HospitalInspections.org

Based on record review and interview, the Governing Body failed to ensure the members of the medical staff were accountable to the Governing Body for quality of care provided to patients. This deficient practice was evidenced by medical staff members not assessing and pronouncing death for 1 (#9) of 1 (#9) sampled patients reviewed for pronouncement of death from a total sample of 30.

Findings:

A review of hospital policy titled, Pronouncement of a Patient's Death in Louisiana last reviewed 04/2020 revealed in part:
A. Death Pronouncement
Louisiana Law defines that a physician must pronounce a patient's death. The attending physician may delegate the pronouncement to another physician which requires a physician order. The pronouncement of death must be preceded by the physician's personal evaluation and examination of the individual; therefore, this duty cannot be delegated to another healthcare provider. L.A. RS9:111 3.2

A review of Patient #9's medical record revealed she was admitted 03/16/2021 and died 03/27/2021.
Further reviewed revealed the nursing staff handed over the patient code to Ambulance Service A Paramedic who after 5 doses of Epinephrine called Hospital B Emergency Department, who called the code.

In an interview on 06/21/2021 at 3:10 p.m. S12DirTherapy verified the hospitals physician failed to pronounce Patient #9. He also verified the record failed to reveal an order for another physician to pronounce Patient #9.

Based on record review and interviews, the hospital failed to ensure each patient received complete information on how to file a grievance or/and complaint. This deficient practice was evidenced by the admission packet provided to the patient on admission to the hospital only having the phone numbers listed for Louisiana Department of Health, KEPRO Quality Improvement Organization and the hospital's phone number if the patient had questions with no further explanation provided for filing a verbal or written grievances and/or complaints. Findings:


Review of the hospital's policy titled, Patient/Family Grievance, revealed in part, B. Upon admission to the hospital, each patient will be provided a copy of the Patient's Rights and Responsibilities which includes information on the patient or his/her legal representative's right to file a complaint with United Medical Rehabilitation Hospital, the Louisiana Department of Health and Hospital as well as EQ Health Solutions (see contact information under Section O.)

Review of the Admission Packet provided to the patients and/or patient representatives on admission revealed, please feel free to call any of the numbers below should you have question: United Medical Rehabilitation Hospital of Hammond, KEPRO Quality Improvement Organization and Louisiana Department of Health and Hospital. There was no clear explanation on how and to whom to report a complaint and/or a grievance.

An interview was conducted with S10Case Manager on 06/21/2021 at 2:30 p.m. S10Case Manager reported the patients and patient's representative are verbally given instructions on how to file a complaint or grievance, but the only written information given to the patients and patient representatives is in the admission packet.

Based on record reviews and interview, the hospital failed to ensure a registered nurse supervised the nursing care for each patient. This deficient practice was evidenced by failure of the RN to obtain daily weights as ordered by the physician for 1 out of 1 patient (Patient #10) reviewed for daily weights out of a sample of 30 patients.
Findings:

Review of the physician orders for Patient #10 revealed an order dated 06/15/2021 for daily weights.

Review of the Electronic Medical Record, navigated by S4LPN, revealed the following dates daily weights were not documented on Patient #10; 06/16/2021, 06/17/2021, 06/18/2021, 06/19/2021, and 06/21/2021.

An interview was conducted with S4LPN on 06/23/2021 at 9:30 a.m. She confirmed the above daily weights were not documented in the patient's electronic medical record.

Based on record review and interview, the facility failed to provide supervision of the nursing staff. The deficient practice is evidenced by: 1) Failure of the nursing staff to provide care as ordered by the physician in 2 (#4, #7) of 8 (#1, #2, #3, #4, #5, #6, #7, #8) current patients from a sample of 30 patients and 2) Failure of 2(S2DON, S3ADON) of 3 (S2DON, S3ADON, S4LPN) nursing staff members to follow hospital policy after deficient practices were discovered.
Findings:

1. Failure of the nursing staff to provide care as ordered in 2 (#4, #7) of 8 (#1, #2, #3, #4, #5, #6, #7, #8) current patients from a sample of 30 patients.

