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Based on record review and interview, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care of each patient as evidenced by 1) failing to assess wounds upon admission (Patient #3), 2) failing to stage and measure wounds weekly per policy (Patient #5) and 3) failing to document an assessment of patient who had a physician order for "EKG now" (Patient #3)\.
Findings:

1) Failing to assess wounds upon admission

Review of the electronic medical record for Patient #3 revealed the patient was admitted on 01/09/23 with diagnoses including bilateral lower extremity venous stasis wounds.

Review of the RN admission assessment dated 01/09/23 revealed the patient had right and left heel dressings but wounds "not visible with dressing". There was no documented assessment of the patient's wounds upon admit.

Review of the nurses notes dated 01/10/23 revealed the dressing were clean, dry and intact. There was no documented assessment of the patient's wounds on 01/10/23.

On 01/11/23, the patient was transferred out to an acute care hospital without any assessment conducted of the wounds that the patient had been admitted with.

On 01/11/23 at 9:45 a.m., S1DON reviewed the patient's electronic medical record with the surveyor and confirmed that there was no documented assessment of the patient's wounds.

2) Failing to stage and measure wounds weekly per policy

Review of the hospital policy titled Wound Stage revealed that the pressure sore status tool would be implemented and completed weekly and on the day of discharge.

Review of the electronic medical record for Patient #5 revealed an admission date of 12/29/22 with a diagnosis of unstageable wound to left heel.

Review of the RN admission assessment dated 12/29/22 revealed the wound was measured and staged with a picture of the wound obtained.

Further review of the medical record revealed that as of 01/10/23, no further measurements or staging of the wound had been performed since admission (12 days).

On 01/11/23 at 11:00 a.m., S1DON reviewed the patient's medical record and confirmed there had been no further measurements of staging of the patient's wound since admit. S1DON further stated that wounds should be staged and measured at least weekly per policy.

3) Failing to document an assessment of patient who had a physician order for "EKG now"

Review of the medical record for Patient #3 revealed an admission date of 01/09/23 with diagnoses including venous stasis wounds, diabetes and declining mobility.

Review of the physician orders dated 01/10/23 at 1:30 p.m. revealed an order for "EKG now".

Review of the nurses notes dated 01/10/23 revealed no documented assessment of the patient's status regarding the need for an immediate EKG. Further review of the nurses notes for 01/10/23 revealed no documentation that the EKG was performed or that the physician was notified of the results.

Review of the copy of the EKG in the patient's record revealed it indicated normal sinus rhythm with premature atrial contractions.

Review of the nurses notes dated 01/11/23 at 1:30 a.m. revealed the patient was diaphoretic with a temperature of 102.5 Fahrenheit and oxygen saturation on room air at 92%. The patient was transferred to the local acute care hospital.

On 01/11/23 at 10:20 a.m., review of the electronic medical record with S1DON confirmed that their was no documented assessment of the patient when the physician ordered the EKG on 01/10/23 and there was no evidence that the physician was notified of the result of the EKG. S1DON further stated that the patient was sent out in the early morning of 01/11/23 and later diagnosed with a heart attack.

Based on record review and interview, the hospital failed to ensure that medical records were promptly completed by having discharge summaries not completed by the physician within 30 days of discharge.
Findings:

Review of the Medical Staff bylaws policy #02-01-02, 9387.J Completion of Records revealed:
Medical records will be completed by 30 days post discharge.

Review of the list of discharged patients with incomplete medical records presented by S4HIM revealed there were 32 patients with discharge summaries not completed over 30 days after discharge.

Review of the medical records for discharged patients #7-13 revealed the following:
Patient #7 was discharged 11/17/22. The discharge summary was completed on 01/10/23.
Patient #8 was discharged 11/23/22. The discharge summary was completed on 01/10/23.
Patient #9 was discharged 11/22/22. The discharge summary was completed on 01/10/23.
Patient #10 was discharged 11/21/22. The discharge summary was completed on 01/10/23.
Patient #11 was discharged 11/28/22. The discharge summary was completed on 01/10/23.
Patient #12 was discharged 11/25/22. The discharge summary was completed on 01/10/23.
Patient #13 was discharged 11/25/22. The discharge summary was completed on 01/10/23.

On 01/10/23 at 9:30am, an interview with S4HIM confirmed that the above records did not have discharge summaries completed within 30 days of discharge.

Based on record review and interview, the hospital failed to ensure that a qualified full-time, part-time or consulting radiologist supervised the ionizing radiology services by failing to have a current contract or agreement with a radiologist appointed by the governing body to perform the duties of the Medical Director for Radiology Services.
Findings:

Review of an agreement dated 03/07/19 by a radiologist to accept the appointment of oversight of the Radiology Department revealed no terms of agreement and no delineation of duties or responsibilities.

