blue) medication management and safety, restraints, processes that improved patient outcomes (LTRAX), infection prevention program, environment of care and safety program. He stated the hospital's Performance Improvement Committee had not chosen performance improvement indicators from Respiratory Services, Rehabilitation Services, or environment of care services, specific to equipment maintenance, to demonstrate the hospital was able to improve health outcomes.

Review of the hospital document titled, "QUALITY ASSESSMENT PERFORMANCE IMPROVEMENT PLAN," revised 11/2021, indicated the scope of the plan reflected the organization and services; involved all hospital departments and services, including those services furnished under contract or arrangements, and focused on indicators related to improve health outcomes and prevention and reduction of medical errors.

There was no documentation the hospital ensured a comprehensive performance improvement program was implemented, which demonstrated opportunities for improvement, in relationship to the provision of patient care services provided, to include Respiratory Services, Rehabilitation Services, and the environment of care specific to equipment maintenance.

Based on administrative staff interview, and document review, the hospital failed to ensure an effective performance improvement program, for identified hospital services, which accurately reflected the depth and scope of departmental operations, to ensure services furnished were evaluated on a routine basis to identify quality and performance problems, implement appropriate corrective or improvement activities, and to ensure the monitoring and sustainability of those corrective or improvement activities.

Failure to develop a comprehensive program that identified opportunities for improvement, may result in compromised patient outcomes in relationship to the patience care services provided.

Findings:

On 8/23/22 at 1:40 p.m., the hospital's performance improvement plan was reviewed with Administrative Staff E. He described a program that was implemented by the Performance Improvement Committee. It was noted the program was limited to evaluating Rapid Response (change in condition), grievances/complaints, transfers, the results of resuscitation (code blue) medication management and safety, restraints, processes that improved patient outcomes (LTRAX), infection prevention program, environment of care and safety program. He stated the hospital's Performance Improvement Committee had not chosen performance improvement indicators from Respiratory Services, Rehabilitation Services, or environment of care services, specific to equipment maintenance, to demonstrate the hospital was able to improve health outcomes.

Review of the hospital document titled, "QUALITY ASSESSMENT PERFORMANCE IMPROVEMENT PLAN," revised 11/2021, indicated the scope of the plan reflected the organization and services; involved all hospital departments and services, including those services furnished under contract or arrangements, and focused on indicators related to improve health outcomes and prevention and reduction of medical errors.

There was no documentation the hospital ensured a comprehensive performance improvement program was implemented, which demonstrated opportunities for improvement, in relationship to the provision of patient care services provided, to include Respiratory Services, Rehabilitation Services, and the environment of care, specific to equipment maintenance.

Based on observation, administrative staff interview, and document review, the hospital failed to ensure an effective performance improvement program for identified hospital services, which accurately reflected the depth and scope of departmental operations, to ensure services furnished were evaluated on a routine basis to identify quality and performance problems, implement appropriate corrective or improvement activities, and to ensure the monitoring and sustainability of those corrective or improvement activities.

Failure to develop a comprehensive program that identified opportunities for improvement may result in compromised patient outcomes in relationship to the patience care services provided.

Findings:

On 8/23/22 at 1:40 p.m., the hospital's performance improvement plan was reviewed with Administrative Staff E. He described a program that was implemented by the Performance Improvement Committee. It was noted the program was limited to evaluating Rapid Response (change in condition), grievances/complaints, transfers, the results of resuscitation (code blue) medication management and safety, restraints, processes that improve patient outcomes (LTRAX), infection prevention program, and environment of care and safety program. He stated the hospital's Performance Improvement Committee had not chosen performance improvement indicators from Respiratory Services, Rehabilitation Services, or environment of care services, specific to equipment maintenance, to demonstrate the hospital was able to improve health outcomes.

During a concurrent observation and interview, on 8/19/22 at 8:45 a.m., Occupational Therapist (OT) A stated the department had recently implemented the white board, located on the wall in the department, demonstrating the current patients requiring Rehabilitation Services. When asked how the department evaluated short-staffing schedules and patient-missed treatments, she stated, through emails. She stated the rehabilitation department did not implement a Quality Assurance Performance Improvement project within the department on the inability to provide Rehabilitation Services, due to short-staffing, resulting in patient-missed treatments.

During an interview and document review on 8/23/22 at 1:40 p.m., Administrative Staff E confirmed the Quality Assurance and Performance Improvement (QAPI) committee had not evaluated the preventative maintenance and testing activities, and the hospital had not incorporated the preventative maintenance and testing activities in the hospital's QAPI plan.

Administrative Staff B confirmed the hospital had not developed a process and procedure to track Equipment V ventilators and include the Equipment V ventilators in the hospital's preventative maintenance program. Administrative Staff B confirmed the hospital had not developed a Quality Assurance and Performance Improvement program to ensure Equipment V ventilators were maintained, per the manufacturer's recommendations.

Administrative Staff B stated he was the current interim respiratory department director. Administrative Staff B stated the respiratory department did not have a Quality Assurance Performance Improvement project for the evaluation of short staffing issues and missed respiratory therapy treatments.

Review of the hospital document titled, "QUALITY ASSESSMENT PERFORMANCE IMPROVEMENT PLAN," revised 11/2021, indicated the scope of the plan reflected the organization and services; involved all hospital departments and services, including those services furnished under contract or arrangements, and focused on indicators related to improve health outcomes and prevention and reduction of medical errors.

There was no documentation the hospital ensured a comprehensive performance improvement program was implemented, which demonstrated opportunities for improvement, in relationship to the provision of patient care services provided, to include Respiratory Services, Rehabilitation services, and the environment of care, specific to equipment maintenance.

Based on interview and record review, the hospital: 1. Did not provide adequate staffing to keep one of 31 sampled patients (Patient 18) safe from falls. This failure resulted in Patient 18 falling out of her bed; and, 2. Did not provide adequate staffing in the Intensive Care Unit (ICU). This failure had the potential to compromise patient and staff safety.