Review of United Medical Rehabilitation Hospital Policy Number PH 8.0 revised 12/15 revealed in part, "At the TWELVE HOUR and MIDNIGHT chart checks, the nurse will: *Compare the original orders to the MAR. * Indicate any corrections or new orders on the MAR and fax a copy back to the pharmacy. *Midnight checks- compare the next 24-hour period's MAR with the previous one and the chart. * Corrections will appear on the MAR for the following day on midnight chart check."

Patient #4
Review the EMR for Patient #4, navigated by S3ADON on 06/21/2021 at 1:20 p.m., revealed Patient #4 was admitted for rehabilitation after a cerebral vascular accident and had Type II Diabetes.
Review of orders dated 06/08/2021 at 7:16 p.m. revealed the order- "Accucheck- Routine ACHS & at 2AM x 2days."
Review of the MAR dated 06/09/2021 revealed the following order- "Accuchecks before meals and at bedtime," with a start date of 06/08/2021. Accucheck was performed at 2:00 a.m. as per the original order.
Review of the MAR dated 06/10/2021 revealed the order- "Accuchecks before meals and at bedtime." 2:00 a.m. accucheck was not performed.
Interview on 06/21/2021 at 1:23 p.m., S3ADON reviewed Patient #4's record including the MAR, Nursing Notes and Vital Signs Record and verified the original- "Accucheck- Routine ACHS & at 2AM x 2days" was still an active order and had not been changed. The order on the MAR was incorrect.
Interview on 06/23/2021 at 10:10 a.m., S4LPN verified the MAR should be check against the orders at midnight review and the pharmacy notified of problems.

Patient # 7
Review of the EMR for Patient #7, navigated by S3ADON on 06/21/2021 at 1:30 p.m., revealed Patient #7 was admitted for rehabilitation after left hip replacement surgery and had a history of deep vein thrombosis.
Review of orders dated 06/182021 at 7:29 p.m. revealed the order- "Plexipulses- routine."
Review of the Nursing Notes, Therapeutic Administration Record, and Vital Signs Record for Patient #7 revealed the order was not initiated.
In combined interview on 06/21/ 2021 at 1:45 p.m., S2DON and S3ADON reviewed Patient #7's record and verified prescribed orders for care were not initiated. Patient #7 did not have plexipulses.

2. Failure of 2 (S2DON, S3ADON) of 3 (S2DON, S3ADON, S4LPN) nursing staff members to follow hospital policy after deficient practices were discovered.

Review of United Medical Rehabilitation Hospital Policy Number III-B.2.09 titled, "Occurrence Reporting," and revised 12/2017, revealed in part, the definition of an occurrence includes, "Deviations from established standards or guidelines." It continues," In cases where the Clinical Auditor identifies an occurrence based on his/her medical record review an occurrence report will be initiated ... within 24 hours of identifying the occurrence." "Staff members or members of the medical staff who initiate an occurrence report must submit the report to the Department Head within 24 hours of the occurrence." The policy states that, "any deficient practice identified which does not follow established standards, protocols or regulations. Investigation Follow-up is Root Cause Analysis."

In a combined interview on 06/21/2021 at 1:45 p.m., S2DON and S3ADON were informed of deviations in care involving 2 current patients.

Patient # 7
Review of the EMR for Patient #7, navigated by S3ADON on 06/21/2021 at 1:30 p.m., revealed Patient #7 was admitted for rehabilitation after left hip replacement surgery and had a history of deep vein thrombosis.
Review of orders dated 06/18/2021 at 7:29 p.m. revealed the order- "Plexipulses- routine."
Review of Nursing Notes, Therapeutic Administration Record, and Vital Signs Record for Patient #7 for all dates revealed the order was not initiated. The patient did not have plexipulses.

