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Based on document review and medical record review, the facility failed to ensure qualified staff performed assessments in the Dedicated Emergency Department (DED) for 13 of 20 (Patient #2, 3, 5, 6, 7, 8, 9, 10, 12, 21, 22, 23 and 24) sampled patients presenting to the DED seeking seeking treatment.

The findings included:

1. The facility failed to ensure it followed the State's Nurse Practice Act (NPA) and ensure assessments in the DED were performed by a Registered Nurses (RN) or were supervised by RN if performed by Emergency Medical Technician- Paramedics.
Refer to A 023

Based on policy review, the States Nurse Practice Act, document review, and interview, the Governing Body failed to assume responsibility and provide oversight for the hospital's Medical Staff Bylaws, Quality Assessment and Performance Improvement (QAPI) Program and Infection Control Program.

The findings included:

1. The Governing Body failed to ensure assessments in the DED were performed by Registered Nurses (RN) or were supervised by a RN if performed by Emergency Medical Technician- Paramedics.
Refer to A 023

2. The Governing Body failed to ensure current Medical Staff Bylaws to provide oversight and direction to the practicing medical staff.
Refer to A 047

3. The Governing Body failed to ensure the QAPI program reflected all the hospital's services, and tracked, trended and analyzed data to improve health outcomes.
Refer to A 263

4. The Governing Body failed to ensure the hospital developed, implemented and maintained an active hospital - wide Infection Control Program for the prevention and control of infections.
Refer to A 747

Based on document review and interview, the facility failed to develop and implement a hospital-wide Quality Assessment and Performance Improvement (QAPI) program.

The findings included:

1. The facility failed to update and revise their QAPI program annually.
Refer to A 273

2. The facility failed to measure, track, trend and analyze quality indicators identified to improve health outcomes.
Refer to A 273

3. The Governing body failed to provide oversight for the development and implementation of the Quality Assessment and Performance Improvement (QAPI) program.
Refer to A 308

Based on document review and interview, the hospital failed to ensure it employed a dietary service director who demonstrated through education, experience and/or specialized training the qualifications necessary to manage the service appropriate to the scope of the food service operations.

The findings included.

1. The hospital failed to ensure the dietary food service director was qualified by experience and or education to perform the complex duties of the food service operations.
Refer to A620

Based on facility policy and interview, the facility failed to ensure an active Infection Control Program (ICP) for the prevention, control, and investigation of infections and communicable diseases.

The findings included:

1. The facility failed to have evidence of a current Infection Control Officer and an active Infection Control Program.
Refer to A 748

2. The Chief Executive Officer, Medical Staff and Director of Nursing failed to be responsible for the implementation of the ICP.
Refer to A 756

Based on document review and interview, the hospital failed to ensure it developed and maintained a comprehensive emergency preparedness program utilizing an all-hazards approach.

The findings included:

1. The hospital failed to ensure it maintained and updated its emergency preparedness plan.
Refer to E004.

2. The hospital failed to ensure a risk assessment was completed annually utilizing an all-hazards approach.
Refer to E006.

3. The hospital failed to ensure a process was in place for collaboration with emergency officials.
Refer to E009.

4. The hospital failed to ensure policies included for all the subsistence needs of patients and staff.
Refer to E015.

5. The hospital failed to ensure a policy was developed to track the location of off-duty staff.
Refer to E018.

6. The hospital failed to ensure it developed polices/procedures for sheltering in place.
Refer to E022.

7. The hospital failed to ensure it developed policies for maintaining confidentiality of records during an emergency.
Refer to E023.

8. The hospital failed to ensure it developed arrangements with other healthcare facilities.
Refer to E025.

9. The hospital failed to ensure it developed a communication plan.
Refer to E029.

10. The hospital failed to ensure it developed a communication plan that included contact information.
Refer to E030.

11. The hospital failed to ensure it developed a communication plan that included emergency officials contact information.
Refer to E031.

12. The hospital failed to ensure it included an emergency plan for alternate communicating with staff, state, federal, local and emergency management agencies.
Refer to E032.

