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Based on record review, observation and interview, the hospital's governing body failed to ensure that written policies and procedures for appraisal of emergencies and initial treatment was implemented as evidenced by failing to have emergency medications in the crash cart.
Findings:

Review of the hospital policy titled Emergency Medications/Crash Cart revealed that emergency medications shall be readily available to the patient-care staff. Emergency medications shall be appropriate to the needs of the patient-care area and shall include, but will not be limited to: Standard emergency medications (epinephrine and cardiopulmonary medications). The policy further revealed that a list of approved medications shall be maintained.

Review of the policy titled Provision of Emergency Services revealed that any patient presenting with an emergency will be stabilized by staff and sent to the nearest ER. This hospital has ACLS certified nurses on site, if one of these nurses are present, they will initiate measures deemed appropriate by their training.

Review of the "Crash Cart List", provided as current by S3RN, revealed 12 emergency medications would be on the crash cart. Some of these medications included: Epinephrine, Furosemide, Glucagon, Nitroglycerine tablets, Vasopressin.

On 01/14/19 at 9:00 a.m., observation of the crash cart revealed the only cardiopulmonary medications on the cart were Sodium Bicarbonate, Lidocaine and Adenosine. The crash cart list did not indicate that Sodium Bicarbonate and Lidocaine would be on the crash cart.

On 01/14/19 at 9:15 a.m., interview with S3RN revealed that the medications on the "Crash Cart List" were not included in the hospital's crash cart. S3RN further revealed that all nurses are ACLS certified.

Based on record review and interview, the hospital failed to ensure the Quality Assurance/Performance Improvement program measured, analyzed and tracked quality indicators to monitor the safety and effectiveness of services and quality of care. The deficient practice was evidenced by failure to include all services/departments in their Performance Improvement Plan.
Findings:

Review of hospital's policy 02-02-01 titled, "Quality Assessment and Performance Improvement" revealed in part:
The Performance Improvement Committee is designed to objectively and systematically monitor and evaluate on an ongoing basis the quality and appropriateness of patient care ...and resolve identified multidisciplinary problems. This team will review all clinical activities and address any patient care issues.

Review of the hospital's Quarterly Performance Improvement Committee Minutes dated April 2018, July 2018 and October 2018 failed to reveal the Laboratory, Radiology, and Utilization Review departments were included.

During an interview on 01/15/2019 at 9:30 a.m., S1Administrator confirmed their Performance Improvement Plan did not include the Laboratory, Radiology and Utilization review departments.

Based on record review and interview, the hospital failed to ensure that drugs were administered in accordance with physician orders as evidenced by failing to administer sliding scale insulin as ordered by the physician for 2 of 2 patients reviewed for insulin administration in a total sample of 30 (Patient #10 and #17).
Findings:

Review of hospital's Policy 05-19-01 titled, "Medication Administration" revealed in part:
Holding Medications - 1. If a medication, dosage or route of administration is questionable by the nurse; he/she should hold the medication and notify the physician to confirm the medication, dose and/or route.

Patient #10
Review of the physician orders dated 01/10/19 revealed to perform blood glucose checks before meals and at bedtime with sliding scale Humalog insulin ordered. The sliding scale insulin orders revealed the following:
170-199, 4 units
200-249, 8 units
250-299, 12 units
300-349, 16 units
350 and above, give 20 units and recheck in one hour

Review of the patient's January 2019 MAR revealed the following documentation:
01/10/19 at 9:00 p.m., glucose 267, 6 units administered (physician ordered 12 units per sliding scale)
01/11/19 at 11:00 a.m., glucose 276, 8 units administered (physician ordered 12 units per sliding scale)
01/12/19 at 11:00 a.m., glucose 470, 20 units administered (no evidence that glucose checked one hour later per physician orders)
01/13/19 at 11:00 a.m., glucose 231, 0 units administered (physician ordered 8 units per sliding scale)
01/13/19 at 9:00 p.m., glucose 155, 4 units administered (physician ordered no insulin to be given per sliding scale)
01/14/19 at 4:00 p.m., glucose 444, 20 units administered (no evidence that glucose checked one hour later per physician orders)
10/14/19 at 9:00 p.m., glucose 451, 20 units administered (no evidence that glucose checked one hour later per physician orders)

On 01/15/19 at 3:20 p.m., S4RN reviewed the patient's electronic medical record and confirmed that the physician orders for sliding scale insulin was not followed on the above dates.

Patient #17
Review of physician orders dated 10/13/2018 revealed Levemir 100 units/ml vial give 50 units subcutaneous every morning at 7:30 a.m.

Review of the patient's October MAR revealed the following documentation:
10/14/2018 9:39 a.m., Levemir dose not given.
10/16/2018 8:03 a.m., Levemir dose not given.
10/17/2018 8:50 a.m., Levemir dose not given.
10/22/2018 8:25 a.m., Levemir dose not given.
10/23/2018 9:23 a.m., Levemir dose not given.

On 01/16/2019 at 10:20 a.m., S3RN reviewed the patient's nurses notes, MAR and physician's orders and confirmed the medication was not administered as ordered and the physician was not notified when the patient's medication was withheld.

Based on observation and interview, the hospital failed to ensure patients' medical records were stored where they were secured and protected from fire and water damage as evidenced by having patient records stored in cardboard boxes on shelves in an unlocked closet in the hallway and on open metal shelving units in rooms that were sprinklered.