On 01/10/23 at 11:00 a.m., an interview with S2ADM revealed that the above radiologist had retired at some point within the last couple of years and they did not have a current agreement with a radiologist to perform the services of Medical Director for Radiology Services.

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 failing to ensure the functionality of a nurse call button located on the handrails of 10 of 10 inpatient beds.
Findings:

On 01/09/23 at 10:30 a.m., observation of unoccupied inpatient rooms (a,b,c,d,e) revealed the patient beds had non-functional nurse call buttons on the side rails of the beds. The nurse call button on the beds were pressed by the surveyor during the observations and no alert of any type was generated when it was pressed.

On 01/09/23 at 10:50 a.m., S1DON confirmed that the nurse call buttons on all 10 inpatient beds were not functional. S1DON reported patients/patient families were instructed to use the nurse call feature on the corded call light located at the patient's bedside to call for staff assistance. The surveyor discussed the possibility of patient/patient family/visitor confusion with having the non-functional nurse call feature available for use as well as the nurse call feature on the corded call light and the potential of the non-functional nurse call feature being pressed to summon help from staff. S1DON agreed that having the non-functional nurse call feature available for use could result in potential confusion when calling for staff assistance.

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Based on observation and interview, the hospital failed to ensure the infection prevention and control program included maintaining a clean and sanitary environment to avoid sources and transmission of infection. This deficient practice was evidenced by 1) failing to maintain a sanitary environment in patient care areas, and 2) failing to ensure the freezer, hydrocollator and paraffin baths in the rehabilitation department were cleaned monthly.
Findings:

1. On 01/09/23 at 10:30am, a tour of the hospital with S1DON revealed the following:

- Rooms c, e and f had over bed tables with vanity trays that were covered with dried brown, sticky substances and dirt and grime.
- Room b had brown splatters on the side rails and old sticky tape on the television remote control. A large cloth covered recliner was in the room, which was unable to be appropriately disinfected. The over bed table and vanity tray was coated with a dried brown, sticky substance and dirt and grime.
- Room a had old pieces of tape stuck to the footboard of the bed and on the television remote control.
At that time, S1DON confirmed the above rooms had been cleaned and were ready for new patient admits.

- The shower room toilet had a vinyl seat cover that was peeling away and exposing the cushion underneath, a tear in the seat cushion of a chair sitting near the shower, and other cushions which were stacked in the chair had tears in them. The whirlpool tub door was taped together with black tape.

- The outpatient therapy room had a therapy bed with tears in the vinyl covering, exposing the cushion inside.

- The central supply room had bins that contained new supplies. Observations inside the bins revealed dirt, debris and dead insects.

An interview at that time with S1DON confirmed that the tables in the cleaned patient rooms were not acceptable for a new patient admission, and confirmed that the tears in the coverings of the toilet, chairs, table and whirlpool tub door would not allow the items to be properly disinfected.

2. Review of the temperature and cleaning logs in the rehabilitation department on 01/11/23 at 1:00 p.m. revealed the freezer was not cleaned in July and October of 2022; the hydrocollator was not cleaned in June of 2022; and the paraffin baths were not cleaned from June of 2022 through December of 2022.

In an interview on 01/11/23 at 1:30 p.m., S5PTA confirmed that the routine cleanings of the freezer, hydrocollator and paraffin baths were not performed.


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Based on observation and interview, the hospital failed to follow their policy as described in their scope of rehabilitation services offered by the hospital related to ADL/Transitional Training Apartment rehabilitation.
Findings:

Review of the hospital policy titled Scope of Services revealed ADL/Transitional Training Apartment would be a part of the hospital's rehabilitation program. The policy further stated that this designated room/apartment contains a home-like bed and furniture typical to a home environment. Further, this space contains a small self-contained kitchen where the patient can practice cooking and/or homemaking skills supervised by Occupational Therapy personnel. The functional purpose of this space is to encourage the patient to practice home-going skills prior to being discharged.

On 01/09/23 at 11:00 a.m., during tour of the hospital with S1DON, observation revealed the room labeled "ADL" room had a small self-contained kitchen with a stove and cooking devices in the room. Further observations in this room revealed two old hospital beds were stored in the room. The self-contained kitchen was not accessible. Interview with S1DON at that time confirmed that this ADL room was not used and there was no other room in the hospital with this set-up.

On 01/11/23 at 1:20 p.m., observation of the "ADL" room with S3Director of Rehab confirmed that the ADL/Transitional Training Apartment was a part of the hospital's rehabilitation program, but states that this component was unable to be utilized for approximately six months due to the room being used as storage.