13. The hospital failed to ensure it developed a plan for sharing medical information.
Refer to E033.

14. The hospital failed to ensure it developed an emergency plan for providing information to the authority having jurisdiction.
Refer to E034.

15. The hospital failed to ensure it developed a written emergency plan for training and testing.
Refer to E036.

16. The hospital failed to ensure all employees received emergency preparedness training upon hire and annually.
Refer to E037.

17. The hospital failed to conduct exercises to test its emergency plan.
Refer to E039.

Based on review of the Tennessee Board of Nursing, and the Tennessee Code Title 68, Chapter 140, and medical record review, the facility failed to ensure triage assessments were performed by a Registered Nurse (RN) or under RN supervision for 13 of 20 (Patient #2, 3, 5, 6, 7, 8, 9, 10, 12, 21, 22, 23 and 24) sampled patients presenting to the Dedicated Emergency Department (DED )for treatment.

The findings included:

1. Review of the Tennessee Board of Nursing Rules and Regulations of Registered Nurses, 1000-01-.14 (1) (a) revealed, "1. Conduct and document nursing assessments...(i) Collecting objective and subjective data in an accurate and timely manner...8. Evaluate the response of individuals...9. Communicate accurately in writing and orally with recipients of nursing care and other professionals...6. Delegate to another only those nursing measures which that person is prepared or qualified to perform..."

Review of the Tennessee Board of Nursing Rules and Regulations of Licensed Practical Nurses, 1000-02-.14(1)(a) revealed, "1. Contribute to the nursing assessment by collecting, reporting and recording objective and subjective data in an accurate and timely manner. 2. Participate in the development of the plan of care/action in consultation with a Registered Nurse..."

Review of the Tennessee Board of Nursing Position Statements Reaffirmed February 2012 revealed, "...It is apparent from these rules the interpretation of the standard of care for the licensed practical nurse in terms of assessment is that the individual is not prepared educationally in the basic vocational program with the requisite scientific skills to expand his or her practice to assessment of patients, formulation of a plan of care, or evaluation of the plan of care developed by the registered nurse..."

2. Review of the Tennessee Code Title 8 Health, Safety and Environmental Protection Chapter 140 Emergency Services Part 5 Emergency Medical Services (EMS) Act of 1983 revealed, " ...Duties and authority of EMS personnel and physician on the scene ...An EMT [Emergency Medical Technician] or EMT-P [Paramedic] may function within hospital emergency services under nursing supervision in accordance with policies and procedures adopted by the hospital ..."

3. Medical record review revealed Patient #2 was a 38 year old male who presented to the DED on 2/5/18 at 12:08 AM with a chief complaint of being Short of Breath.

Licensed Practical Nurse (LPN) #4 performed the patient triage assessment at 12:10 AM and documented the patient reported a history of anxiety and he woke up about an hour prior to arrival with chest tightness and shortness of breath.

There was no documentation a RN performed an assessment of Patient #2.

4. Medical record review revealed Patient #3 was a 26 year old male who presented to the DED on 3/26/18 at 5:04 PM with a chief complaint of seeking help to get off drugs.

LPN #1 performed the patient triage assessment at 5:14 PM and documented the patient was homeless, had thoughts of harming himself and used Methamphetamine daily. LPN #1 documented protocols for suicide was initiated, which included 1:1 observation.

LPN #1 did not document how the patient would continually be observed/monitored for suicide precautions.

There was no documentation a RN performed an assessment of Patient #3.

5. Medical record review revealed Patient #5 was a 12 year old female who presented to the DED on 11/14/17 at 8:19 PM with the chief complaint of suicidal ideations.

LPN #2 performed the patient triage assessment at 8:39 PM and documented the Patient told the foster parents that she wanted to kill herself by slicing her wrist open.

At 9:06 PM LPN #2 stated she initiated protocols for suicide which included 1:1 observation.

LPN #1 did not document how the patient would continually be observed/monitored for suicide precautions.

At 9:38 PM LPN #2 documented, " ...[Name of Mental Health Agency #2] Crisis line called for referral ...All information given and a counselor should be here [Hospital DED] within 2 hours."

There was no documentation a RN performed an assessment of Patient #5.

