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Based on record review and interview the governing body failed to appoint members of the medical staff after considering the recommendations of the existing members of the medical staff. This deficient practice is evidence by the governing body failing to appoint a director of rehabilitation services and a director of respiratory services.
Findings:

Review of the organizational chart on 07/31/2024 at 3:00 p.m. failed to reveal a director of rehabilitation services or director of respiratory services employed by the hospital.

In an interview on 07/31/2024 at 3:10 p.m., S2ADM verified that there is no director of rehabilitation services or director of respiratory services.

Based on observation, record review and interview the hospital failed to ensure each patient received care in a safe setting. This deficient practice is evidenced by the hospital's failure to ensure 2 (S6Driver, S7Driver) of the 2(S6Driver, S7Driver) transport drivers were CPR certified and a first aid kit available in the transport van.
Findings:

Review of the provided job description for Transportation Driver revealed in part: ESSENTIAL FUNCTIONS INCLUDE BUT ARE NOT LIMITED TO: Transportation Driver: 11. Maintains CPR and First Aid equipment in the vehicle. 15. Follows all city and state laws with regards to driving the company vehicle.

An observation on 07/31/2024 at 11:20 a.m. of the transport van revealed no first aid kit available in the transport van. Further observation revealed inspection sticker with an expiration date of 04/2024.

In an interview on 07/31/2024 at 11:25 a.m. S6Driver verified there was no first aid kit in the transport van and the inspection sticker expired 04/2024.

In an interview on 07/31/2024 at 12:20 p.m., S3NM verified that S6Driver and S7Driver are not certified CPR as required by the facility job description.

Based on policy review, observation, and interviews, the hospital failed to ensure patients had the right to confidentiality of his/her clinical records. This deficient practice is evidenced by:
1) Failure to ensure an unattended computer screen accessible to visitors, patients and staff did not contain private patient information; and
2) Failure to ensure patients' medical records were not left unattended.
Findings:

1)Failure of the hospital to ensure an unattended computer screen accessible to visitors, patients and staff did not contain private patient information.

Direct observation on 07/29/2024 at 1:00 p.m. revealed an unattended computer at the nursing station accessible to visitors, patients, and staff with visible patient information on the screen.

In an interview on 07/29/2024 at 1:05 p.m., S3NM verified the unattended computer with confidential information on the screen at the nursing station was visible to visitors, patients, and staff with patient information.

2)Failure of the hospital to ensure patients' medical records were left unattended.

An observation on 07/29/2024 at 1:08 p.m. medical records department door open with no one attending the area. Further observation revealed open access to a shred box with the ability to access patient information.

In an interview on 07/29/2024 at 1:10 p.m. S3NM verified that the medical records were not secured.

Based on record review and interview, the director of nursing failed to ensure all nursing staff adhered to the policies and procedures of the hospital. The deficient practice is evidenced by failure of the nursing staff to adhere to the service animal policy.
Findings:

Review of the policy titled, "Pet visits and/or Assisted Therapy" last approved 03/2024 revealed in part: PROCEDURE: The Infection Control Professional or designee must be notified prior to any Pet visits/therapy in an attempt to control infectious diseases or eliminate harm to patients, visitors, and/or staff. A copy of this policy must be given to anyone requesting a pet visit. A current health certificate form a licensed veterinarian is required for any pet visits to take place. The pet must be free from external parasites, specifically fleas, ticks, lice, and mites. The pet is free from internal parasites, specifically hookworms, heartworms, roundworms, tapeworms, whipworms, and strongyloides. All necessary immunizations and licenses by the jurisdiction of residence are current. The Pets are allowed to visit in owner/patient rooms only or outside the facility. Pets are not allowed in other rooms or areas of the hospital.

In an interview on 07/29/2024 at 11:15 a.m. S3NM reports that Patient #2 had a pet dog while hospitalized. She verified the Infection Control Professional or designee was not notified, and dog's current health certificate from a licensed veterinarian was not obtained and the dog's vaccination and parasite status was unknown.

In an interview on 07/31/2024 at 9:30 a.m. S8ST verified that Patient #2's pet dog was allowed to come into the therapy room. S8ST verified the dog was not restricted to Patient #2's room or areas outside the facility.

