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Based on review of facility documents and staff interview (EMP), it was determined that the facility failed to ensure the emergency preparedness plan was updated every two years and the facility failed to ensure policies and procedures were revised as needed for five of five policies and procedures reviewed.

Findings include:

Review on December 11, 2025, of the "Bucktail Medical Center Policy and Procedure Issuing Department: Administration Category: General Subject: Departmental Policy Manuals and Changes," last revised June 29, 2005 and last reviewed January 29, 2025, revealed "Policy: All departments are required to develop and maintain a policy and procedure manual specific to that department's operations, which shall contain the information necessary to meet requirements of the Commonwealth of Pennsylvania and Department of Health. Procedure: 1. All manuals shall be revised as needed and reviewed on an annual basis with documented proof of review. ... 3. The facility recognizes as circumstances and situations change, our policies and procedures must reflect those changes. ..."

Review on December 11, 2025, of the "Bucktail Medical Center Disaster Manual Telephone Chain of Command in the Event of Major Disasters," last reviewed January 29, 2025, revealed " ... Contact Person: ... Director of Nursing: OTH1 ... Registration: OTH2 ... Social Service: OTH3 ... Use this list and check off the staff that were called for the disaster ...", "Bucktail Medical Center Disaster Manual Telephone Chain Of Command In The Event Of Major Disasters", last revised February 2012 and last reviewed January 29, 2025, revealed "Contact Person ... 1. Administrator: OTH4 ... 2. Safety Director: OTH5 ... 3. Maintenance: OTH6 If not there... OTH7 ... 5. Director of Nursing: Acute OTH8 ... SNF OTH9 ... OTH10 ... 6. X-ray Tech On-Call: OTH11 ... 7. Laboratory Tech On-Call: OTH12 ... 8. Registration: OTH13 ... 9. Purchasing: OTH14 ... 10. Pharmacy: OTH15 ...11. Social Services: OTH16 ... 12. Housekeeping/Diet: OTH17 ... OTH18 ... Use this list and check off as people are called in for a disaster. ... Bucktail Medical Center ... Function ... Personnel Responsible," last revised February 2025, revealed "... Staff and Conduct Blood Bank: OTH19 ... Patient/Family Liaison: OTH3 Progress Reports: OTH20 ... Prepare Food: OTH21 ..."

Interview with EMP3 on December 11, 2025, at 1600 verified the findings noted above. EMP3 confirmed OTH1, OTH2, OTH3, OTH4, OTH5, OTH6, OCT7, OTH8, OTH9, OTH10, OTH11, OTH12, OTH13, OTH14, OTH15, OTH16, OTH17, OTH18, OTH19, OTH20 and OTH21 are no longer employeed at the facility. EMP3 confirmed the disaster phone chain of command and function personnel responsible did not contain the correct responsible staff names.

Interview with EMP2 on December 11, 2025, at 1610 verified the findings noted above. EMP2 confirmed OTH4, OTH5, OTH6, OTH11, OTH12, OTH15, OTH16, and OTH17 left several years ago, OTH7, OTH8 and OTH21 left in 2022, OTH13 and OTH20 left in 2023, OTH2 left June 2024, OTH1 and OTH18 left April 2025, OTH9, OTH10, and OTH19 left May 2025, OTH3 left August 2025, and OTH14 left October 2025. EMP2 confirmed the Contact list was not current.

Review on December 9, 2025, of the "Bucktail Medical Center Disaster Preparedness and Emergency Response Plan," revealed the last update was July 30, 2019.

Interview with EMP1 on December 9, 2025, at 1215 confirmed the facility did not update the Emergency Preparedness Plan in the past two years.

A request was made of EMP1 on December 9, 2025, for a policy specific to the update of the Emergency Preparedness Plan. None was provided.

Interview with EMP1 on December 9, 2025, at 1215 revealed the facility does not have a policy specific to the update of the Emergency Preparedness Plan.

Based on review of facility documents, observation, and staff interview (EMP), it was determined the facility failed to label an opened multi-dose vial and failed to remove and dispose of 26 expired medication tablets per facility policy.