Findings:

1. During a record review on 8/19/22 at 1:30 p.m., Administrative Staff F opened Patient 18's electronic medical record. Patient 18's history and physical (H&P), dated 6/8/22, indicated she had been transferred to the hospital on 6/8/22, with multiple diagnoses including seizures, acute respiratory failure resulting in artificial ventilation, vocal cord paralysis, and microcytic anemia (red blood cells that are too small to carry oxygen throughout the body, resulting in fatigue). The H&P also indicated the plan of care included physical and occupational therapy reconditioning.

Patient 18's Nursing Progress Note, dated 6/28/22, indicated the Certified Nursing Assistant (CNA) found Patient 18 on the floor, and a sitter had been assigned to Patient 18 at that point. On Patient 18's nursing daily assessment, dated 7/9/22 at 9 p.m., Licensed Nurse H (LN H) indicated she had a fall risk score of 85 (score of over 25 indicates high risk for falls). Patient 18's nursing assessment note, written by LN H, dated 7/10/22 at 1:05 a.m., indicated, "Pt (patient) had unwitnessed fall. On assessment no indication of injury, head trauma or bleeding. Pt has history of seizures and had signs of seizure after fall. . . ." Patient 18's Fall Flowsheet, dated 7/10/22 at 1:05 a.m., indicated, "No sitter was able to be present, understaffed."

Review of the hospital census, dated 7/9/22, indicated there were 30 patients on the medical-surgical unit. LN H was assigned four patients, including Patient 18. Patient 18 was assigned an acuity level (a measurement of the intensity of nursing care required) of, "1 (one)" (lowest acuity level). For the remaining three patients assigned to LN H, the spaces to indicate an acuity level were blank. Review of the document, "Daily Staffing Plan," dated 7/9/22, indicated there were three CNAs scheduled to work NOC shift (7 p.m. to 7 a.m.), but all three had, "C/O" (called off) written next to their names.

During an interview on 8/23/22 at 3:30 p.m., Administrative Staff B verified there were no CNAs working NOC shift on 7/9/22. Administrative Staff B stated, when they were short staffed, they put out a request to all staff with an offer of overtime and a bonus for working extra. Administrative Staff B stated when they were short of CNAs, it put everyone behind (in their work) and the outcome for patients was, "not good."

During an interview on 8/23/22 at 3:50 p.m., LN H verified she worked NOC shift on 7/9/22. LN H stated she recalled Patient 18's fall during that shift. LN H stated Patient 18 was in soft mitten restraints that were tied to the side of the bed, and she had all four side rails up. LN H stated Patient 18 fell trying to get out of bed, but LN H did not know why Patient 18 was trying to get up. LN H stated Patient 18 could not stand up. LN H stated Patient 18 was really small, and she had slipped out of the mittens and then slid between the side rails. LN H stated, to keep Patient 18 safe from falls she charted outside her room, had a bed alarm on, and made the others nurses aware that she was high-risk for falls so they could check on her. LN H stated she felt they were understaffed that night, which she felt affected patient safety. LN H stated she had requested a sitter for Patient 18 at the beginning of her shift, but when the supervisor made the calls to staff, no one could come in to sit with her. LN H stated, if Patient 18 had a sitter, she would not have fallen.

A copy of the sitter request form LN H filled out on 7/9/22, was requested but not provided.

Review of hospital policy, "Fall," last revised 1/18/22, indicated, "The current literature also supports that the greatest risk predictor for in-hospital fall is a previous fall. For those patients deemed at high fall risk due to . . . history of fall, additional precautions called --Enhanced Fall Prevention strategies will be implemented as applicable." The policy indicated the, "Enhanced Fall Reduction Strategies" included, "Consideration for bedside sitter as needed."

Review of hospital policy, "Acuity Staffing," last revised 6/30/22, indicated, "Staffing schedules are developed based on the dynamics of the patients [sic] acuity and the complexity of the assessment required. . . . RNs will use --Patient Acuity worksheet at the end of each shift for oncoming shift acuity score."


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2. During the tour and observation of the Intensive Care Unit (ICU) on 8/16/22 at 1:10 p.m., the ICU had a census of five patients. The ICU was licensed to care for five critically-ill patients. There were two registered nurses assigned to care for the five patients. The licensed nurse-to- patient ratio should be one licensed nurse to two patients or fewer patients at all times in an ICU. (Reference California Code of Regulations Title XXII. Social Security. Division 5. Licensing and Certification of Health Facilities. Nursing Service Staff. 70217 (a)(1)).

Review of the ICU census and staffing schedules for the following dates: 8/3/22, 8/6-8/9/22, 8/11-8/18/22, day shift, indicated a census of five patients for each day and two registered nurses.

Review of the ICU staffing schedules for the period of 8/3/22 - 8/18/22, night shift, indicated a census of five patients for each night and two registered nurses.

During an interview on 8/22/22 at 2:07 p.m., Administrative Staff B confirmed the hospital staffed the ICU with two nurses for both day shift and night shift with a census of five patients. If staff need assistance, the staff were to call for help.

Review of the policy and procedure titled, "ADMISSION TRANSFER TO ICU," last reviewed 6/30/22, indicated, "...COMPLEXITY OF CARE: Admission to the Intensive Care Unit is based upon the need for acute inpatient hospital services...requiring continuous observation and medical services intervention to prevent complications and promote wellness...The scope of services includes higher level medical nursing care, including cardiac monitoring, the treatment of respiratory conditions requiring continuous oxygenation to the patient via mask or cannula; ventilator care..."

Based on observation, interview and document review, the hospital failed to: 1. Maintain the biohazard storage area; 2. Maintain the loading zone; and, 3. Ensure preventative maintenance and testing was performed on patient care equipment. This had the potential to increase hazard risks to patients, staff and visitors.