Patient # 8
Review of the EMR for Patient #8, navigated by S3ADON on 06/21/2021 at revealed she was admitted for rehabilitation after hospitalization for a cerebral vascular accident and pyelonephritis.
Review of orders dated 06/04/2021 at 5:02 p.m. revealed the order- "Ciprofloxacin 250 mg tablet/ 1 tablet by mouth twice daily for 4 days."
Review of the MAR dated 06/04/2021 revealed ciprofloxacin was given at 8:00 p.m.
Review of the MAR dated 06/05/2021 revealed ciprofloxacin was given at 8:00 a.m. and 8:00 p.m.
Review of the MAR dated 06/06/2021 revealed ciprofloxacin was given at 8:00 a.m. and 8:00 p.m.
Review of the MAR dated 06/07/2021 revealed ciprofloxacin 250 mg was given at 8:00 a.m. and 8:00 p.m. Further investigation of the MAR dated 06/07/2021 revealed that the duration of the order was changed from 4 days to 7 days, but an order for the change could not be found.
Review of the MAR dated 06/08/2021 revealed that the ciprofloxacin 250 mg was not given at 8:00 a.m. or 8:00 p.m. with a notation, "Not Available."
Review of the MAR dated 06/09/2021 revealed ciprofloxacin 250 mg was not given at 8:00 a.m. with the notation, "Unavailable to be pulled." Ciprofloxacin 250 mg was given at 11:00 a.m. and 8:00 p.m.

Combined interview on 06/21/2021 at 1:45 p.m. with S2DON and S3ADON, concerns for care of Patient #7 and Patient #8 were discussed. Concerning Patient #7, S4ADON verified that Patient #7 did not have plexipulses and stated, "The order needs to be discontinued." Concerning Patient #8, S2DON and S3ADON stated there were no problems with deliveries from the pharmacy, no known problems with getting ciprofloxacin, and that neither had been aware that Patient #8 had missed doses of antibiotic.

Interview on 06/23/2021 at 10:10 a.m. with S4LPN, concerns for care of Patient #7 and Patient #8 were discussed. Concerning Patient #7, when orders are placed for plexipulses, the supply company is called and the medical device is delivered quickly. Concerning Patient #8, S4LPN stated she had not been aware of the missed antibiotics. AS4LPN verified that nothing was done by S2DON and S3ADON after they were made aware of the deviations in care on 06/21/2021. S4LPN verified the physician should have been notified immediately on discovery and initiation of an occurrence report should have occurred within 24 hours of discovery for both of deviations of care.

Based on record review and interview, the hospital failed to administered drugs and biologicals by accepted standards of practice. This deficient practice is evidenced by:

1. Failing to monitor a patient's blood pressure prior to administration of Lopressor for 1 out of 1 patient (Patient #10) reviewed for blood pressure monitoring prior to administration of a blood pressure medication; and
2. Failing to give antibiotics as ordered for 2 of 2 (#8,#27) patients reviewed for proper antibiotic administration.


Findings:

Review of the hospital policy titled, Medication Administration, revealed in part, 4. 30-minute window is allotted for recent blood pressure or pulse vital signs when administering blood pressure or cardiac medications. If vital signs were obtained < 30 minutes of medication administration, the nurse will document on the medication administration record (MAR) either that the vital signs are stable or why medication are contraindicated/held. If vital signs were obtained >30 minutes of medication administration, the nurse will obtain a new set of vital signs to record with medication administration.

1. Failing to monitor a patient's blood pressure prior to administration of Lopressor.

Review of the Medication Administration Record (MAR) for Patient #10 revealed Metroprol Suc Tab 25mg ER generic for Toprol XL- Give one tablet by mouth once daily at 0800 (Omnicell). Review of Patient #10's MARs dated 06/16/2021, 06/17/2021, 06/18/2021, 06/19/2021, 06/20/2021, 06/21/2021 and 06/22/2021 revealed no documentation of a blood pressure obtained prior to administration of the Lopressor.

Review of the EMR, navigated by S4LPN revealed Patient #10's blood pressures were obtained between 5:30 a.m. and 6:30 a.m. on the 6/16/2021, 06/17/2021, 06/18/2021, 06/19/2021, 06/20/2021, 06/21/2021 and 06/22/2021. The Lopressor was documented as being given at 8:00 a.m.

An interview was conducted with S4LPN on 06/23/2021 at 9:30 a.m. She reported the nurse techs usually obtained vital signs between 6:00 a.m. and 6:30 a.m. and then the nurses document the vital signs in the EMR. S4LPN further reported in the past there was a reminder on the MARS to obtain the patients' blood pressure prior to administering blood pressure medications, but it is no longer on the patients' MARS.

