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Based on observation, interview, and policy and procedure review, the facility failed to post signs which specify the rights of individuals with emergency medical condition's (EMC's) and women in labor in a place or places likely to be noticed by all individuals entering the emergency department on three (3) of three (3) days of survey.

Findings Include:

Observation of the Emergency Department (ED) revealed there were no visible postings of the Emergency Medical Treatment And Labor Act (EMTALA) at the ED entrance, admitting area, waiting room or treatment areas.

During an interview with Registered Nurse (RN) #1 on 05/01/2024 at 2:54 p.m., it was confirmed that there are no signs available to be posted in any areas of the ED.

Review of facility policy and procedure EMTALA Transfer Policy dated 06/01/2023 revealed, " ...policy is to provide guidance and processes to comply with the laws and regulations applicable to patients with an Emergency Medical Condition (EMC) who either request or require transfer to a receiving facility following the EMTALA ...to ensure the public has access to emergency services regardless of their ability to pay ...This includes active labor as well ...".

During the exit conference held on 05/03/2024 at 5:00 p.m., findings were discussed with the Administrator and Payroll Clerk. No further documents submitted for review.

Based on observation, staff interviews, policy and procedure review, the facility failed to remove outdated medications available for patient use from the crash cart in the Emergency Department on three (3) of three (3) days of survey.

Findings Include:

Observation of the crash cart in the Emergency Department at 2:40 p.m. on 05/01/2024 with RN #1 and Certified Respiratory Therapist revealed; expired medication in the Crash Cart are as follows: Three (3) Procainamide Hydrochloride injection 100 milligrams (mg) per milliliter (ml), Lot #KS074D2, Expiration date 03-24 (March 2024). Five (5) Clopidogrel 75 mg tablets, Lot # 1008081, expiration date 04/24 (April 2024). Three (3) Potassium Chloride injection 20 milliequivalents (mEq) per 10 ml, lot #6025748, expiration date 04/24 (April 2024). Calcium Gluconate 1000 mg per 50 ml, 20 mg per ml for infusion, lot # 10031 expiration date 01/2024 (January 2024).

During an interview with RN #1 on 05/01/2024 at 2:40 p.m. RN #1 confirmed the above expired medications in the crash cart.

During an interview with Pharmacist on 05/01/2024 at 3:52 p.m. it was confirmed that the nursing staff are responsible for monitoring expired medications in the crash cart.

Review of facility policy and procedure Medication Management Policy dated 06/01/2023 revealed, " ...medication management process ...ensure medications are ...monitored according to nationally evidenced-based practice and standards of care ...Ensure compliance with federal and state laws and regulations ...all expired ...medications ...to prevent them from being administered ...".

During the exit conference held on 05/03/2024 at 5:00 p.m., the findings were discussed with the Administrator and Payroll Clerk. No further documents submitted for review.

Based on observation and staff interview, the facility failed to appoint an individual qualified through education, training and experience or certified in infection prevention and control as the infection preventionist(s)/infection control professional responsible for the infection control program for three (3) of three (3) days of survey.

Findings Include:

During an interview with the Administrator on 05/01/2024 at 4:15 p.m., it was confirmed the designated infection preventionist resigned March 31, 2024, and an appointment for replacement has not been made and no one has been temporarily appointed to fulfill the role of infection preventionist.

No documented evidence of a policy and procedure regarding the designation of an infection preventionist/infection control professional or letter of appointment for an infection preventionist/infection control professional available for review.

During the exit conference on 05/02/2024 at 5:10 p.m. with the Administrator and the payroll clerk, survey findings were discussed, and no further documentation was submitted for review.