Community Hospital Inc.

“PHYSICAL ENVIRONMENT CFR(s): 482.41 The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. This Condition is not met as evidenced by: 49797 Based on observations and interviews with staff during a tour of the hospital by Life Safety Code and health surveyors, 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-0293, K-0353, K-0781, K-0923 and A-0724”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 41624 Based on observations in the New Day Senior Care unit, hospital policy and procedure, and interview with staff, it was determined the hospital failed to ensure a safe and ligature risk free environment was maintained for psychiatric patients. Findings include: Hospital Policy: Unit Safety Checks Policy Number: None Revised Date: 8/17/22 I. Purpose: To ensure a safe patient environment and the safety of each patient on the unit. II. Policy: The charge registered nurse (RN), or designee, at the beginning of the shift, will inspect the entire unit. A log will be kept to include...any deficiencies...found on the unit. III. Procedure: A. The charge RN, or designee, will walk the entire unit at sometime near the start of the shift. B. The inspection will include all the areas of the unit. ...F. Any deficiencies will be immediately corrected by the program staff. If this is not possible, a report will be made to the appropriate hospital department. G. The program director will review the worksheets on a weekly basis to ensure compliance and patient safety. Issues identified on a recurring basis will be addressed as part of the program’s CQI (continuous quality improvement) process. 1. A tour of the New Day Senior Care unit was conducted on 10/1/24 at 11:28 AM with Employee Identifier (EI) # 4, Program Director. The unit consisted of nine patient care rooms. The following ligature risks were observed within patient rooms 201, 202, 203, 204, 206, and 208: A. Windows with a “T” shaped handle extending approximately five inches from window base. B. Bathtubs with waterspout extending approximately six inches from the tub EI # 4 was present during the tour and confirmed the ligature risks.”

“CONTENT OF RECORD: ORDERS,NOTES,REPORTS CFR(s): 482.24(c)(4)(vi) [All records must document the following, as appropriate:] All practitioner’s orders, nursing notes, reports of treatment, medication records, radiology and laboratory reports, and vital signs and other information necessary to monitor the patient’s condition. This Standard is not met as evidenced by: 49797 Based on review of medical records (MR), Alabama Board of Nursing Administrative Code Chapter 610-X-6 Standards of Nursing Practice, and interviews with the staff it was determined the facility failed to ensure the staff documented the wound care performed. This affected MR # 16, one of two wound care MR’s reviewed and had the potential to affect all patients treated by this hospital. Findings include: Administrative Code Chapter 610-X-6-.04 Practice Of Professional Nursing (Registered Nurse Practice)... (1) The practice of professional nursing includes, but is not limited to: ...(f) Documentation of nursing interventions and responses to care in an accurate, timely, thorough and clear manner... Administrative Code Chapter 610-X-6-.05 Practice Of Practical Nursing (Licensed Practical Nurse Practice)... (1) The practice of practical nursing includes, but is not limited to: ...(h) Documentation of nursing interventions and responses to care in an accurate, timely, thorough and clear manner... 1. MR # 16 was admitted to the hospital with cellulitis to the left lower leg on 7/17/24. A review of physicians orders dated 7/17/24 revealed, “Wrap leg BID (twice daily) with Lotrimin cream, abd pads and kerlix. apply cream to pads, then apply to ulcerations on leg, secure with Kerlix and paper tape.” A review of the medical record dated 7/17/24 to 7/20/24 revealed no documentation wound care was provided. An interview was conducted on 10/3/24 at 5:00 PM with Employee Indentifier (EI) # 2, Director of Nursing, who confirmed the staff failed to document the wound care provided during the dates of 7/17/24 to 7/20/24.”

“DIRECTOR OF DIETARY SERVICES CFR(s): 482.28(a)(1) The hospital must have a full-time employee who- (i) Serves as director of the food and dietetic services; (ii) Is responsible for daily management of the dietary services; and (iii) Is qualified by experience or training. This Standard is not met as evidenced by: 49797 Based on observations, review of hospital policies and procedures, and interviews with staff it was determined the hospital failed to ensure: 1. Safe storage of food items in the dietary department. 2. Foods were labeled with the date opened and use by date or expiration date. 3. Foods placed in the steam table were covered when not being served. This had the potential to affect all patients admitted to this hospital. Findings include: Hospital Policy: Food Storage ( Dry, Refrigerated, and Frozen) Policy Number: None Issued: None Revised: 9/25/16 Policy: Guideline: Food shall be stored on shelves in a clean, dry area, free from contaminants. Food shall be stored at appropriate temperatures and using the appropriate methods to ensure the highest level of food safety. Procedure: 1. General storage guidelines to be followed: a. All food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed or discarded... Hospital Policy: Serving Temperatures for Hot and Cold Foods. Policy Number: None Issued: None Revised: None Guideline: Staff will follow the guidelines below when serving hot and cold beverages and food. Procedure: ...6. Foods will be covered when not being served. During service, lids to cover one half of the pans will be used... 1. A tour of the dietary department was conducted on 10/1/24 at 11:10 AM with Employee Identifier (EI) #15, Cook, which included observations in the following areas: a. Dry storage: One bag of classic Barilla noodles with an open date of 9/10/24 unsecured on the shelf with no expiration date. One opened bag of noodles without a label and an expiration date. One opened bag of Grits without an expiration date. b. Salad prep counter: 10 bottles of various dry seasoning were observed opened with no expiration date or open date. The staff failed to ensure foods were labeled, and stored appropriately. An interview was conducted on 10/1/24 at 11:20 AM with EI # 15, who confirmed foods were not stored and labeled per policy. 2. An observation was conducted on 10/2/24 at 11:30 AM with EI # 14, Dietary Relief, while preparing patient trays. The staff failed to protect the prepared foods from possible contamination by leaving containers uncovered on the steam table. An interview was conducted on 10/2/24 at 5:22 PM with EI # 2, Director of Nursing, who confirmed the staff did not follow the policy regarding keeping the foods covered while in the steam table.”