6. Medical record review revealed Patient #6 was a 59 year old female who presented to the DED on 4/4/18 at 3:55 PM with the chief complaint of suicidal ideation.

LPN #1 performed the patient triage assessment at 4:25 PM and documented the patient made attempt to kill self with a gun that jammed and was at the DED for a psychiatric evaluation. LPN #1 documented Patient #5 had extensive psychiatric history with several attempts made of suicide in the past.

LPN #1 documented she initiated protocols for suicide which included 1:1 observation.

LPN #1 did not document how the patient would continually be observed/monitored for suicide precautions.

At 5:41 PM LPN #1 documented, "Patient attempted to take pills and put in her pocket, 2 tabs out, noticed, removed pills from hand, identified as Tylenol #3 [narcotic pain medication]. Removed personal belongings from patient, checked pockets, 1:1 supervision continues. Physician made aware."

There was no documentation a RN performed an assessment of Patient #6.

7. Medical record review revealed Patient #7 was a 42 year old male who presented to the DED on 4/2/18 at 4:30 PM via law enforcement with the chief complaint of drug abuse.

Emergency Medical Technician-Paramedic (EMT-P) #1 performed the patient triage assessment at 4:40 PM and documented the patient was agitated, confused, hallucinating, had used Methamphetamine and had right and left foot pain.

At 4:55 PM LPN #2 documented the patient had abrasions to the upper and lower extremities.

At 4:59 PM EMT-P #1 documented, "Pt presented into the ER [emergency room] by PD...Pt had on t-shirt, underwear. No socks or shoes...Pt was hand cuffed by PD...Pt was hallucinating...alert and confused...Pt stated he was hearing noises and people were after him with guns...stated someone was going to get him. Pt stated he had done Meth [Methamphetamine] ..." There was no documentation the patient was continuously assessed regarding the use of the handcuffs to ensure they were used safely.

There was no documentation a RN provided an assessment of Patient #7 or provided oversight for EMT-P #1.

8. Medical record review revealed Patient #8 was 68 years old and presented to the DED on 3/4/18 at 4:20 AM with the chief complaint of Bradycardia.

EMT-P #2 performed the patient triage assessment at 4:25 AM and documented the patient woke up at 2:30 AM feeling like she was in Atrial Fibrillation, took some medications and began to feel like she was going to pass out.

There was no documentation a RN provided an assessment of Patient #9 or provided oversight for EMT-P #2.

9. Medical record review revealed Patient #9 was a 52 year old female who presented to the DED on 3/13/18 at 3:48 PM via ambulance with a chief complaint of recent right below knee amputation (BKA) pain.

LPN #1 performed a triage assessment at 3:48 PM and documented right extremity pain post BKA with blackened necrotic areas around the site and reddened areas extending from the necrosis.

There was no documentation a RN performed an assessment of Patient #9.

10. Medical record review revealed Patient #10 was 15 years old and presented to the DED on 3/5/18 at 10:25 AM with the chief complaint of abdominal pain.

At 10:39 AM LPN #2 performed the triage assessment and documented the patient was grimacing, moaning and restless. The nurse documented the patient had pain of 8, on a scale of 0-10 with 0 being no pain and 10 being the worst pain.

There was no documentation a RN performed an assessment of Patient #10.

11. Medical record review revealed Patient #12 was 16 years old and presented to the DED on 12/23/17 at 10:05 PM via law enforcement with the chief complaint of suicidal ideations.

At 10:05 PM LPN #1 performed the patient triage assessment and documented the patient had cuts to her right upper thigh with several surface lacerations noted. LPN #1 documented the patient stated she would probably harm self if left alone.

LPN #1 initiated protocols for suicide which included 1:1 observation. LPN #1 documented the mother, not trained hospital staff, was providing the 1:1 supervision.

There was no documentation a RN performed an assessment of Patient #12.

12. Medical record review revealed Patient #21 was a 16 year old female who presented to the DED on 11/5/17 at 8:00 PM with a chief complaint of accidental fall from a high river bridge.

LPN #6 performed a patient triage assessment at 8:00 PM and documented bilateral shoulder, back and neck pain, with no loss of consciousness at any point.

There was no documentation a RN performed an assessment of Patient #21.