Findings:

Observation on 01/14/19 at 9:00 a.m., during the initial tour of the facility, revealed an unlocked closet labeled "clean linen" located in the alcove of the hallway near the office of the Medical Director. Eight cardboard boxes, some of which contained patient records with health information, were sitting on the open closet shelves.

In an interview on 01/15/19 at 2:30 p.m., S1Administrator confirmed that the medical records were unsecured and unprotected, and stated that the records "shouldn't be here."

Observation on 01/16/19 at 10:15 a.m. of the medical record storage areas with S5LPN revealed 2 locked offices were used to store medical records in cardboard boxes on open metal shelving units. Further observation revealed the rooms were sprinklered.

In an interview on 01/16/19 at 10:15 a.m. with S5LPN, she confirmed that the paper medical records stored in cardboard boxes on the open metal shelving units would not be protected from water damage if the sprinkler was activated or there was a water leak from the ceiling.

Based on review of contract services and interview, the hospital failed to ensure there was a full-time, part-time or consultant pharmacist responsible for supervising activities of the pharmacy services as evidenced by: 1) Failure to have documented evidence of a written agreement with a pharmacist and 2) Failure to identify the responsibilities of the pharmacist.
Findings:

Review of the hospital's list of Contracted Services revealed pharmacy services was to be provided by Contract A, however, in reviewing the current contract on file dated 06/11/18, there was no provision in the agreement naming a pharmacist director of pharmacy services.

On 01/14/19 at 1:00 p.m., interview with S1Administrator revealed that S7Pharmacist was the director of pharmacy services for the hospital. At that time, the surveyor requested the written agreement with S7Pharmacist.

On 01/16/19 at 12:00 p.m., S1Administrator provided an email (dated 01/16/19) from S7Pharmacist stating that S8Pharmacist is the "Pharmacist in Charge and therefore he would act in the capacity of Director for your facility". At that time, the surveyor requested documentation stating the S8Pharmacist was in agreement to be the Director and was aware of his duties.

On 01/16/19 at 2:00 p.m., S1Administrator provided an email from S8Pharmacist stating that he was director of pharmacy services for the hospital. There was no documented evidence of his duties and responsibilities. At that time, S1Administrator confirmed that there was no documented evidence of a job description or written agreement that included S8Pharmacist's responsibilities that were clearly defined and included development, supervision and coordination of all activities of pharmacy services.

Based on record review and interview, the hospital failed to ensure identified medication errors were documented in the patient's chart for 1 of 1 patient (#1) records reviewed who had hospital identified medication errors.
Findings:

Review of the hospital's medication policies revealed they did not address the requirement of documenting medication errors in patient records.

Review of the hospital's Variance/Occurrence Reports revealed the hospital identified one medication error for the year 2018, which involved patient #1. Review of the report dated 11/23/18 revealed patient #1 was administered another patient's medication (Cipro 500mg).

Review of the patient #1's electronic medication record revealed no documented evidence that the medication error was documented. On 01/15/19 at 2:00 p.m., S4RN reviewed the patient's electronic medical record and confirmed that the medication error on 11/23/18 was not documented.

Based on record review and interview, the hospital failed to ensure there was a Radiologist appointed by the Governing Body to supervise the Radiology Services on either a full-time, part-time, or consulting basis as evidenced by having no documentation indicating the hospital had a Director of Radiology for the hospital.
Findings:

Review of a list of physicians practicing at the hospital revealed no physician had been appointed as the medical director of Radiological Services.

Review of governing body meeting minutes revealed no physician had been appointed as the medical director of Radiological Services.

In an interview on 01/15/19 at 2:20 p.m. with S1Administrator, she verified there had been no physician appointed as the director of Radiological Services.

Based on observation and interview, the hospital failed to ensure all supplies and/or equipment were maintained to ensure an acceptable level of safety and quality. This deficient practice was evidenced by the hospital failing to ensure expired supplies were not available for patient use.
Findings:

Observation on 1/14/19 at 10:30 revealed the following expired supplies:
IV CART -
1 - Winged infusion 25 gauge expired 08/2018
1 - OPSITE 2 ½" x 2" expired 04/2018
14 - 5cc syringes expired 11/2018

WOUND DRESSING CART-
1 - Roll of Interdry dressing expired 11-2018
1 - Packet of A&D ointment expired 04-2018
1 - SteriStrip packet expired 10-2017
12 - SteriStrip packages expired 03/2018
2 - Opstetrical Antiseptic Wipes expired 11/2018
2 - Mesalt 4x4 Dressing 10/2018
8 - Duoderm CGF 10/2018
1 - Box of Biopatches 02/2018
14 - Trach drain sponges 4x4 expired 09/2017

During an interview on 01/14/2019 at 10:50 a.m., S4RN confirmed the expired supplies and acknowledged they should have been discarded and not available for patient use.

Based on record review and interview, the hospital failed to comply with Federal, State and local emergency preparedness requirements by failing to develop a comprehensive emergency preparedness plan. This deficient practice was evidenced by the hospital failing to include a plan for an emergency influx of patients during an emergency or disaster.
Findings:

Review of the hospital's policy 01-06-01 titled, Emergency Preparedness" revealed in part:

Emergency Influx of patients:
If there is an emergency influx of patient referrals due to an emergency or disaster, all patients will be assessed for appropriateness at this level of care, basic treatment provided (within the limits of our abilities as a specialty hospital)...

Review of the hospital's emergency preparedness plan failed to reveal a plan for an influx of patients during an emergency or disaster.

After reviewing the Disaster Plan on 01/16/2019 at 1:35 p.m., S6RN confirmed the plan did not include for an influx of patients during an emergency or disaster.