2. Failing to give antibiotics as ordered for 2 of 2 (#8,#27) patients reviewed for proper antibiotic administration.

Review of the hospital policy titled, "Medication Administration," in part revealed, "The reason for omission will be indicated on the MAR and in the nurse's notes." "The nurse will notify the physician for any refusal or inability to give the medication so that an alternative may be selected by the physician.

Patient # 8
Review of the EMR for Patient #8, navigated by S3ADON on 06/21/2021 at revealed she was admitted for rehabilitation after hospitalization for a cerebral vascular accident and pyelonephritis.

Review of orders dated 06/04/2021 at 5:02 p.m. revealed the order- "Ciprofloxacin 250 mg tablet/ 1 tablet by mouth twice daily for 4 days."

Review of the MAR dated 06/04/2021 revealed ciprofloxacin was given at 8:00 p.m.

Review of the MAR dated 06/05/2021 revealed ciprofloxacin was given at 8:00 a.m. and 8:00 p.m.

Review of orders dated 06/06/2021 at 5:29 p.m. revealed the order-"Ciprofloxacin 250 mg tablet/ 1 tablet by mouth twice daily for 4 days," was "Discontinued, read back and verified."

Review of the MAR dated 06/06/2021 revealed ciprofloxacin was given at 8:00 a.m. and 8:00 p.m.

Review of the MAR dated 06/07/2021 revealed ciprofloxacin 250 mg was given at 8:00 a.m. and 8:00 p.m. Further investigation of the MAR dated 06/07/2021 revealed that the duration of the order was changed from 4 days to 7 days, but an order for the change could not be found.

Review of the MAR dated 06/08/2021 revealed that the ciprofloxacin 250 mg was not given at 8:00 a.m. or 8:00 p.m. with a notation, "Not Available."

Review of the nurse's notes dated 06/08/2021 revealed no evidence that the physician was notified of the inability to give the medication.

Review of the MAR dated 06/09/2021 revealed ciprofloxacin 250 mg was not given at 8:00 a.m. with the notation, "Unavailable to be pulled." Ciprofloxacin 250 mg was given for the date 06/09/2021 at 11:00 a.m. and 8:00 p.m.

Interview on 06/21/2021 at 1:45 p.m. with S2DON and S3ADON verified patient #8 had not received antibiotics as ordered, hospital policy was not followed, and the physician was not notified. S2DON and S4ADON verified the physician should have been notified and there had been no problems with pharmacy delivering medications.
In interview on 06/23/2021 at 10:10 am S4LPN verified that the orders for Patient #8 were discontinued on 06/06/2021 and the patient received medication after it was discontinued.

Patient #27
Review of the EMR for Patient #27 navigated by S4LPN on 06/23/2021 revealed he was admitted for rehabilitation due to myopathy and was re-diagnosed with C. difficile while at the facility.

Review of orders dated 02/22/2021at 9:15 p.m. revealed Vancomycin 125mg one p.o. every 6 hours for 10 days.

Review of the MAR dated 02/24/2021 revealed that the patient refused the 2:00 a.m. dose of Vancomycin 125 mg.

Review of the nurse's notes dated 02/24/2021 revealed no documentation of the refusal and no documentation the physician was notified.

Review of the MAR dated 02/25/2021 revealed the patient did not receive the 2:00 a.m. dose of Vancomycin 125 mg. No documentation on MAR of reason.

Review of the nurse's notes dated 02/25/2021 revealed no documentation of why Vancomycin 125 mg was not administered at 2:00 a.m. and no documentation of notification of the physician.

Interview on 06/23/2021 at 10:00 a.m. S4LPN verified that the nurse did not administer the medication as prescribed and failed to properly document the missed doses.





44495

Based on record review and interview, the hospital failed to ensure all patient medical records were promptly completed as evidenced by 1) failing to ensure the medical record contained the Louisiana Organ procurement Agency (LOPA) Notification of referral and the authorization of Release and Remains form within 30 days and 2) failing to ensure patients' paper medical records were stored in a secured area and where they would not be damaged by fire and water, if the sprinkler system was activated.