13. Medical record review revealed Patient #22 was a 41 year old male who presented to the DED on 12/22/17 at 3:37 PM via police, with a chief complaint of suicidal thoughts.

LPN #1 performed a patient triage assessment at 3:44 PM and documented the patient admitted to taking oxycodone and opioid's and using marijuana. The patient reported he thought the fumes from his car and the medication would kill him and that he was hearing auditory hallucinations telling him to kill himself all day. The handcuffs were removed by the PD upon arrival and LPN #1 documented 1:1 supervision was initiated.

LPN #1 did not document how the patient would continually be supervised/monitored for suicide precautions.

At 8:07 PM LPN #1 documented Mental Health Agency #1 had been consulted for a psychiatric evaluation.

There was no documentation a RN performed an assessment of Patient #22.

14. Medical record review revealed Patient #23 was a 28 year old female who presented to the DED on 1/9/18 at 12:53 PM via ambulance with a chief complaint of overdose.

LPN #2 performed the patient triage assessment at 12:45 PM, 8 minutes prior to the patient's arrival. There was no documented suicide assessment by the LPN.

At 1:35 PM LPN #2 documented the patient became combative and pulled out intravenous lines and her foley catheter. LPN #2 documented, ..." Patient has been cleared medically, however Vs [vital signs] checks needed every 2 hours for 24 hours".

There was no documentation a RN performed an assessment of Patient #23.

15. Medical record review revealed Patient #24 was a 16 year old male who presented to the DED on 12/9/18 at 11:00 PM with a chief complaint of left wrist pain.

LPN #4 performed a patient triage assessment at 11:10 AM and documented the patient fell playing basketball and landed on his left wrist.

There was no documentation a RN performed an assessment of Patient #24.

Based on document review and interview, the Governing Body failed to ensure it maintained current Medical Staff Bylaws to provide oversight and direction to the practicing medical staff.

The findings included:

1. Review of the Medical Staff Bylaws presented to the survey team on 4/16/18 revealed the Bylaws were last reviewed and updated in September 2015.

2. During an interview on 4/17/18 at 2:00 PM in the conference room the Director of Nursing verified the Medical Staff Bylaws provided (dated 2015) were the most current available.

Based on document review and interview, the facility failed to failed to annually review and approve a Quality Assessment and Performance Improvement (QAPI) Program and failed to measure, analyze and track quality indicators to ensure an effective QAPI.

The findings included:

1. Review of the facility "Quality Quest Plan" dated 2016 revealed, "[Name of Hospital] is committed to continuously improving the quality and safety of patient care and services. The commitment will be incorporated throughout the organization. The plan will be reviewed/revised annually and on an as needed basis...DATA AGGREGATION AND ANALYSIS: Data is aggregated by the Department Managers or staff from CQI [Continuous Quality Improvement] Department. Analysis of the data collected may be presented in the form of internal or external comparative data...Analysis of the data is reviewed by the Department Managers, QI, Medical Staff and Board. Undesirable patterns or trends are identified and presented to the leadership as performance improvement priorities...SCOPE: Improvement activities occur for governance, medical staff, nursing, support, managerial and clinical functions...REPORTING MECHANISMS: Department Managers and or designated staff will gather monthly data...addressing any areas of concerns, plans for correction with their departmental employees. Designated hospital-wide focus indicators will be reported to CQI, Department Managers,Medical Staff and Board of Trustees at least quarterly...Department Managers should review both individual and hospital wide indicators with their department employees [at least quarterly and prn [as needed]..."

2. Review of the Quality Indicators for Discharge Planning revealed 10 charts were reviewed each month. The indicator of '"Discharge record complete" had a goal of 100 %. The following 2017 data was recorded: September- 60%, October- 100%, November- 70%, December- 60%.

There were no QAPI committee meeting minutes for December 2017 to address the indicators that did not meet the facility goal.

There was no Discharge Planning data to review for 2018.

Review of the Quality Indicators for Med Surg revealed "IV [intravenous] start/stop times documented" had a goal of 100%. The following data was recorded: September- 40%, October- 30%, November-10% and December- 10%.

