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Base on review of documentation, and interviews with the CAH staff, the CAH failed to ensure the health and safety of the patients as the state license had expired.

Findings were:

In an interview with staff #1 on 12/3/19 at 10:52 am, staff #1 said the state license had expired. Staff #1 said they were waiting for the state fire marshal to sign off on the deficiencies from the building inspection report which had been corrected. The surveyor was given documentation of communication with the state fire marshal. As of the date of the survey the state license had expired.

Based on observation, review of documentation, and interviews with facility staff, the facility failed to ensure that all direct patient care employees maintained a current Cardio Pulmonary Resuscitation (CPR) certification or a current Trauma Nursing Core Course (TNCC) in accordance with facility policy.

The facility policy titled, "Cardio-Pulmonary Resuscitation Certification," states, "All patient care provider employees including nursing personnel (Registered Nurses, Licensed Vocational Nurses) must be certified every two years in the performance of CPR. All other personnel should at least take the heart savers course every two years."

The facility "Registered Nurse (RN) Job Description," states, "Job Specific Competencies: Maintains specialized education requirements (ACLS, PALS, TNCC) and familiarity with policies and procedures which dictate when to implement emergency hospital and/or department operation and procedures in response to internal or external disasters/trauma."

During the review of medical personnel records on 12/4/19, it was observed:
- Staff #23 (RN) did not have a current CPR certification
- Staff #25 (RN) did not have a current CPR and current TNCC certification


In an interview with Staff #3 on the afternoon of 12/4/19, Staff #3 acknowledged the findings above.

Based on observation and interviews with the facility staff, the facility failed to ensure that expired supplies were removed and thus not potentially available for use.

The findings were:

During the tour of the facility on 12/2/19, it was observed:
2nd Floor Radiology Crash Cart
- Pediatric defibrillator pad x1 expired 10/13/19

2nd Floor Geriatric Psych Unit
- Hand sanitizer x3 bottles expired 9/2018

Emergency Room #2
- AirLife Arterial Blood Sampler kit x2 expired 3/7/19

Emergency Room #3
- Tiger Top test tube x2 expired 8/31/19
- Culture swab x2 expired 8/31/19
- Thin Prep Pap Test x3 containers expired 5/4/19

Computed Tomography (CT) Room
- Pediatric defibrillator pad x1 expired 10/13/19
- Gastrografin x1 bottle expired 2/2019

In an interview with Staff #3 on the afternoon of 12/2/19, Staff #3 acknowledged the findings above.


During the tour of the facility on 12/3/19, it was observed:
Physical Therapy Wound Care Room
- BD EZ Scrub 4% CHG x17 expired 1/2019
- Sterile tongue depressor x1 box (100 count) expired 7/201733.5
- Sterile tongue depressor x 7 blades expired 9/2018
- Microcyn 33.5 oz x3 bottles expired 5/2019
- Algidex Ag West Gauze x3 boxes (25 count) expired 8/2016
- Acticoat Flex x3 boxes expired 5/2019
- Gentian Violet x1 bottle expired 10/2018
- Silver Nitrate applicator x1 container expired 5/2018
- Iodosorb Cadexomer Iodine Gel x3 boxes expired 11/2019
- Iodosorb Cadexomer Iodine Gel x5 boxes expired 12/2018

3rd Floor Medical-Surgical Unit
- ChloraPrep One-Step x1 expired 1/2018
- ChloraPrep One-Step x2 expired 9/2019

In an interview with Staff #20 on the afternoon of 12/3/19, Staff #3 acknowledged the findings above.

Based on observation, document review, and interviews the CAH failed to maintain a clean and sanitary environment to ensure patient's health, safety and mitigate risks of possible (HAI) hospital acquired infections, transmissions of infectious diseases, and communicable diseases in physical therapy wound treatment room, geriatric intensive outpatient unit (IOP), in-patient rooms, and the emergency department. These deficient practices have the likelihood to cause harm to all patients and staff.

Findings include:
Geriatric intensive outpatient unit (IOP)
During a tour of the dining area on the Geriatric Psych Unit 12/2/19 at 2:45 pm accompanied by staff # 8, program manager the following was observed;
1. Top surface of the two heating/cooling units were rusty. It is impossible to clean rust.
2. Debris and worn shelf bottom appearing to be water damage was observed under the sink.
3. Three Bottles of hand sanitizer on the table tops were expired 9/2018 causing the sanitizer not to be effective.
4. Microwave contained brown stains, greasy debris.
5. Refrigerator contained brown color stains on the outside, top of refrigerator was covered in gray/black dirt and grime. Inside of the refrigerator the shelves were stained with food, liquids, dirty with debris. Juices, ensure, drinks and a frozen dinner were in the refrigerator available for patient use.
6. Brown oblong table finish was peeling exposing the brown material underneath which is impossible to clean.
7. White stain dirty plastic bin containing crackers was in the pantry available for patient use.
8. Edge of wall was crumbling exposing the white crumbling underneath.

During a tour of the Geriatric Psych Therapy Room, accompanied by staff #8 the following was observed;
1. Dents and holes were observed in the wall with paint peeling and the wall material crumbling.
2. Two black chairs were stained, available for patient use.