Findings:

1) Failing to ensure the medical record contained the Louisiana Organ procurement Agency (LOPA) Notification of referral and the authorization of Release and Remains form within 30 days.

A review of the hospital policy titled Patient Death last reviewed 04/2020 revealed in part:
2. Complete "Authorization of Release and Removal of Remains" form prior to release of body. Original copy stays with patient chart, copy sent with body to funeral home.

A review of the hospital policy titled Organ and Tissue Donation last reviewed 03/2020 revealed in part:
All deaths require completion of the Louisiana "Notification of Death" form or the hospital's equivalent death paperwork.

A review of Patient #9's medical record revealed she was admitted 03/16/2021 and died 03/27/2021.
Further review failed to reveal a completed Authorization of Release and Removal of Remains and the Louisiana Notification of Death forms.

In an interview on 06/21/2021 at 2:40 p.m. S12DirTherapy verified the missing forms from Patient #9's medical record.

2) Failing to ensure patients' paper medical records were stored in a secured area and where they would not be damaged by fire and water, if the sprinkler system was activated.

An observation of the Medical Records room revealed 4 cardboard boxes of patient medical records stored on top of the file cabinets with water sprinklers noted in the room.

In an interview on 06/22/2021 at 8:20 a.m. S6MR verified the medical records are being kept until the end of the year and that the records could be damaged by fire and water.

44495

Based on record review and interview the facility failed to ensure that all medical records contained sufficient information to identify the patient and included the date and time of treatment. This deficient practice is evidenced by 1) Failure to assure all pages in the medical record contained the date and time of treatment for 3 of 3 (#4, #7, #19) records reviewed for complete documentation and 2) Failure to assure all pages in the medical record contained the patient's name on 4 of 4 (#4. #7, #19, #26) records reviewed for complete documentation.
Findings:

1. Failure to assure the date of treatment was included on the MAR in 3 of 3 (#4, #7, #19) records reviewed for complete documentation.

Patient #4
Review of the medical record for Patient #4 on 06/21/2021 revealed the second page of each record labeled "TAR" did not contain a date or time. This deficiency applied to all dates of admission.
Interview on 06/21/2021 at 3:30 S2DON verified the record was not labeled with date or time.

Patient #7
Review of the medical record for Patient #7 on 06/21/2021 revealed the second page of each record labeled "TAR" did not contain a date or time. This deficiency applied to all dates of admission.
Interview on 06/21/2021 at 3:30 S2DON verified the record was not labeled with date or time.

Patient #19
Review of the medical record for patient #19 on 06/21/2021 revealed several pages of the MAR that do not contain a date.
Interview on 06/21/2021 at 3:30 S2DON verified the record was not labeled with a date.

2. Failure to assure all pages in the medical record contained the patient's name on 3 of 3 (#4. #7, #19) records reviewed for complete documentation.

Patient #4
Review of the medical record for Patient #4 on 06/21/2021 revealed the second page of each record labeled "TAR" did not contain the patient's name. This deficiency applied to all dates of admission.
Interview on 06/21/2021 at 3:30 S2DON verified the record was not labeled with the patient's name.

Patient #7
Review of the medical record for Patient #7 on 06/21/2021 revealed the second page of each record labeled "TAR" did not contain the patient's name. This deficiency applied to all dates of admission.
Interview on 06/21/2021 at 3:30 S2DON verified the record was not labeled with the patient's name.

Patient #19
Review of the medical record for Patient #19 on 06/21/2021 revealed the Interdisciplinary Rehabilitation Plan of Care and Weekly Team Conference record consisting of 24 pages was stamped and signed on the first page. The following pages did not contain the patient's name or any other identifying factor.
Interview on 06/ 21/2021 at 3:30 S2DON verified the record was not labeled with the patient's name.

Patient #26
A review of Patient #26's medical record revealed the Plan of Care and Weekly Team Conference failed to contain any patient identifiers to include patient name, on pages 2- 24.

In an interview on 06/22/2021 at 2:00 p.m. SS3ADON verified Patient #26's Plan of Care and Weekly Team Conference failed to contain any patient identifiers on pages 2- 24.