Findings:

1. During a concurrent tour of the hospital grounds and interview on 8/16/22 at 3:20 p.m., Administrative Staff C confirmed the biohazard storage area was unkept, being used as a storage for non-biohazard waste and had not had safety rounds or removal of the biohazard trash in the biohazard storage area for two months.

During an observation and concurrent interview on 8/16/22 at 2:15 p.m., Administrative Staff D stated, "This area has been a little neglected. We need to address this right away, [Administrative Staff C]!"

2. a. During a concurrent tour of the hospital grounds and interview on 8/16/22 at 3:20 p.m., Administrative Staff C confirmed the area of the loading zone had three one-gallon containers containing dialysis bath. Administrative Staff C could not state why the gallon containers were on the ground or how long the gallon containers were on the ground. Administrative Staff C confirmed the top of each gallon container was covered with a black dirt-like substance.

b. During a concurrent tour of the hospital grounds and interview on 8/16/22 at 3:20 p.m., Administrative Staff C confirmed the area of the loading zone had one 35-gallon container, storing canola liquid frying oil. Administrative Staff C could not state why the 35 gallons of canola oil was on the ground or how long the 35 gallons of canola oil was on the ground.
Administrative Staff C could not state when he had last made safety rounds in this area.

3. a. During an observation and concurrent interview on 8/16/22 at 1:30 p.m., Patient 20 was in bed in his room. When asked if he had any concerns with his room, Patient 20 stated he had no shades on the middle window of his room. Patient 20 stated, "People can see me naked." The room had three windows, the outer two windows were covered with blinds, and the middle window, which looked out onto a parking lot and walkway up to the building, had no blinds. Patient 20's bed was positioned right in front of the windows.

During a concurrent tour of the hospital and interview on 8/22/22 at 10:25 a.m., with Administrative Staff, C, Patient 20's room had three windows. Administrative Staff C confirmed the middle window did not have a window blind present.

b. During a concurrent tour of the hospital and interview on 8/22/22 at 10:34 a.m., with Administrative Staff C, Room 120's window bed had a pole containing three infusion pumps. Two of the infusion pumps, identified as BEC Number 8, had the biomedical preventative maintenance sticker in place denoting BEC Number 8 was due for testing and preventative maintenance in 2021. One of the infusion pumps, identified as BEC Number 7, had infusion tubing threaded through the pump. BEC Number 7 was due for testing and preventive maintenance in 2019.

During a concurrent tour of the biomedical work and storage area and interview with Administrative Staff C on 8/22/22 at 10:55 a.m., observation revealed approximately 22 individual pieces of patient care equipment, with dated red tags denoting, "Defective Do Not Use." In the annex area, 11 hospital-grade patient beds were being stored. Administrative Staff C confirmed the equipment was waiting for evaluation and repairs.

During a concurrent interview and review of the biomedical services, "...Filtered Assets List...," on 8/22/22 at 10:25 a.m., the document indicated 18 pages of hospital patient care equipment denoting in the last column, the last scheduled preventative maintenance date. Administrative Staff C and Administrative Staff D confirmed the hospital had not evaluated the Filtered Assets List for completeness. Review of the Filtered Assets List demonstrated the hospital's 162 line items/281 line items, or 58 percent, of the patient care equipment contained in the Filtered Assets List, were past due for scheduled preventative maintenance.

During an interview and document review on 8/23/22 at 1:40 p.m., Administrative Staff E confirmed the Quality Assurance and Performance Improvement (QAPI) committee had not evaluated the preventative maintenance and testing activities, and the hospital had not incorporated the preventative maintenance and testing activities in the hospital's QAPI plan.

c. During an interview on 8/22/22 at 1:15 p.m., Administrative Staff B stated the hospital had been using the Equipment V ventilators for approximately one and one-half years. The biomedical service preventative maintenance asset list was requested and reviewed with Administrative Staff B. The ten Equipment V ventilators were not included in the asset list; only the Equipment W ventilators were listed. Administrative Staff B confirmed the hospital had not developed a process and procedure to track Equipment V ventilators and include the Equipment V ventilators in the hospital's preventative maintenance program. Administrative Staff B confirmed the hospital had not developed a Quality Assurance and Performance Improvement program to ensure Equipment V ventilators were maintained, per the manufacturer's recommendations.

Review of the [Equipment V] Clinical and Technical Manual pages 10-1, 10-3 and 10-7, indicated recommended maintenance tasks at recommended intervals.
Page 10-1, "...The organization responsible for the use and maintenance of [Equipment V] should perform all adjustment, cleaning, and disinfection of [Equipment V]. Follow all instructions provided in this Clinical and Technical manual to prevent damage to [Equipment V] during cleaning and maintenance procedures..."
Page 10-3, "...Clean the air and fan filters every two weeks to ensure [Equipment V] internal components are protected from dirt and dust. Replace the filters every six months, or as needed due to damage..."
Page 10-7, "...Every month during use...Replace the [Equipment V] Bacterial Filter and Nebulizer Filter..."

Based on observation, interview and document review, the hospital failed to properly store and dispose of trash. This had the potential for increased risk of exposure of potential hazards for employees and visitors.

Findings:

During a concurrent tour of the hospital grounds and interview, on 8/16/22 at 3:20 p.m., Administrative Staff C confirmed there were two dumpsters overflowing with large trash bags approximately four feet above the rim of the dumpsters. Both dumpsters lids were open and Administrative Staff C confirmed the dumpsters were over filled, and the dumpster lids were not able to cover the trash. Behind the two dumpsters was a box approximately 8 feet by 10 feet located on the ground with several filled large trash bags. Administrative Staff D confirmed the box contained more than 15 filled large trash bags. Administrative Staff C confirmed the refuse company collected trash on Tuesdays. Administrative Staff C could not state when the last time the refuse company collected the trash. Administrative Staff C could not state when he had made safety rounds in this area.