Based on observation and interview, the hospital failed to ensure all drugs and biologicals were kept in a secure area. This deficient practice is evidenced by failing to lock the medication room door.
Findings:

During a tour of the facility on 07/29/2024 at 12:20 p.m. the medication room door was unlocked and propped open leaving medications unsecure. Observation in the medication room included an unlocked medication cart with patients' prescription medications and the unit's OTC medications.

In an interview on 07/29/2024 at 12:30 p.m., S3NM verified the medication room door should not be propped open and should be locked to secure the patient's prescription medications and the unit's OTC medications.

Based on record review and interview the hospital failed to employ a full time director of food and dietetic services.
Findings:

Review of the personnel files revealed the dietician was contracted for consultations as needed and was not a full time employee. Further review revealed there was no one trained to perform the duties of dietary manager or food director.

In interview on 07/30/2024 at 3:10 p.m., S2ADM verified there was no full time employee trained to manage the dietary services.

Based on observation and interview the facility failed to maintain the condition of the physical plant and overall hospital environment in such a manner that the safety and well-being of patients are assured. The deficient practice is evidence by failing to label all chemicals used with MDS information maintain on all chemicals used.
Findings:

During a tour of the housekeeping closet on 07/30/2024 at 2:15 p.m., two unlabeled spray bottles with liquid were identified on the housekeeper cart.

In an interview on 07/30/2024 at 2:20 p.m., S5Main verified that all products on the housekeeping cart are used in the facility for cleaning including the 2 unlabeled spray bottles with unidentified liquid. Furthermore S5Main verified there is no MSDS information regarding the unidentified liquid.

Based on observation, record review and interview, the facility failed to maintain an infection prevention and control program which includes surveillance, prevention, and control of HAIs, and maintains a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities. This deficient practice was evidenced by failing to maintain patients' shower room in a sanitary condition.
Findings:

During a tour of the facility on 07/29/2024 at 12:33 p.m., direct observation revealed dirty towels, dirty washcloths, used gloves, and trash left in Room a.

In an interview on 07/29/2024 at 12:34 p.m., S3NM verified that Room a should be cleaned after use by each patient and dirty towels/washcloths or trash should not be left in Room a.

During a tour of the facility on 07/29/2024 at 12:35 p.m., direct observation in Room b revealed a torn "crash" mat with exposed foam filling which was used in patient care.

In an interview on 07/29/2024 at 12:36 p.m. verified that the torn "crash" mat should not be used due to unable to effectively clean the foam.

Based on record review and interview, the hospital failed to designate a director of rehabilitation services who had the knowledge, experience, and capabilities to properly supervise and administer the services. The deficient practice is evidenced by failure of the facility to designate a qualified employee as Director of Rehabilitation services.

Findings:

Review of the provided organizational chart failed to reveal a Director of Rehabilitation services

In an interview on 07/31/2024 at 3:00 a.m., S2ADM verified the hospital did not have anyone designated as the Director of Rehabilitation Services.

Based on record review and interview, the hospital failed to ensure compliance with all requirements for Respiratory Services. The deficient practice is evidenced by failure of the facility to appoint a doctor to supervise the service.
Findings:

Review of the hospital's organizational chart revealed no documented evidence that a doctor of medicine or osteopathy was appointed to supervise the respiratory services.

In interview on 07/31/24 at 3:15 p.m., S2ADM confirmed there was no doctor appointed to provide medical direction for respiratory services.

Based on record review and interview the hospital failed to ensure personnel were qualified to perform specific respiratory care procedures. This deficient practice was evidenced by failure to provide policies and procedures that included the qualifications, including job title, education, training and experience of personnel authorized to perform each type of respiratory care service and whether they may perform it without respiratory supervision.

Findings:

Review of S9RT's orientation skills assessment/competency checklist revealed only a self-evaluation with no evaluation done to show competencies.

In an interview on 07/31/2024 at 12:40 p.m. S3NM verified S9RT's Orientation Skills Assessment/Competency Checklist was only has a self-evaluation with no evaluation of S9RT's Skills Assessment/Competencies.