There was no QAPI committee meeting minutes for December 2017 to address the indicators that did not meet the facility goal.

3. Review of the Quality Indicators for Medical Surgical units revealed, "Physical Assessment" had a goal of 100%. The following data was recorded: September- 70%, October- 90%, November-70% and December- 90%.

There was no QAPI committee meeting minutes for December 2017 to address the indicators that did not meet the facility goal.

4. During an interview with Registered Nurse (RN) #4 on 4/17/18 at 12:35 PM in the conference room the RN stated she was the Discharge Planner in 2017 but she stepped down from the position and the discharge planning data had not been tracked since December 2017.

During an interview with Licensed Practical Nurse (LPN) #7 on 4/17/18 at 10:30 AM in the conference room, LPN #7 stated she had been employed in the position of Quality Director but left the position due to the instability of the hospital in September 2017. She stated she was re-hired after the hospital's recent purchase. The LPN stated her official date of hire was 4/19/18, however she came in at the request of Chief Executive Officer (CEO) to assist the survey team.

During an interview with LPN #7 on 4/17/18 at 1:00 PM in the conference room the LPN stated she was unable to find the December 2017 meeting minutes. She further verified the committee was supposed to meet quarterly to discuss and review data gathered.

During an interview with LPN #7 on 4/17/18 at 1:30 PM in the conference room the LPN stated the "Quality Quest Plan" was last approved in 2016 and there was no evidence it had been updated since 2016.

During an interview on 4/18/18 at 8:50 AM in the conference room the CEO verified there was no evidence the Governing body had approved the "Quality Quest Plan" for 2017 or 2018.

During an interview with the Director of Nursing (DON) on 4/18/18 at 9:25 AM in the conference room the DON verified the "Quality Quest Plan" was the facility policy for QAPI.

Based on document review and interview, the Governing Body failed to provide oversight for the development and implementation of the Quality Assessment and Performance Improvement (QAPI) program.

The findings included:

1. The facility "Quality Quest Plan" provided to the survey team for review was dated "2016".

2. There were no QAPI committee meeting minutes for December 2017.

3. During an interview with LPN #7 on 4/17/18 at 1:30 PM in the conference room, she stated the "Quality Quest Plan" was last approved in 2016 and there was no evidence it had been updated since 2016.

During an interview on 4/18/18 at 8:50 AM PM in the conference room, the CEO verified there was no evidence the Governing body had approved the "Quality Quest Plan" 2017 or 2018.

Refer to A 273

Based on document review, observation and interview, the facility failed to ensure a qualified director of food and dietetic services to provide daily management of the food services for 1 of 1 (Dietary Manger #1) dietary managers (DM) reviewed during the survey.

The findings included:

1. Review of the "Food and Nutrition Services Director Job Description" revealed, "Responsible for planning and directing the Food and Nutrition Services Department to provide dietary service for patients...set forth in the most recent version of the 'Accreditation Manual for Hospitals'..."

2. Review of the DM personnel file revealed her most recent Job Description was for "Environmental Services" and was signed on 4/20/15.

The DM's most recent performance evaluation was completed on 8/21/17 and was for an Aide II in the Environmental Department.

3. Observations on 4/16/18 ay 10:05 AM revealed the DM was working in the kitchen and accompanied the surveyor on a tour of the dietary department..

4. During an interview in the kitchen on 4/16/18 at 10:15 AM the DM stated, "I just transferred in here from the floor (environmental services) in January [2018]."

During an interview in the kitchen on 4/17/18 at 10:45 AM the DM stated she worked in a jail kitchen about 4-5 years ago. The DM verified she had not completed any dietetic training in a classroom or on-line. She verified she had not met the contracted Registered Dietician since she had taken the position in January of this year.

Based on facility policy and interview, the facility failed to ensure one or more individual(s) were designated as its Infection Control Officer (ICO) and that the ICO implemented an effective infection Control Program (ICP).