Based on observation and interviews, the hospital failed to ensure outdated, mislabeled, or otherwise unusable drugs and biologicals must not be available for patient use.

Findings:

A review of the hospital policy titled Medication Administration previous review 03/19 revealed in part:
Medications by injection:
Multi dose vial expires 28 days after opened and must be labeled.

An observation of Campus A's Stock Medication Cart contained the following opened undated and or expired medications.
a) 2 open bottles 1% 20 ml Lidocaine not dated;
b) 1 tube Lidocaine Hydrochloride Jelly open not dated;
c) 1 bottle Sore Throat Spray open and expired 05/16/2021;
d) 1 bottle Sore Throat Spray open and expired 03/14/2020;
e) 1 bottle Chlorhexidine Gluconate 0.12% expired 06/19/2020;
f) 1 open bottle 250/5 ml Valproic Acid expired 06/07/2021;
g) 1 tube Nystatin Cream 100,000 USP open and expired 05/26/2021;
h) Hemorrhoid Ointment 2 oz. open and expired 05/03/2021;
i) Clotrimazole and Betamethasone Dipropionate Cream 1% open and not dated.

In an interview on 06/21/2021 at 10:15 a.m. S4LPN verified the above medications

An observation of Campus B's Wound Care Cart revealed:
a) 1 red top vacutainer expired 11/30/2020;
b) 1 Tube Silver Nitrate Applicators expired December 2019
c) 1 tube expired April 2021 and 1 debridement tray expired 09/30/2018.

In an interview 06/22/2021 at 9:30 a.m. S5Adm2 verified the findings during the tour for Campus B.

Based on record review and interview, the hospital failed to ensure medication administration errors were documented in the patients' medical records and reported to the attending physician as evidenced by:
1) failing to ensure known medication errors were documented in the patients' medical record and reported to the physician for 3 of 3 (#20, #21, #22) sampled patients reviewed with known medication errors out of a total sample of 30, and;
2) failing to document an incident report and notify the physician of a medication error for 1 of 1 (#8) current sampled patients with a medication error out of a total sample of 30.

Findings:
1) failing to ensure known medication errors were documented in the patients' medical record and reported to the physician for 3 of 3 (#20, #21, #22) sampled patients reviewed with known medication errors.

Review of the hospital policy titled, Administration of Medication: Error Reporting, revealed in part, when medication is administered improperly or a drug reaction occurs, the following procedure is used: 1. Notify Director of Nursing or Assistant Director of Nursing 2. Notify physician immediately 3. Record occurrence in nurses' notes...

Patient #20
Review of the Incident Report for Patient #20, dated 03/14/21, revealed Zyvox 600 mg po Q12 hours was not administered as ordered on 03/14/2021. The first and second dose was not given.

Review of the EMR for Patient #20, navigated by S2DON, revealed no documentation of the missed doses of antibiotics in the Patient #20's medical record and no documentation the physician was notified of the missed doses of antibiotics.

Patient #21

Review of the Incident Report for Patient #21, dated 01/29/2021, revealed Gabapentin 100 mg po TID was ordered on admission. It was printed out as 300 mg po TID on the MAR. Five doses of Gabapentin 300 mg were administered prior to the mistake being found.

Review of the EMR for Patient #21, navigated by S2DON, revealed no documentation of the increase dose of Gabapentin in the patient's medical record and no indication the physician was notified of the medication error.

Patient #22

Review of the Incident Report for Patient #22, dated 02/08/2020, revealed Vancomycin 125 mg capsule- 1 capsule by mouth q 6 hours for 10 days was not administered as ordered. Two doses of Vancomycin were not administered on 02/08/2021 as ordered.

Review of the EMR for Patient #22, navigated by S2DON, revealed no documentation of the missed doses of Vancomycin in the patient's medical record and no indication the physician was notified of the medication error.

An interview was conducted with S2DON on 06/22/2021 at 12:00 p.m. She reported she was not aware the incidents should have been documented in the patients' medical record, but she further reported the physician should have been notified of all the medication errors.

Based on observation and interview, the hospital failed to ensure all equipment was maintained in a manner to ensure an acceptable level of safety and/or quality as evidenced by 1) failing to ensure the functionality of a nurse call button located on the handrails of 25 of 40 patient beds and 2) failing to ensure patient beds at Campus A were maintained and free from defects.