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 49894 Based on observations, review of hospital policy, and staff interviews it was determined the hospital failed to ensure expired supplies were not available for patient use. This deficient practice had the potential to negatively affect all patients served by the hospital. Findings include: Hospital Policy: Handling of Medicines, Medical Consumables, and Chemicals Policy Number: 140.13 Written: 8/23/12 Approved by Medical Staff: 8/11/15 This policy applies to all medications, medical consumables...stored in this facility. Purpose: To identify expired products/items... To avoid the use of expired...medical consumables... To arrange return/disposal of expired...medical consumables... Policy: ...All...medical consumables...are to be considered expired on the manufacturer stated day of expiration or at the last day of the manufacturer stated month of expiration. ...Medical consumables...which have expired are not to be used in the facility. ...Medical consumables/supplies...are to be returned to the dispensing department and/or disposed of in an appropriate manner based upon the item. Procedure: ...Staff are to check the expiration date of the products on a regular basis... ...All products are to be checked monthly for expiration... All expired...medical products are to be collected, labeled clearly as expired items, and kept in a separate place for proper disposal. Expired...medical consumables...are to be removed from all patient care areas. ...Discard or return to purchasing expired supplies. Table: Expiration Date of Open Medicine Containers in Patient Care Areas ...Topicals...Creams, ointments, lotions, pastes...Expiration date...30 days after opening... Manufacture containers of items such as ... alcohol are to be considered expired on the manufacturer stated day of expiration ... it is recommended they be used as single patient use items... 1. A tour of the Emergency Department (ED) was conducted on 10/1/24 at 11:30 AM. The following supplies were found to be expired in the supply cabinet in Room ED 1. Eight Ear Curette Loop, Sterile with an expiration date of 4/6/24. Two Large Airlife SeeBreath Carbon Dioxide Detectors with an expiration date of 5/9/24. An interview was conducted on 10/3/24 at 5:30 PM with Employee Identifier (EI) # 2, Director of Nursing, who confirmed the supplies were expired and available for patient use. 2. A tour of the New Day Senior Care Unit Nurse Station was conducted on 10/1/24 at 12:58 PM which included review of the crash cart. The following items were observed in the crash cart as expired and available for patient use: Two 6.5 millimeter (mm) Shiley Hi-Lo Oral/Nasal Tracheal cuffed tubes with expiration date 8/20/24. Three Cardinal Health IV (intravenous) start kits with expiration date 9/1/24. EI # 4, Program Director, was present during the tour and confirmed the items were expired and available for patient use. 3. A tour of the Surgical Department including the Post Anesthesia Care Unit (PACU) and Supply Room was conducted on 10/1/24 at 1:30 PM with EI # 10, Surgery Manager, the following items were observed expired on the unit and available for patient use: One Urinary catheter tray with an expiration date 9/20/23. Five sets of Laproscopy Suction/Irrigation Tubes with an expiration date of 2/18/24. One bottle of Isopropyl Alcohol 16 fluid ounces with a date opened label of 6/5/24. EZ Lubricating Jelly, (brand name), with a date opened label of 8/3/24. One bottle of Iodoform Packing Strip, one inch, with an expiration date of 7/20/24. One bottle of Iodoform Packing Strip, one inch, with an expiration date of 8/12/24. An interview was conducted on 10/1/24 at 2:00 PM with EI # 10, who confirmed the items were available for patient use and were expired and should have been discarded. 4. A tour of the Medical/Surgical unit was conducted on 10/1/24 at 1:50 PM. The following supplies were found to be expired in the crash cart: One Covidien Shiley Intubating Stylet with an expiration date of 5/22/22. One Infusomat Space Pump IV set with an expiration date of 5/31/24. Two 14 Gauge (G) STRL Intravenous (IV) Start Kits, one with an expiration date of 3/1/24, and one with an expiration date of 4/1/24. One 24 G IV Start Kit with an expiration date of 4/1/24. One Covidien 8 millimeter (mm) Hi/Lo Oral/Nasal Tracheal Tube, Cuffed with an expiration date of 12/19/23. One Covidien 8 mm Hi/Lo Oral/Nasal Tracheal Tube, Cuffed with an expiration date of 1/22/24. An interview was conducted on 10/3/24 at 5:30 PM with EI # 2, who confirmed the supplies were expired and available for patient use. 41624 41623”