Review of the policy and procedure titled, "Waste - Regular Waste Handling," revised 8/3/22, indicated, "...Regular hospital waste (non-infectious) will be handled, transported and disposed of in a manner that keeps staff and patients safe from injury and/or contamination..."

Based on observation, interview, and record review, the hospital failed to adequately staff the Rehabilitation (Rehab) Services Department when the department had open positions for the director of Rehab Services, a Physical Therapist, a Physical Therapy Assistant, and a Restorative Nursing Assistant. This failure resulted in missed sessions with Occupational and Physical Therapists for eight of 31 sampled patients (Patients 3, 4, 17, 18, 22, 23, 27, 30,) and potentially resulted in patient functional decline or delayed progress towards goals.

Findings:

1. During an entrance conference on 8/16/22 at 12:31 p.m., Administrative Staff D stated he had started the licensing process for adding 17 new beds to the hospital.

During an observation and concurrent interview on 8/17/22 at 10:44 a.m., Patient 22 was in his room lying in bed. Patient 22 stated he had been at the hospital for two weeks. When asked if he was receiving Rehab Services, Patient 22 stated, "They keep saying they will come by to go on walks, but they haven't done it." Patient 22 verified he had asked hospital staff about getting rehab. When asked about the hospital's response, Patient 22 stated, "They say, 'We'll do it,' but they don't." When queried, Patient 22 stated he felt his joints in his arms and legs were getting stiffer from lack of exercise.

During a record review and concurrent interview on 8/18/22 at 4:51 p.m., Administrative Staff F opened Patient 22's Electronic Medical Record. Patient 22's History and Physical (H&P), dated 8/9/22, indicated Patient 22 was admitted to the hospital on 8/9/22, with multiple diagnoses including right tonsillar B-cell carcinoma, diabetes mellitus (disease that results in too much sugar in the blood), and neuropathy (weakness or numbness, usually in the hands or feet, caused by nerve damage). Patient 22's H&P also indicated Patient 22 was transferred to the hospital after he had, "a pretty prolonged hospital course" and, "he remains profoundly weak deconditioned." Patient 22's Occupational Therapist (OT; encourages rehabilitation through the performance of activities required in daily life) and Physical Therapist (PT; treats disease, injury or deformity by physical methods such as massage, heat treatment, or exercise) initial interview notes, both dated 8/11/22, indicated they would each see Patient 22 two to four times per week. Review of Patient 22's PT documentation revealed one PT session on 8/17/22 at 2:51 p.m., six days after the initial interview with PT. The PT session note indicated, "Pt (patient) eager to participate w/therapy, 'I am proud of how far I walked.' Per nursing pt's [blood pressure] under control today." Patient 22's chart did not contain any documentation of OT sessions. Administrative Staff F verified there were no documented OT sessions after the initial interview on 8/11/22. Administrative Staff F did not comment when queried about Patient 22 not having any documented OT sessions for seven days after the initial interview on 8/11/22. Administrative Staff B stated he would expect the therapist to document any attempts to see the patient.

During a record review and concurrent interview on 8/18/22 at 5:11 p.m., Administrative Staff F opened Patient 23's Electronic Medical Record. Patient 23's H&P, dated 8/2/22, indicated he had been admitted to the hospital on 8/2/22, for an extended course of intravenous antibiotics for cervical osteomylitis (infection of the bones of the neck). Patient 23's OT initial interview note, dated 8/3/22, indicated the plan of care was for OT to see Patient 23 two to four times per week. Review of Patient 23's record revealed no documented OT sessions, which was verified by Administrative Staff F.

During an interview on 8/19/22 at 8:45 a.m., OT A stated she had gone to see Patient 22 on 8/17/22, to work with him, but he was, "really out of it." OT A stated she should have documented her attempt to work with him. OT A stated, "Our practice is to write a missed visit note." When asked if she had attempted to work with him between 8/11/22 and 8/17/22, OT A stated, "Probably not, he's very ill and we have a very heavy case load." OT A stated she had 25 patients to see this week. OT A stated the rehab staff did not always see who they needed to see because of their heavy case load. OT A stated they did not currently have a director of Rehab Services. When queried, OT A stated the start date for therapy sessions was not documented in the plan of care, and the reason for missed visits was not typically discussed with the patient. When asked what could be the outcome for patients who did not get the Rehab Services that were ordered, OT A stated she was not going to speculate on that. When asked about Patient 23, OT A stated she had seen him up and moving around, so she had discharged him from OT. OT A stated she should have documented that he was discharged. OT A stated that charting missed visits was very time consuming, and she did not always have the time to complete them. OT A stated she was fully aware that if she did not document it, it did not happen.

During the same interview and concurrent observation on 8/19/22 at 8:45 a.m., OT A stated Rehab Services were provided Sunday through Saturday, and the rehab staff worked four 10-hour shifts per week. PT G stated the rehab staff did not schedule ahead of time on which days a patient would be seen. PT G stated they had a PT assistant who left in February, and since then it had been difficult getting to all the sessions. PT G stated, if the hospital added the 17 patients to the new hall, the caseload would be unmanageable without a PT assistant. When asked about what system they used to track who had been seen and how many sessions per week the patients had received, OT A pointed at the white board behind them and stated they had all the patients names written on the white board, and they put a dot next to each patient as they were seen. A large white board on the wall had patient names written in a table. Several patient names had one dot next to the name, the remaining names did not have a dot. When asked why none of the patients had more than one dot next to their name, PT G stated the board had not been updated for two days, and OT A stated it was, "just a rough draft." OT A stated they also had a report they could run which would show who had been seen and when.