The findings included:

1. Review of the facility's "INFECTION CONTROL PLAN 2016" policy revealed, "...The mission of the infection surveillance, prevention, and control program is to help reduce the possibility of acquiring and transmitting an infection and to promote the well-being of patients, healthcare workers, and visitors through a commitment to excellence and respectful patient care, effective use of resources, and continuous improvement...Goals The goals of the program are to reduce or prevent the acquisition and transmission of potentially infectious agents by doing the following: 1. Identify expected and unexpected infections early and implement appropriate interventions when they occur...2. Analyze practices that have the potential to affect the rate of hospital-acquired infections...3. Institute changes as needed to reduce the health acquired infections...4...educate personnel, patients and visitors regarding infection prevention and control issues...5. Coordinate and integrate infection prevention and control activities with medical staff...7. Assure [name of hospital] compliance with various regulatory and accrediting agency requirements on infection control issues...Responsibility...[name of hospital] has identified the individual with clinical authority over the infection prevention and control program. (Infection Preventionist)...Identifying Risks...[name of hospital] identifies risks for acquiring and transmitting infections...Implementation of Plan...[name of hospital] implements its infection prevention and control activities, including surveillance, to minimize, reduce, or eliminate the risk of infection...uses standard precautions...implements transmission-based precautions...investigates outbreaks of infectious disease...minimizes the risk of infection...implements its methods to communicate responsibilities for preventing and controlling infection...reports infection surveillance, prevention and control information..."

2. During an interview with Licensed Practical Nurse (LPN) #7 on 4/17/18 at 2:15 PM in the conference room, LPN #7 stated she had been the ICO during her previous employment at the hospital. LPN #7 stated the hospital currently did not have anyone designated as the ICO. LPN #7 stated there was no current Infection Control Program in place and no evidence of an infection control program since September 2017.

During an interview with the Chief Executive Officer (CEO) on 4/17/18 at 3:30 PM in the conference room, the CEO stated she was unable to locate meeting minutes that included infection control or an infection control program.

Based on medical record review and interview, the facility failed to ensure the discharge planning evaluation assessed for all activities of daily living for 4 of 5 (Patient #1, 2, 3 and 4) sampled patients reviewed for discharge assessments and plans.

The findings included:

1. Medical record review for Patient #1 revealed an admission date of 4/14/18 for abdominal pain and constipation. Review of the "Initial Interview" revealed no documentation of the patients activities of daily living related to grooming, personal hygiene, feeding or bowel and bladder. Patient #1 was discharged on 4/16/18. The facility staff failed to fully document assessment of potential discharge needs.

2. Medical review for Patient #2 revealed an admission date of 8/2/17 for diarrhea and abdominal pain. Review of the "Initial Interview" revealed no documentation of the patients activities of daily living related to grooming, personal hygiene, feeding or bowel and bladder. Patient #2 was discharged on 8/4/17. The facility staff failed to fully document assessment of potential discharge needs.

3. Medical review for Patient #3 revealed an admission date of 12/3/17 for hyperglycemia and abdominal abscess. Review of the "Initial Interview" revealed no documentation of the patients activities of daily living related to grooming, personal hygiene, feeding or bowel and bladder. Patient #3 was discharged home on 12/8/17. The facility staff failed to fully document assessment of potential discharge needs.

4. Medical review for Patient #4 revealed an admission date of 1/22/18 for recurrent Urinary Tract Infection, weakness and fever. Review of the "Initial Interview" revealed no documentation of the patients activities of daily living related to grooming, personal hygiene, feeding or bowel and bladder. Patient #4 was discharged on 1/25/18. The facility staff failed to fully document assessment of potential discharge needs.

5. During an interview in the conference room on 4/16/18 at 2:30 PM, the Director of Nursing verified there was no additional information regarding discharge planning in the medical record.

Based on record review, the facility failed to maintain and update the emergency preparedness plan annually.

The finding included:

Record review on 4/16/18 at 2:30 PM, revealed the facility's emergency preparedness plan was last reviewed and updated in 2014.

This finding was verified by the maintenance supervisor during review of the emergency preparedness program and was acknowledged by the administrator during the exit conference on 4/16/18.

Based on record review, the facility failed to complete the risk assessment annually utilizing an all-hazards approach.

The finding included:

Record review on 4/16/18 at 2:30 PM, revealed the facility's risk assessment for the emergency preparedness program was last completed in 2011.