Review on December 9, 2025, of the facility policy, "Ampules and Multi-Dose Vials", last reviewed, January 29, 2025, revealed "Policy: It is the policy of the Bucktail Medical Center patients will not receive medication that is not dated, mislabeled, or otherwise unusable. Procedure ... 2. The date opened and the initials of the first person to use a multi-dose vial are recorded on the vial ... "

Observation of the Emergency Department on December 9, 2025, at 1000 with EMP3 revealed a locked cabinet with a multi-dose vial of Lidocaine 1% (local anesthetic) that had been opened and did not have an intact sealed cap. The vial did not contain the date it was opened or the initials of the person who opened the vial.

Interview with EMP3 on December 9, 2025, at approximately 1005 confirmed this vial had been opened and should have been labeled with the date it was opened and the initials of the person who opened the vial.

Review on December 9, 2025, of the facility policy, "Outdated Drugs, Devices and Supplies", last reviewed, January 29, 2025, revealed "Policy: Nursing staff will have a method of meeting the responsibility and achieving the goal of identifying and disposing outdated, visibly deteriorated, recalled, discontinued, of [sic] obsolete drugs and supplies. Procedure ...3. Any drug of [sic] supply which is outdated ...will be disposed of according to policy."

Observation of the Pharmacy on December 9, 2025, at 1015 with EMP3 revealed a medication drawer with stock medications. This drawer contained the medication, Metoprolol 50mg tablet. There was a total of 26 Metoprolol tablets with an expiration date of November 25, 2025.

Interview with EMP3 on December 9, 2025, at approximately 1015 confirmed the above findings. EMP3 confirmed these tablets were expired and should have been removed from the stock medication drawer.

Based on review of facility documents and staff interview (EMP), it was determined that the facility failed to ensure documentation of all attendees at the Infection Control Committee meeting for two of three meetings, and documentation of all attendees at the Pharmacy & Therapeutic Committee meetings for three (3) out of four (4) meetings.

Findings include:

Review on December 11, 2025 of the Pharmacy & Therapeutic Committee meeting minutes for September 25, 2024, January 24, 2024, and July 30, 2025, and the Infection Control Committee meeting minutes for July 20, 2025 and October 1, 2025, revealed there was no signature of a Pharmacy representative.

Interview with EMP2 on December 11, 2025, at 1315, confirmed the findings noted above. EMP2 revealed a pharmacist may attend the meetings onsite or via phone. EMP2 revealed OTH22 was not on the attendee list for the Pharmacy & Therapeutic Committee and the Infection Control Committee meetings.

Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined that the facility failed to ensure the Gift of Life monthly report was reconciled with the facility death list for two of eight deaths (MR16 and MR17).

Findings include:

Review on December 11, 2025 of the facility policy, "Organ and/or Tissue Donation", last reviewed January 29, 2025, revealed "Policy: In accordance with Pennsylvania's Uniform Anatomic Gift Act as amended December 1994 (PA Act 102), all acute hospitals are required to develop policies and procedures to ensure the routine referral of all deaths or pending deaths to their regional Organ Procurement Organization (OPO) for the determination of medical suitability for organ tissue and eye donations with attending physician or his/her designee. ..."

Review on December 11, 2025 of the "Death Summary Report from December 1, 2024 to February 28, 2025," revealed MR17 expired on February 24, 2025.

Review on December 11, 2025, of "Donation & Referral Activity Report for Bucktail Medical Center February 1, 2025 - February 28, 2025," revealed MR 16 expired on February 7, 2025.

Interview with EMP3 on December 11, 2025, at 1115 confirmed the findings noted above. EMP3 revealed the facility death summary report from December 1, 2024 to February 28, 2025, was missing documentation of MR16 death on February 7, 2025. EMP3 revealed the Donation & Referral Activity Report dated February 1, 2025 - February 28, 2025, was missing documentation MR17 death on February 25, 2025. EMP3 confirmed these reports are to be reconciled monthly when the facility receives their OPO report.