During a record review on 8/19/22 at 1:30 p.m., Administrative Staff F opened Patient 18's Electronic Medical Record. Patient 18's H&P, dated 6/8/22, indicated she had been transferred to the hospital on 6/8/22, with multiple diagnoses including seizures, acute respiratory failure resulting in artificial ventilation, vocal cord paralysis, and microcytic anemia (red blood cells that are too small to carry oxygen throughout the body, resulting in fatigue). The H&P also indicated the plan of care included PT and OT reconditioning. Patient 18's PT initial interview, dated 6/9/22, indicated PT sessions would be two to four times per week. Review of Patient 18's PT sessions revealed she had PT sessions on 6/15/22 (one visit over a 12 day period), 6/21/22, 6/22/22, and 6/28/22. On 7/1/22, PT G entered a missed visit note indicating Patient 18 refused PT due to lethargy, "Will check back." No further PT sessions or missed visit notes were documented. Patient 18 was discharged on 7/13/22.

Patient 18's OT initial interview note, dated 6/9/22, indicated Patient 18 would benefit from OT, but the plan did not indicate a frequency of sessions. Patient 18's OT initial interview note also indicated she currently needed maximum assistance to caregiver-dependent for Activities of Daily Living (ADLs). Patient 18's short-term goals were listed as: 1. Patient to come to edge of bed with minimum assistance to increase participation overall in ADLs; 2. Patient to perform edge of bed ADL of choice with minimum assistance; and, 3. Patient to tolerate out of bed for greater than 25 minutes to participate in ADL of choice. Review of Patient 18's OT sessions indicated she had sessions on 6/15/22, 6/19/22, 6/22/22, and 7/10/22 (a gap of 18 days), dedicated to working towards these goals. On 7/1/22, OT A documented a missed visit. All other OT sessions documented were dedicated to working on Patient 18's swallowing goals.

During an interview on 8/19/22 at 3:50 p.m., OT A stated the frequency of sessions for OT should be in the plan of care documented in the initial interview note. When asked about the frequency of OT sessions for Patient 18, OT A stated Patient 18 needed more swallowing therapy than OT. When asked about Patient 18's PT sessions after 7/1/22, PT G stated it was due to Patient 18's pain issues, but then PT G stated it was because she (PT G) was on vacation and she had no PT coverage. PT G stated, "I'm the only PT." PT G stated Administrative Staff B and Human Resources were responsible for arranging for her coverage. OT A stated the Rehab Department was very short-staffed.

During an interview on 8/19/22 at 4 p.m., Administrative Staff B stated that whenever PT G went on vacation, he would try to get a traveler PT from an agency to cover her. During a subsequent interview at 4:25 p.m., Administrative Staff B stated he checked the travel agency log and did not see there was any PT coverage for PT G's vacation in July.

During a record review and concurrent interview on 8/22/22 at 10:24 a.m., Administrative Staff B opened Patient 30's Electronic Medical Record. Patient 30's H&P, dated 6/29/22, indicated he was transferred to the hospital on 6/29/22, with multiple diagnoses including substance abuse, abscess (pocket of pus) in epidural space (one of the layers of the spinal cord) of the cervical spine, and heart failure. Patient 30's H&P indicated he was, "profoundly deconditioned," and he was admitted to the hospital for intravenous antibiotics and to, "continue with aggressive OT PT evaluation." Patient 30's Discharge Summary, dated 7/29/22, indicated Patient 30 was discharged on 7/29/22, to a Skilled Nursing Facility. Patient 30's OT initial interview, dated 6/30/22, indicated OT sessions would be once a week with increased frequency as tolerated. Patient 30's short-term goals were listed as: 1. Patient to follow 50% commands with minimal assistance to progress overall ADL return; and, 2. Patient to tolerate sitting at edge of bed, with good balance, for more than 15 minutes to progress ADL activity. Review of Patient 30's OT sessions revealed he had sessions on 7/2/22, 7/18/22, and 7/25/22, dedicated to these goals. All other documented OT sessions were dedicated to working on Patient 30's swallowing goals. Administrative Staff B verified the plan of care indicated OT once per week to work on ADLs, not swallowing. Administrative Staff B also verified a gap of 16 days between 7/2/22 and 7/18/22, and there were no missed visit notes documented.

Patient 30's PT initial interview note, dated 6/30/22, indicated, "Pt presents w/ increased risk for contractures (permanently stiff joints)/wounds. Requires RNA (Restorative Nursing Assistant) services for PROM (Passive Range Of Motion, movement of a joint without the patient using their muscles)/positioning." The note further indicated the plan was for RNA services one to three times a week, with PT assessing once a week for rehab potential/increased ability to participate. Review of Patient 30's RNA documentation revealed sessions on 7/3/22 and 7/4/22. No other sessions were documented. Administrative Staff B verified the RNA saw Patient 30 twice between 6/29/22 and 7/29/22, and the RNA worked at the hospital until 8/11/22. Administrative Staff B stated the RNA position was being advertised, and no one had been hired yet. Administrative Staff B stated the RNA should document missed visits with the reason the patient was not seen. Administrative Staff B stated, when a patient did not get their RNA sessions as planned, they did not get the movement they needed to prevent contractures.

During the same record review, Administrative Staff B opened Patient 17's Electronic Medical Record. Patient 17's H&P, dated 9/17/21, indicated Patient 30 was transferred to the hospital on 9/17/21, with multiple diagnoses including hemorrhagic stroke (bleeding in the brain), diabetes and high blood pressure. Patient 30's H&P indicated Patient 17 was ventilator dependent and was being admitted to the hospital for Respiratory Therapy, reconditioning and rehabilitation. Patient 17's OT initial interview, dated 9/19/21 revealed, and Administrative Staff B verified, the plan of care did not indicate a frequency for OT sessions. Review of Patient 17's OT sessions revealed sessions were at least two to three times per week, except between 9/24/21 and 10/3/21 (nine days) and between 11/15/21 and 11/22/21 (seven days) when he received no OT sessions and had no missed visit notes.