This finding was verified by the maintenance supervisor during review of the emergency preparedness program and was acknowledged by the administrator during the exit conference on 4/16/18.

Based on record review, the facility failed to provide a process for cooperation and collaboration with emergency officials.

The findings included:

Record review on 4/16/18 at 2:30 PM, revealed the facility could not provide documentation of cooperating with emergency officials.

This finding was verified by the maintenance supervisor during review of the emergency preparedness program and was acknowledged by the administrator during the exit conference on 4/16/18.

Based on record reviews, the facility failed to include all policies and procedures for the subsistence needs of residents and staff in the emergency preparedness program.

The findings included:

During the records review on 4/16/18 at 2:30 PM, the facility failed to provide policies and procedures for alternate sources of energy to maintain the following:

a. Temperatures to protect resident health.
b. Emergency lighting
c. Fire detection, extinguishing, and alarm systems
d. Sewage and waste disposal

This finding was verified by the maintenance supervisor during review of the emergency preparedness program and was acknowledged by the administrator during the exit conference on 4/16/18.

Based on program review and interview, the hospital administration failed to develop a policy to track the location of on-duty staff and sheltered patients in the facility in the event of an emergency.

The findings included:

1. Review of the hospital's Emergency Preparedness plan revealed it was last reviewed and updated in 2014.

2. During an interview in the conference room on 4/18/18 at 9:51 AM, the Chief Executive Officer verified there was not a policy to track patients and on-duty staff during an emergency.

Based on record review, the facility failed to include policies and procedures for sheltering in place in the emergency preparedness program.

The finding included:

Record review on 4/16/18 at 2:30 PM, revealed the facility had no record of polices and procedures for sheltering in place.

This finding was verified by the maintenance supervisor during review of the emergency preparedness program and was acknowledged by the administrator during the exit conference on 4/16/18.

Based on program review and interview the hospital failed to ensure patient confidentiality of medical records and failed to secure and maintain availability of resident records in the event of an emergency

The findings included:

1. Review of the hospital's Emergency Preparedness plan revealed no documentaion of policies and procedures to preserve resident information, protect resident confidentiality, or secure and maintain the availability of resident records.

2. During an interview in the conference room on 4/18/18 at 10:04 AM, the Chief Executive Officer verified that the plan had not been updated to include the electronic medical record.

Based on record review, the facility failed to develop arrangements with other facilities.

The finding included:

Record review on 4/16/18 at 2:30 PM, revealed the facility failed to develop arrangements with other facilities to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients.

This finding was verified by the maintenance supervisor during review of the emergency preparedness program and was acknowledged by the administrator during the exit conference on 4/16/18.

Based on record review, the facility failed to develop a communication plan.

The finding included:

Record review on 4/16/18 at 2:30 PM, revealed the facility failed to provide a emergency preparedness communication plan.

This finding was verified by the maintenance supervisor during review of the emergency preparedness program and was acknowledged by the administrator during the exit conference on 4/16/18.

Based on records review, the facility failed to develop a communication plan that includes contact information.

The findings included:

Records review on 4/16/18 at 2:30 PM, revealed the facility could not provide a communication plan that included names and contact information for the following:

a. Staff.
b. Entities providing services under arrangement.
c. Patients' physicians
d. Other [facilities].
e. Volunteers

This finding was verified by the maintenance supervisor during review of the emergency preparedness program and was acknowledged by the administrator during the exit conference on 4/16/18.

Based on records review, the facility failed to provide a communication plan that included contact information for emergency officials.

The findings included:

Records review on 4/16/18 at 2:30 PM, the facility could not provide a communication plan that included a list with contact information for federal, state, regional, and local emergency preparedness staff.

This finding was verified by the maintenance supervisor during review of the emergency preparedness program and was acknowledged by the administrator during the exit conference on 4/16/18.

Based on record review, the facility failed to provide a communication plan that included a primary and alternate means for communicating with facility staff, Federal, State, tribal, regional, and local emergency management agencies in the emergency preparedness program.

The finding included:

Record review on 04/16/2018 at 2:30 PM, revealed the facility could not provide a communication plan that included a primary and alternate means for communicating with facility staff, Federal, State, tribal, regional, and local emergency management agencies during an emergency.

