HospitalInspections.org

Based on observations and interviews with staff during a tour of the hospital by Life Safety Code, it was determined the hospital was not constructed, arranged and maintained to ensure patient safety.

This had the potential to affect all patients served by this hospital.

Findings include:

Refer to tags: K-0211, K-0321, K-0324, K-0345, K-0351, K-0353, K-0741, and
K-0923.

Based on review of the emergency preparedness program, and staff interview, it was determined the agency failed to ensure the emergency preparedness program described a comprehensive approach to meeting the health, safety and security needs of staff and patients during an emergency or disaster situation.

This had the potential to negatively affect all patients, staff and visitors served by the hospital.

Findings include:

Refer to: E004, E006, E007, E009, E018, E036 and E037

Based on a review of the Bylaws, Rules and Regulations, it was determined the Governing Body failed to ensure the Rules and Regulations were updated to include a Nurse Practioner (NP) being listed among the medical professionals allowed to perform the Medical Screening Exam (MSE) in the Emergency Department (ED).

This had the potential to affect all patients served by the hospital's ED.

Findings Include:

Elmore Community Hospital's Medical Staff Rules and Regulations...

F. Emergency Services..

7. If any individual, regardless of the ability to pay, comes by him/herself or with another person to the Emergency Department and a request is made on the individual's behalf for examination or treatment of a medical condition by qualified medical medical personnel...
...The examination will be conducted by the Emergency Room Physician with the assistance of the Emergency Room Nurse...

An interview was conducted on 6/19/25 at 1:02 PM with Employee Identifier # 14, Chief Operating Officer, who confirmed the hospital failed to update the Rules and Regulations to include allowing the NP to perform the medical screening exam in the ED.

Based on policy review and interviews with staff it was determined the Governing Body failed to assure that all hospital policy and procedures were approved every three years.

This had the potential to affect all patients served by the facility.

Findings include:

A review of the policy and procedures revealed there were policies not reviewed and approved in five years or more.

An interview was conducted on 6/19/25 at 1:02 PM with Employee Indentifer # 1, Director of Nursing, who confirmed the policies had not been reviewed, and all policies should be reviewed at least every three years.

Based on medical record (MR) review, hospital policy and procedure, and interview, it was determined the hospital failed to ensure a physician order was obtained prior to administration of blood products.

This deficient practice affected Patient Identifier (PI) # 9, one of two MRs reviewed for administration of blood products and had the potential to affect all patients receiving blood at this hospital.

Findings include:

Hospital Policy: Blood and Blood Product Administration
Policy Number: None listed
Review date: 6/1/25

Purpose: The purpose pf this policy is to outline nursing responsibilities for the administration of blood and blood products...

...Policy: Only physicians and mid-level providers may order transfusion of blood or blood products...

Procedure:
Pre-transfusion

A... Access physicians orders in CPSI (electronic medical record) review and print it...

1. PI # 9 was admitted to the hospital on 4/16/25 with a diagnosis of Urinary Tract Infection and Clostridium Difficile.

Review of the MR revealed Employee Identifier (EI) # 13, RN, administered a unit of packed red blood cells intravenously to PI # 9 on 4/18/25 at 3:30 PM.

Further review of the MR revealed there was no physician order for the unit of blood administered.

The RN failed to obtain and document a physician's order prior to administration of the packed red blood cells.

An interview was conducted on 6/19/25 at 12:55 PM with EI # 12, medical scribe, who confirmed there was no physician order within the MR for the unit of packed red blood cells administered to PI # 9.

Based on medical record (MR) review, hospital policy and procedure, and interviews with staff it was determined the hospital failed to ensure the staff documented the wound care provided per the policy and procedure.

This did affect PI # 10, one of two wound care medical records reviewed, and had the potential to affect all wound care patients served by this facility.

Findings include:

Hospital Policy and Procedure: Dressing changes: Wet, Dry or Sterile.

Policy number: None listed

Revision date: 4/2013

...Guidelines:...

25. Document time, amount and character of drainage, condition of wound and surrounding area, presence of odor, type of dressing applied, any type of solution used and the patient's response to the procedure...


1. PI # 10 was admitted to the facility on 5/2/25 with a diagnosis of Wound Dehiscence.

A review of the physician order dated 5/2/25, revealed the following, Wound Vac (vacuum-assisted closure) Orders: Apply the Wound Vac to ulcer on left leg lateral to knee, use foam dressing, Pressure 125 millimeters of mercury continuous. Change Monday, Wednesday and Friday. Replace canister only when full.