Patient 17's PT initial interview note, dated 9/21/21 (four days after the physician order, dated 9/17/21) indicated Patient 17 was to be seen three to five times per week. Review of Patient 17's PT sessions revealed sessions were not three to five times per week during the weeks of 10/17/21 (had two sessions), 10/24/21 (had one session), 11/7/21 (had two sessions), 11/28/21 (had no sessions, one missed visit note), 12/5/21 (had one session and one missed visit note), 12/12/21 (had one session), and 12/19/21 (had one session).

During an interview on 8/22/22 at 3 p.m., Human Resources Staff (HR Staff) stated she was on a medical leave at the same time as PT G's vacation. HR Staff stated someone from, "corporate" covered human resources duties during her leave. HR Staff stated the hospital used to have another Physical Therapist who would cover PT G when she was out. HR Staff stated the Physical Therapist resigned, and her open position was posted. During a subsequent interview at 3:34 p.m., HR Staff stated PT G was on vacation from 7/12/22 to 8/8/22, and the hospital had no PT coverage during that time. HR Staff confirmed the hospital had a contract with an agency that could have provided PT travelers to cover PT G. HR Staff stated she was on leave from May until the beginning of August and was, "catching up" (on the status of human resources).

Review of Patient 27's H&P, dated 7/7/22, indicated she was admitted to the hospital on 7/7/22, with multiple diagnoses including AIDP (Acute Inflammatory Demyelinating Polyneuropathy; an autoimmune disorder that causes progressive weakness and can lead to respiratory failure), quadraplegia, diabetes, and morbid obesity. Patient 27's H&P also indicated she was admitted for care including ventilator support, and PT and OT evaluation. Patient 27's PT initial interview, dated 7/12/22, indicated the plan was for her to have Physical Therapy two to four times a week, and RNA sessions one to three times per week. Review of Patient 27's PT sessions indicated she had no sessions with PT after 7/12/22 until 8/9/22. Review of Patient 27's RNA documentation revealed Patient 27 had no RNA sessions. Review of Patient 27's physician orders indicated an order, dated 7/12/22, for, "RNA treatment."

In response to a request for the Rehab Department staffing for the past six months, the staffing schedule for OT and PT services from 5/22/22 to 9/10/22, was provided. Review of the provided schedule for OT and PT services revealed the hospital had one Physical Therapist (PT G) and two Occupational Therapists on the schedule. The schedule indicated PT G worked on 15 of 30 days in June 2022, and four of 31 days in July 2022, for a total of 42 days with no Physical Therapist in a 61-day time period. The schedule also revealed there was no OT or PT working on 12 days during the time period of 5/22/22 to 9/10/22.

During an interview on 8/23/22 at 3:30 p.m., Administrative Staff B stated the staffing goal for the OT and PT schedule was to have someone from the Rehab Department working every day. Administrative Staff B also stated having both disciplines (OT and PT) every day was their goal.

In response to a request for the Rehab Department staffing policy, hospital policy and procedure, "Prioritization of Delivery of Service," last reviewed 12/2020, was provided. Review of the policy revealed, "Rehabilitation Services will prioritize the delivery of therapy services in the event of . . . a sudden decrease in staffing due to staff absenteeism, illness or disability. . . . Should it become necessary to increase existing staff, the Rehabilitation Services staff shall be called to work until adequate staffing needs are met."


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2. During a concurrent interview and record review on 8/23/22, with Administrative Staff B, Patient 4 was admitted to the hospital on 7/14/22, with a diagnosis of acute respiratory failure (inability to oxygenate adequately).

Review of the physician's orders, dated 7/14/22, indicated orders for Rehabilitation Services - Physical Therapy, Speech Therapy, and Occupational Therapy for evaluation and treatment.
Review of the, "Initial Interview for PT" (Physical Therapy), dated 8/19/22, indicated the first evaluation by the Physical Therapist, greater than one month post physician's order. Administrative Staff B confirmed the delay in the evaluation was due to the Physical Therapist was not available.

Review of the Patient Progress Notes from 7/14/22 - 8/22/22, did not indicate an initial evaluation by the Speech Therapist.

During an interview on 8/19/22 at 8:45 a.m.,with Occupational Therapist (OT) A, she confirmed the Rehabilitation Department did not have a Speech Therapist on staff since 08/2021.

Review of the, "Initial Interview for OT" (Occupational Therapy), dated 7/17/22, indicated the initial evaluation by the Occupational Therapist was three days post physician's order. Administrative Staff B confirmed the delay in the OT evaluation.

3. During a concurrent interview and record review on 8/23/22, with Administrative Staff B, Patient 3 was admitted to the hospital on 7/12/22, with a diagnosis of acute hypoxemic respiratory failure.

Review of the physician's orders, dated 7/12/22, indicated orders for Rehabilitation Services - Physical Therapy, Speech Therapy, and Occupational Therapy for evaluation and treatment.

Review of the Patient Progress Notes from 7/12/22 - 8/22/22, did not indicate an initial evaluation by the Physical Therapist. Administrative Staff B confirmed there was no initial evaluation by PT.

Review of the Patient Progress Notes from 7/12/22 - 8/22/22, did not indicate an initial evaluation by the Speech Therapist.

During an interview on 8/19/22 at 8:45 a.m., with Occupational Therapist (OT) A, she confirmed the Rehabilitation Department did not have a Speech Therapist on staff since 08/2021.

4. During a concurrent observation and interview, on 8/19/22 at 8:45 a.m., Occupational Therapist (OT) A stated the department had recently implemented the white board located on the wall in the department demonstrating the current patients requiring Rehabilitation Services. When asked how the department evaluated short-staffing schedules and patient missed treatments, she stated through emails. She stated the Rehabilitation Department did not implement a Quality Assurance Performance Improvement project, within the department, on the inability to provide Rehabilitation Services due to short-staffing resulting in patient missed treatments.