During a tour of the Emergency Department 12/2/19 at 3:45 pm, accompanied by staff #3, Director of Nursing (DON) the following was observed
1. Navy wheelchair arm pads were crack exposing the white material underneath causing potential for transmission of infection.
2. Patient supplies urine specimen containers, disposable sheets and 1 ceiling tile was observed under the sink.
3. Un-covered linen, pillow cases, blankets, and towels were observed on top of the blanket warmer. The linen and laundry were noted to be uncovered and exposed to environmental hazards.

Cat Scan Area Emergency Department
1. 4-5-inch area on edge of the cat scan table contain gummy sticky tape, impossible to clean.

During a tour of the physical therapy department on 12/3/19 at 9:00 am the following was observed in the wound care room.
1.White fan covered with gray dust dirt was observed in the wound care room where patient care is performed.
2. 2 black and 1 blue circular pads were observed on the sink with 3 pair of black handle scissors on paper towels. In an interview, staff # 12 said the ground pads are washed in the sink, place on paper towels to dry on the side of the sink for reuse. This creates potential for transmission of infection. The pads are next to the faucet/sink where staff washed their hands.
3. Whirlpool was uncovered. Review of policy #VII R. January 2001, revised 8/2010, Whirlpool treatments, page 4; stated, "29. All whirlpools will be covered with plastic bags to help keep contaminants out of the whirlpools.

During an interview 12/3/19 at 9:36 am with staff #12 physical therapy director, staff # 12 said the whirlpool is used, but not often. During the interview the surveyor asked staff #12 how often are infection control rounds performed? Staff #12 said I don't know. Staff # 12 agreed with the findings.

During a tour of the in-patient floor on 12/3/19 at 10:15 am accompanied by staff #3 DON, the bedside table legs were covered with rust in room 312 and 313. The bedside tables were at the bedside available for patient use. It is impossible to clean rust. Staff #3 agreed with the findings.

Based on interviews with staff and review of documentation the CAH governing body fail to have an effective quality assurance program to evaluate the quality and appropriateness of the infection control program.

Findings were:
In an interview at the facility on 12/4/19 at 10:36 am with staff #5 Infection Control Coordinator said she has not done any environmental rounds. Staff #5 said she depends on the staff to notify her of environmental deficiencies.

Review of form Key Function Sheet revealed "Performance measures whirlpool cleanliness. Threshold/Benchmark 100%. Data source culture reports. In an interview with staff #5 stated there were no culture reports for the whirlpool."

Review of Environmental Cultures, Policy Number: V11 X. Revised 8/2010 stated, "Culturing is done on all whirlpools with in the first week of each month. Additional environmental may be ordered by Physical Therapy Department Director, Physical Therapy Department Assistant Director or Infection Control Nurse to: provide basis for in-service education on departmental level in proper maintenance of hospital environment."

Infection Control Policies. Functions of Infection Control Committee: 1. Establish a systematic review and reporting. 3. Review cleaning and aseptic techniques of each department concerned with infection control.
Review of Department managers quality improvement meeting September 19, 2019 revealed Physical Therapy, all criteria are being met. There was no documentation in the report revealing environmental rounds from the infection control department.

In the interview with staff #5 said she does not attend the quality meetings only the monthly infection control committee meetings. Staff #5 agreed with the findings.

Based on review of documentation and interview, the facility failed to develop and maintain an Emergency Preparedness plan that included all of the required elements for CFR 491.12(a). This presents a risk that facility staff will not be prepared to respond in an emergency situation.

Cross refer to E0006 plan based on all hazard risk assessment
Cross refer to E0036 ep training and testing
Cross refer to E0037 ep training program

Based on review of documentation and interviews with facility staff, the facility failed to implement an emergency plan that includes a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach; and including strategies for addressing emergency event identified by the risk assessment.

The findings were:

During the review of the facility's current emergency preparedness plan on the afternoon of 12/3/19, no documentation could be found or provided to surveyor to indicate an all-hazards risk assessment has been performed.

In an interview with Staff #6 and Staff #20 on the afternoon of 12/3/19, both staff members acknowledged the findings above.

Based on observation, review of documentation and interviews with facility staff, the facility failed to ensure that the Emergency Preparedness plan included staff training and testing program based on the emergency plan, risk assessment, policies and procedures, and the communication. The training and testing program must be reviewed and updated at least annually.

During the review of the facility's current emergency preparedness plan on the afternoon of 12/3/19, no documentation could be found or provided to surveyor to indicate that the facility developed and implemented a plan for providing staff training and testing on emergency preparedness.

In an interview with Staff #6 and Staff #20 on the afternoon of 12/3/19, both staff members acknowledged the findings above. Staff #20 stated, "We don't have a hospital wide disaster training program."

Based on review of documentation and interviews with facility staff, the facility failed to provide initial and/or ongoing training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. This failure could limit the ability of the facility staff, volunteers and individuals providing services under arrangement to react with proper knowledge and actions prior to, and during emergency situations.

During the review of the facility's current emergency preparedness plan and employee training records on the afternoon of 12/3/19, no documentation could be found or provided to surveyor to indicate that the facility provided initial and/or ongoing training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role.

In an interview with Staff #6 and Staff #20 on the afternoon of 12/3/19, both staff members acknowledged the findings above.