A review of the wound assessment document dated 5/5/25, 5/7/25, 5/9/25, 5/12/25, 5/15/25, 5/19/25, 5/21/25 and 5/23/25 revealed no documentation of the wound care provided.

An interview was conducted on 6/19/25 at 12:52 PM with Employee Indentifer # 1, Director of Nursing, who confirmed the staff failed to complete documentation of the wound care provided.

Based on observation, hospital policy review, and interviews, it was determined the hospital failed to ensure expired medications and biologicals were not available for patient use.

This deficient practice had the potential to negatively affect all patients served by this hospital.

Findings include:

Hospital Policy: Checking for Expired Supplies
Policy Number: None
Effective Date: 3/14
Purpose: To prevent the use of expired supplies

Policy:

1. All departments that have supply rooms, supply closets, refrigerators...will maintain a monthly check of inventory to make sure supplies are in date and properly stored.

2. All departments that have supplies will maintain a running log to monitor inventory.

A tour of the operating rooms (ORs) was conducted on 6/18/25 at 8:45 AM.

During the tour of OR 1, OR 2, and the Endoscopy room, multiple medications and supplies were found to be expired in the anesthesia carts, including but not limited to:

OR 1

Succinylcholine chloride 10 milliliter (ml) multidose vial (MDV) x1 expired 02/2025
Dexmedetomidine 2 ml single dose vial (SDV) x 8 expired 9/2024
Isoflurane liquid for inhalation 250 ml bottle x2 expired 5/31/23
Hypodermic needle 25 gauge (g) 1.5 inch x 3 with an expired 3/2019
Laryngeal mask airways (LMA) size 1.5 x1 expired 1/28/22, size 2.5 x1 expired 12/28/21

OR 2

LMA size 1.5 x 9 expired 1/28/22
Intranasal mucosal atomization device (MAD Nasal) x1 expired 8/2017
LMA size 5 x1 expired 10/28/19
Flexicare Brite Blade Pro fiberoptic metal disposable laryngoscope blade x1 expired 11/1/23 and x1 expired 7/1/24
Covidien Mallinckrodt intubating stylet 14 french x1 expired 11/24/21

Endoscopy

Succinylcholine chloride 10 ml MDV x1 expired 9/2021
Braun safety intravenous catheter 22 g x1 expired 5/1/22, x1 expired 5/1/23, and 20 g x2 expired 8/31/23

During an interview conducted on 6/18/25 at 8:10 AM with Employee Identifier (EI) # 8, Certified Registered Nurse Anesthetist (CRNA), EI # 8 stated he/she is responsible for stocking and maintaining the anesthesia carts in the ORs.

An interview conducted on 6/18/25 at 11:00 AM with EI # 15, OR Director, confirmed the CRNA is responsible for maintaining the anesthesia carts and ensuring expired medications and supplies are not available for patient use.

Based on preventative maintenance record review and interviews with staff it was determined the hospital failed to perform preventative maintenance (PM) or maintain contracted services for PM of the radiology equipment.

This had the potential to affect all patients served by the radiology department.

Findings include:

During a tour of the radiology department with Employee Identifier (EI) # 6, Radiology Director, the surveyor requested to review the preventative maintance records for the radiology equipment. None were given.

An interview was conducted on 6/18/25 at 9:25 AM, with EI # 6, who confirmed the radiology department did not have any PM records. The hospital did not have contracted services to perform PMs of the equipment, nor did the hospital perform the PM checks. The department only had corrective maintenance performed when equipment needed repair.

Based on observations, manufacturer's directions for use (DFU) for Ecolab Trupower Ultra San dishwasher rinse solution, and interviews with staff it was determined the facility failed to test the dishwasher rinse solution for proper concentration of chlorine.

This had the potential to affect all patients admitted to this hospital.

Findings include:

Ecolab Trupower Ultra San 5-gallon bucket
Liquid Sanitizer/Multi-Use Chorine Sanitizer/Sodium Hypochlorite

Directions For Use (DFU) ...

...Sanitation
Tableware sanitizer and destainer for mechanical spray warewashing machines

For sanitizing tableware in low temperature warewashing machines, inject Ultra San into the final rinse water at concentration of 100 parts per million (ppm) available chlorine. Do not exceed 200 ppm.

To ensure that available chlorine concentration does not fall below 50 ppm, periodically test the rinse solution with a suitable test kit and adjust the dispensing rate accordingly.