Findings:

1) Failing to ensure the functionality of a nurse call button located on the handrails of 25 of 40 patient beds

A tour of Campus A revealed Patient rooms a- p contained beds with nonfunctioning call bell system on the upper handrails of the beds.

In an interview on 06/21/2021 at 9:35 am S4LPN verified the nonfunctioning bed call bell systems on Campus A.

A tour of Campus B revealed Patient rooms aa, bb, cc, dd, ee, ff, gg, hh, and ii contained patient beds with nonfunctioning call bell system on the upper handrails of the beds.

In an interview on 06/22/2021 at 9:30 a.m. S5Adm2 verified the nonfunctioning bed call bell systems on Campus B.

2) Failing to ensure patient beds at Campus A were maintained and free from defects.

A tour of Campus A on 06/21/2021 at 9:55 a.m. revealed frayed cords on 4 beds (a, c, o, p) of 6 beds (a, b, c, d, o, p) examined for maintenance of beds.

Interview on 06/21/2021 at 10:00 a.m. S4LPN verified that the above mentioned cords were frayed and a hazard for patients.


44495

38777



Based on record review, observations and interviews, the hospital failed to identify, report, investigate and control infections and communicable diseases of patients and personnel. This deficient practice was evidenced by the hospital failing to maintain a sanitary environment.

Findings:

A tour of Campus A revealed:

1. A dialysis machine was stored in a bathroom with a toilet;
An interview was conducted with S9Dialysis on 06/21/2021 at 9:30 a.m. S9Dialysis reported it was not the ideal location to store a dialysis machine.

2. The AED machine and suction machine on top of the code cart was covered with dust and debris;
An interview was conducted with S4LPN on 6/20/2021 at 9:30 a.m. S4LPN confirmed the equipment was dirty and needed to be cleaned.

3. The medicine cart drawers had loose pills and debris in the bottom of the drawers and the pill crusher on the top of the medicine cart was dirty. The observation was confirmed by S11RN.

4. The clean linen was stored uncovered in a storage room;

5. The dirty housekeeping cart was stored in the clean equipment closet.

In an interview on 06/21/2021 at 10:00 a.m. S4LPN verified the uncovered clean linen and the dirty housekeeping cart.

A tour of Campus B revealed:

1. Clean patient equipment was stored in the women's bathroom;

2. Clean linen was stored uncovered in 2 closets with the doors within the laundry room;

3. An observation of the kitchen failed to reveal temperature logs for the patient nourishment refrigerator and freezer;

A review of the hospital policy titled Infection Control Subject Refrigerator Guidelines revealed in part:
Temperatures are to be recorded daily on Log by designated staff member.

4. An observation of the food temperature log failed to reveal food temperatures for May 2-8, 11- 31, 2021 and the entire month of June 2021.

In an interview on 06/22/2021 at 8:30 a.m. S7DieTec verified the missing refrigerator, freezer and patient food temperature logs and also stated she did not have any logs for the 3 compartment sink to show the chemicals met the manufactures recommended concentration for sanitation.

5.An observation of the patient nourishment refrigerator revealed: 2- 1% low fat 1/2/ pint milk expired April 16, 2021 and 4- 4.2 fl. Oz Cranberry Juice exp. May 19, 2021;

In an interview 06/22/2021 at 9:30 a.m. S5Adm2 verified the findings during the tour for Campus B.

Based on interview, the hospital failed to ensure its emergency preparedness training program included training in emergency preparedness policies and procedures to all new and existing staff and individuals providing services under arrangement upon hire and at least annually.

Findings:

A review of the following employee personnel files failed to reveal training in emergency preparedness policies and procedures to all new and existing staff and individuals providing services under arrangement upon hire and at least annually: S2DON, S3ADON, S17OT, S18LPN, S19RN, S20CNA, S21RehabTec, S5Adm2, S23RN, and S24RN.

In an interview on 06/23/2021 at 1240 p.m. S22CorpTherOff and S12DirTherapy reviewed the employee files and verified the missing information.