Based on interview and record review, the hospital Rehabilitation Department did not have a director of Rehabilitation (Rehab) Services. This resulted in a lack of oversight for a department which was understaffed and unable to complete Physical Therapy (PT), Occupational Therapy (OT), and Restorative Nursing Assistant (RNA) sessions with patients, according to the plan of care.

Findings:

During an interview on 8/19/22 at 8:45 a.m., OT A stated the Rehab Department did not currently have a director. PT B stated she was the Rehab Director, but had stepped down in February 2022. OT A stated the Rehab staff did not get to see all the patients they were supposed to see because of their heavy case load.

During an interview on 8/22/22 at 10:24 p.m., when asked who had oversight of the Rehab Department, Administrative Assistant B stated OT A was the point contact for the Rehab Department. Administrative Assistant B stated OT A reported any clinical issues to him; staffing issues were reported to Human Resources, and Administrative Assistant D was OT A's, "boss." Administrative Assistant B stated OT A had shown interest in the director position in the past, and he was hoping, after they hired one more PT, she might take the position.

Review of 31 sampled patients revealed eight patients' OT, PT, and RNA sessions were not carried out according to their treatment plans.

The job description for the Rehab Director was requested but not provided.

Review of the hospital organizational chart, last updated 2/2022, revealed PT B was listed as director of the Rehab Department.

Based on interview and record review, the hospital failed to develop treatment plans for patients receiving Rehabilitation (Rehab) Services, when two of 31 sampled patients did not have a frequency or duration documented for receiving Occupational Therapy sessions. This failure could potentially prevent patients from reaching their rehab goals when their plan for treatment was not fully developed.

Findings:

During a record review on 8/19/22 at 1:30 p.m., Administrative Staff F opened Patient 18's Electronic Medical Record. Patient 18's H&P, dated 6/8/22, indicated she had been transferred to the hospital on 6/8/22, with multiple diagnoses including seizures, acute respiratory failure resulting in artificial ventilation, vocal cord paralysis, and microcytic anemia (red blood cells that are too small to carry oxygen throughout the body, resulting in fatigue). The H&P also indicated the plan of care included Physical Therapy and OT reconditioning. Patient 18's OT initial interview note, dated 6/9/22, indicated Patient 18 would benefit from OT, but the plan did not indicate a frequency of sessions.

During an interview on 8/19/22 at 3:50 p.m., Occupational Therapist (OT) A stated the frequency of sessions for OT should be in the plan of care documented in the initial interview note. When asked about the frequency of OT sessions for Patient 18, OT A stated Patient 18 needed more swallowing therapy than OT.

During a record review on 8/22/22 at 10:24 a.m., Administrative Staff B opened Patient 17's Electronic Medical Record. Patient 17's H&P, dated 9/17/21, indicated Patient 30 was transferred to the hospital on 9/17/21, with multiple diagnoses including hemorrhagic stroke (bleeding in the brain), diabetes and high blood pressure. Patient 30's H&P indicated Patient 17 was ventilator-dependent and was being admitted to the hospital for Respiratory Therapy, reconditioning and rehabilitation. Patient 17's OT initial interview, dated 9/19/21, revealed, and Administrative Staff B verified, the plan of care did not indicate a frequency for OT sessions.

Review of facility Rehabilitation Services policy, "Orders and Documentation," last revised 12/2020, indicated, "I. Physician or other authorized medical personal [sic] identifies the need for therapy services. II. Following are requirements for services to start: . . . Frequency/duration . . . III. Upon receipt of referral, patient will be scheduled for evaluation by ordered therapist. . . . V. Evaluation will include plan of treatment which will include: Frequency and duration . . . ."

Review of facility Rehabilitation Services policy, "Scope of Practice OT," last revised 1/2020, subsection, "Standard III. Intervention" indicated, "The occupational therapist ensures that the intervention plan is documented . . . ."

Based on interview and document review, the hospital failed to: 1. Ensure there were two licensed respiratory practitioners on duty at all times; and, 2. Ensure two of 31 patients (Patient 3 and Patient 4) received the prescribed respiratory treatments, as ordered. This had the potential for patients to have missed prescribed respiratory treatments, as ordered, potentially developing worsening respiratory symptoms.

Findings:

1. During a concurrent interview and document review on 8/22/22 at 1:15 p.m., Administrative Staff B confirmed the staffing goal for the Respiratory Department; two Respiratory Therapists on duty at all times. Administrative Staff B provided the Respiratory Therapy Department day and night schedules for the period of 7/1/22 - 7/19/22. Review of the respiratory day schedule confirmed on 7/3/22, 7/6/22 and 7/7/22, the hospital had one licensed Respiratory Therapist on duty. Review of the respiratory night schedule confirmed on 7/1/22 and 7/2/22, the hospital had one licensed Respiratory Therapist on duty.

Review of the policy and procedure titled, "STAFFING RESPIRATORY," last reviewed 12/2/20, indicated "...There will be at least two licensed Respiratory Therapy practitioners on duty at all times..."

2. During a concurrent interview and record review on 8/23/22, with Administrative Staff B, Patient 3 was admitted to the hospital on 7/12/22, with a diagnosis of acute hypoxemic respiratory failure.

Review of the physician's orders, dated 7/28/22, indicated orders for acetylcysteine inhalation every 12 hours. Review of the Patient Progress Notes from 7/12/22 - 8/22/22, indicated the first inhalation therapy Patient 3 received was on 7/30/22 at 7:55 p.m., two days post physician's orders. Further review of the Patient Progress Notes indicated missed treatments on 8/1/22, day shift, 8/3/22, night shift, 8/4/22, day and night shift. Administrative Staff B concurred with the missed treatments. There was no documentation provided why Patient 3 missed the inhalation therapies.