A tour of the dietary department was conducted on 6/18/25 at 12:30 PM with Employee Identifier (EI) # 9, Dietary Manager, which included observing the Ecolab dishwashing machine. When asked what is used to test the sanitizer, EI # 9 stated she did not have testing strips to test the rinse solution.

The dietary manager failed to ensure staff were testing for correct chlorine concentration of the rinse solution.

An interview was conducted on 6/17/25 at 12:30 PM with EI # 9 who confirmed there was no testing of the rinse solution for appropriate concentration per manufacturer's DFU.

Based on review of facility policies and procedures, observation, and interviews, it was determined the staff failed to provide a current dietary manual readily available for staff use in day-to-day practice. This had the potential to affect all consumers served by the dietary department.

Findings include:

During a tour of the Dietary Department on 6/17/25 at 8:45 AM, the surveyor requested the therapeutic diet manual. Employee Identifier (EI) # 8, Dietary Manager, provided a manual with policies and procedures and explained that was the only manual available. The manual did not include current therapeutic diets approved by the dietician and medical staff.

An interview On 6/19/25 at 11:18 AM, EI #10, Registered Dietician, confirmed there was no current dietary manual readily available.

Based on review of the Emergency Preparedness (EP) program and interview, it was determined the facility failed to perform and document a facility-based and community-based risk assessment, utilizing an all-hazards approach, to identify all risks or emergencies that the facility would reasonably expect to encounter.

This has the potential to affect all persons served by the hospital, staff and visitors.

Findings include:

A review of the facilities EP program revealed no documentation:

a. An all hazards risk assessment including facility based and community based risk.

b. The plan was review/revised every two years.

c. Strategies for addressing emergency events in the plan were identified.

An interview conducted 6/19/25 at 12:35 PM with Employee Identifier # 1, Director of Nursing, confirmed the agency had no documentation an all-hazards risk assessment had been performed, strategies for EP events were identified, and no documentation the plan was reviewed every two years.

Based on review of the Emergency Preparedness (EP) documentation, and staff interview, it was determined the staff failed to ensure the facility developed and maintained an emergency preparedness plan to include patient population, including persons at risk, the type of services provided in an emergency and continuity of operations.

This had the potential to negatively affect all patients served by the facility, visitors, and staff.

Findings include:

EP plan was requested, none provided.

An interview was conducted on 6/19/25 at 12:35 PM, with Employee Identifier # 1, Director of Nursing, who confirmed there was no documentation a emergency preparedness plan was developed.

Based on review of the Emergency Preparedness (EP) documentation, and staff interview, it was determined the staff failed to ensure the facility developed and maintained an emergency preparedness plan to include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials.

This had the potential to negatively affect all patients served by the facility, visitors, and staff.

An interview was conducted on 6/19/25 at 12:35 PM, with Employee Identifier # 1, Director of Nursing, who confirmed there was no documentation a emergency preparedness plan was developed which included collaboration with local, tribal, regional, State, and Federal emergency preparedness officials.

Based on review of the Emergency Preparedness (EP) documentation, and staff interview, it was determined the staff failed to ensure the facility developed and maintained an emergency preparedness plan to include a system to track the location of on-duty staff and sheltered patients in the facility's care during an emergency.

This had the potential to negatively affect all patients served by the facility, visitors, and staff.

An interview was conducted on 6/19/25 at 12:35 PM, with Employee Identifier # 1, Director of Nursing, who confirmed there was no documentation of an EP plan which included a system to track the location of on-duty staff and sheltered patients in the facility's care during an emergency.

Based on review of Emergency Preparedness (EP) documentation and interview it was determined the facility failed to develop and maintain an emergency preparedness training and testing program.

An interview was conducted on 6/19/25 at 12:35 PM, with Employee Identifier # 1, Director of Nursing, who confirmed there was no documentation an emergency preparedness training and testing program was developed.

Based on review of the personnel files, and interview with staff, it was determined the hospital failed to ensure the staff received initial training on Emergency Preparedness (EP) and at a minimum of every two years.

This affected eight of eight hospital employee's personnel files reviewed and had the potential to affect all persons served by the hospital.

Findings include:

Review of the personnel files provided revealed no documentation the hospital employees completed initial EP training and every two years.

An interview was conducted on 6/19/25 at 11:35 AM with EI # 11, Human Resources Director, who confirmed the hospital failed to ensure the staff received initial EP training and at a minimum every two years.