This finding was verified by the maintenance supervisor during review of the emergency preparedness program and was acknowledged by the administrator during the exit conference on 4/16/18.

Based on record review, the facility failed to develop a communication plan that included method of sharing information and medical documentation.

The findings included:

Record review on 4/16/18 at 2:30 PM, revealed the facility failed to provide a communication plan that included a means for sharing information and medical documentation for patients with other health care providers.

This finding was verified by the maintenance supervisor during review of the emergency preparedness program and was acknowledged by the administrator during the exit conference on 4/16/18.

Based on records review, the facility failed to develop a communication plan that included a means for sharing information on occupancy/needs.

The findings included:

Record review on 4/16/18 at 2:30 PM, revealed the facility failed to provide a communication plan that contained a means of providing information about the facility's occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.

This finding was verified by the maintenance supervisor during review of the emergency preparedness program and was acknowledged by the administrator during the exit conference on 4/16/18.

Based on record reviews, the facility failed to develop a written emergency preparedness training and testing program that is based on the emergency plan.

The findings included:

Record review on 4/16/18 at 2:30 PM, revealed the facility failed to develop a written emergency preparedness training and testing program that is based on the emergency plan.

This finding was verified by the maintenance supervisor during review of the emergency preparedness program and was acknowledged by the administrator during the exit conference on 4/16/18.

Based on program review and interview, the hospital failed to ensure all employees received training on emergency preparedness upon hire and at least annually.

The findings included:

1. Review of the hospital's Emergency Preparedness plan revealed it was last reviewed and updated in 2014.

2. During an interview in the conference room on 4/18/18 at 10:20 AM, the Chief Executive Officer verified there was no documented emergency preparedness training for employees.

Based on record review, the facility failed conduct exercises to test the emergency plan at least annually per the requirements of Federal CFR §483.475(d)(2)(i) and §483.475(d)(2)(ii).
The findings include:
Record review on 4/16/2018 at 2:30 PM, revealed the facility failed to participate in a full-scale community-based exercise and a second full-scale exercise that is community-based, individual facility-based, or a tabletop exercise that includes a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.

This finding was verified by the maintenance supervisor during review of the emergency preparedness program and was acknowledged by the administrator during the exit conference on 4/16/18.

Based on facility policy and interview, the facility failed to ensure the Chief Executive Officer (CEO), Medical Staff and Director Of Nursing were responsible for the implementation of the Infection Control Program (ICP).

The findings included:

1. Review of the facility's "INFECTION CONTROL PLAN 2016" policy revealed, "...The mission of the infection surveillance, prevention, and control program is to help reduce the possibility of acquiring and transmitting an infection and to promote the well-being of patients, healthcare workers, and visitors through a commitment to excellence and respectful patient care, effective use of resources, and continuous improvement. [Name of the Hospital], represented by the medical and administrative staff, along with the Board of Directors, recognize the need to formalize the infection control efforts. The board of directors of [name of hospital] directs that an Infection Prevention and Control Program be established and that this policy statement be adopted to ensure the organization has a functioning coordinated process in place to reduce the risks of endemic, epidemic, and healthcare acquired infections (HAI) in patients, visitors and healthcare workers...The goals of the program are to reduce or prevent the acquisition and transmission of potentially infectious agents by doing the following: 1. Identify expected and unexpected infections...2. Analyze practices...3. Institute changes as needed...4...educate personnel, patients and visitors...5. Coordinate and integrate infection prevention and control activities with medical staff...7. Assure [name of hospital] compliance with various regulatory and accrediting agency requirements on infection control issues..."

2. During an interview with Licensed Practical Nurse #7 on 4/17/18 at 2:15 PM in the conference room, LPN #7 stated she had been the Infection Control Officer during her previous employment at the facility. LPN #7 stated the facility currently did not have anyone designated as the Infection Control Officer. LPN #7 stated there was no current Infection control program in place and no evidence of an infection control program since September 2017.

During an interview on 4/17/18 at 3:30 PM in the conference room, the CEO stated she was unable to locate meeting minutes that included infection control and an infection control program.