2. During a concurrent interview and record review on 8/23/22, with Administrative Staff B, Patient 4 was admitted to the hospital on 7/14/22, with a diagnosis of acute respiratory failure (inability to oxygenate adequately).

Review of the physician's orders, dated 7/28/22, indicated orders for acetylcysteine inhalation every 12 hours. Review of the Patient Progress Notes from 7/14/22 - 8/22/22, indicated the first inhalation therapy Patient 4 received was on 7/28/22 at 8:38 p.m. Further review of the Patient Progress Notes indicated missed treatments on 8/1/22, day shift, 8/10/22, day shift, 8/11/22, day shift. Administrative Staff B concurred with the missed treatments. There was no documentation provided why Patient 4 missed the inhalation therapies.

Review of the policy and procedure titled, "DOCUMENTATION FOR RESPIRATORY," last reviewed 12/2/20, indicated, "...PURPOSE: To provide an accurate record of the Respiratory Therapy administered to the patient...5. Any patient not receiving Respiratory Therapy treatment as ordered needs documentation that treatment was not given and reason..."

Based on interview and document review, the hospital failed to develop, perform and track recommended maintenance for 10 of 10 Equipment V ventilators. This had the potential for the hospital to be unable to identify the possibility of contamination or damage.

Findings:

During an interview on 8/22/22 at 1:15 p.m., Administrative Staff B stated the hospital had been using the Equipment V ventilators for approximately one and one-half years. The biomedical service preventative maintenance asset list was requested and reviewed with Administrative Staff B. The 10 Equipment V ventilators were not included in the asset list, only the Equipment W ventilators were. Administrative Staff B confirmed the hospital had not developed a process and procedure to track Equipment V ventilators and include the Equipment V ventilators in the hospital's preventative maintenance program. Administrative Staff B confirmed the hospital had not developed a Quality Assurance and Performance Improvement program to ensure Equipment V ventilators were maintained, per the manufacturer's recommendations.

Review of the [Equipment V] Clinical and Technical Manual pages 10-1, 10-3 and 10-7, indicated recommended maintenance tasks at recommended intervals.
Page 10-1, "...The organization responsible for the use and maintenance of [Equipment V] should perform all adjustment, cleaning, and disinfection of [Equipment V]. Follow all instructions provided in this Clinical and Technical manual to prevent damage to [Equipment V] during cleaning and maintenance procedures..."
Page 10-3, "...Clean the air and fan filters every two weeks to ensure [Equipment V] internal components are protected from dirt and dust. Replace the filters every six months, or as needed due to damage..."
Page 10-7, "...Every month during use...Replace the [Equipment V] Bacterial Filter and Nebulizer Filter..."

Based on interview and document review, the hospital failed to administer and consistently document provided Respiratory Services in the medical record for two of 31 patients (Patient 3 and Patient 4).

Findings:

1. During a concurrent interview and record review on 8/23/22, with Administrative Staff B, Patient 3 was admitted to the hospital on 7/12/22, with a diagnosis of acute hypoxemic respiratory failure.

Review of the physician's orders, dated 7/28/22, indicated orders for acetylcysteine inhalation every 12 hours. Review of the Patient Progress Notes from 7/12/22 - 8/22/22, indicated the first inhalation therapy Patient 3 received was on 7/30/22 at 7:55 p.m., two days post physician's orders. Further review of the Patient Progress Notes indicated missed treatments on 8/1/22, day shift, 8/3/22, night shift, 8/4/22, day and night shift. Administrative Staff B concurred with the missed treatments. There was no documentation provided why Patient 3 missed the inhalation therapies.

2. During a concurrent interview and record review on 8/23/22, with Administrative Staff B, Patient 4 was admitted to the hospital on 7/14/22, with a diagnosis of acute respiratory failure (inability to oxygenate adequately).

Review of the physician's orders, dated 7/28/22, indicated orders for acetylcysteine inhalation every 12 hours. Review of the Patient Progress Notes from 7/14/22 - 8/22/22, indicated the first inhalation therapy Patient 4 received was on 7/28/22 at 8:38 p.m. Further review of the Patient Progress Notes indicated missed treatments on 8/1/22, day shift, 8/10/22, day shift, 8/11/22, day shift. Administrative Staff B concurred with the missed treatments. There was no documentation provided why Patient 4 missed the inhalation therapies.

Administrative Staff B stated he was the current interim Respiratory Department Director. Administrative Staff B stated the Respiratory Department did not have a Quality Assurance Performance Improvement project for the evaluation of short-staffing issues and missed Respiratory Therapy treatments.

Based on interview and document review, the hospital failed to develop a current and accurate list of Home Health Agencies (HHA), Skilled Nursing Facilities (SNF), Intermediate Rehabilitation Facilities (IRF) or Long Term Care Hospitals (LTCH) and failed to document in the patients' medical record, the list was presented to the patient or family. This failure had the potential to not provide patients or families with the most current facility types available to patients needing the service.

Findings:

During a concurrent interview and document review, on 8/17/22 at 1:20 p.m., Administrative Staff J stated she had been the director of case management for a couple of months and had been in the role as Case Manager for approximately one year. She stated she did not have the current regulations for the Condition of Participation for Discharge Planning.

Review of the facility lists for HHA indicated eight home health referral forms for eight different Home Health Agencies. The file did not include a list of current HHA. Review of the SNF provider lists indicated the lists were last updated 7/9/21, 7/16/21, 7/23/21 and 8/23/21. There were no IRF or LTCH lists provided.

Review of the policy titled, "CASE MANAGER DISCHARGE," last revised 6/30/22, indicated, "...If long-term care, or Hospice transfer is needed, a list of facilities will be provided to patient/family...Home Health agency list will be provided to patient/family for selection to be made for post-hospital care..." The policy did not contain information for the IRF or LTCH facilities.