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 49797 Based on observations, CDC (Centers for Disease Control) Hand Hygiene in Healthcare Settings guidelines, and interviews with staff it was determined the hospital failed to ensure staff performed hand hygiene per CDC guidelines. This deficient practice affected one of one observations of terminal cleaning, one of three observations of medication administration, and had the potential to affect all patients admitted to this hospital. Findings include: CDC Hand Hygiene in Healthcare Settings: January 2020 The Core Infection Prevention and Control Practices for Safe Care Delivery in All Healthcare Settings recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) include the following strong recommendations for hand hygiene in healthcare settings. Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: Immediately before touching a patient... After touching a patient or the patient ‘s immediate environment... After contact with blood, body fluids, or contaminated surfaces Immediately after glove removal. 1. An observation of terminal cleaning for patient room 205 by EI # 18, Housekeeping Tech (Technician), was conducted on 10/2/24 at 8:46 AM. EI # 18 applied gloves without performing hand hygiene (HH), and changed gloves five times between the tasks of cleaning/disinfecting the patient bed frame and mattress, light switches, door handles, windowsill, air conditioning unit, sweeping/mopping the floor and placing clean linens on the bed without performing HH. The surveyor asked EI # 18 at the completion of the terminal cleaning his/her understanding of HH and glove changes. EI # 18 stated he/she changed gloves between tasks, and used hand sanitizer after completion of room cleaning. An interview was conducted on 10/3/24 at 5:22 PM with EI # 2 who confirmed EI # 18 failed to follow the CDC hand hygiene guidelines and perform HH between glove changes. 2. An observation of oral medication administration by EI # 19, registered nurse, to an unsampled patient was conducted on 10/3/24 at 9:06 AM for four medications. EI # 19 obtained the individual oral tablets from the automated dispensing system, applied gloves without performing HH, went to the patient nourishment refrigerator, unlocked the refrigerator, removed a bottle of water and entered the patient’s room while wearing the same gloves. Still wearing the gloves, EI # 19 opened the individual medications, dropped them in a medication cup and administered the medications to the patient. EI # 19 returned to the nurse station, removed the gloves without performing HH, documented the administration of the medications on the computer and then performed HH. EI # 19 failed to perform HH with gloving per CDC hand hygiene guidelines. An interview was conducted on 10/3/24 at 5:22 PM with EI # 2 who confirmed EI # 19 failed to perform HH per the CDC hand hygiene guidelines. 41624”

“OPERATING ROOM POLICIES CFR(s): 482.51(b) Surgical services must be consistent with needs and resources. Policies governing surgical care must be designed to assure the achievement and maintenance of high standards of medical practice and patient care. This Standard is not met as evidenced by: 41623 Based on observations, review of Scope Buddy Flushing Aid User Manual, hospital policy and procedure, and interviews, it was determined the facility failed to ensure staff followed the manufacturer’s recommended use and facility policy for Personal Protective Equipment (PPE) use. This affected one of one observation of endoscope cleaning in the endoscope unit and had the potential to affect all staff performing procedures requiring use of PPE. Findings include: Scope Buddy Endoscope Flushing Aid User Manual Copyright: 2009 Minntech Corporation ...Operator Safety 1. This device is only to be operated by properly trained and qualified personnel... 2. Avoid biological contamination and chemical burns. Always wear appropriate personal protective (PPE) including clothing, gloves, and safety glasses when handling used endoscopes... Facility Policy: Isolation/Contact Precautions Policy Number: Not Listed Revised: 6/15/2017 Policy: 1. The nursing staff will adhere to universal precautions... 3. Wear protective equipment as indicated for specific precaution/situation... An observation of endoscope cleaning was conducted on 10/2/24 at 9:35 AM. Employee Identifier (EI) # 11, Operating Room Technician, donned a splash proof gown, surgical mask, and gloves. EI # 11 was wearing prescription glasses that did not have splash protection. EI # 11 proceeded to clean the endoscope in the sink using the Scope Buddy. EI # 11 failed to use PPE for eye protection. An interview was conducted on 10/3/24 at 5:15 PM with EI # 2, Director of Nursing, who confirmed the staff failed to wear the appropriate PPE while cleaning the endoscope.”

“. K3 Building: 0101 K6 Plan Approval: 1975, 1994 K7 Surveyed Under: 2012 Existing K8 Hospital Generator: One Diesel, Caterpillar 350 kW (installed 2006) Fire Pump: One Diesel, Fire Master Cummings (installed 2006) FACP: Siemens (installed 05/22/2013) Smoke Detection: Only at Smoke/Fire Barriers and in the OR’s Locking Devices: 2 Full Time in Geri-Psych Beds: 69 Census: 3 Type of Structure: 1975/1994 three story with a partial basement fire-resistive, Type II(222). The facility has a partial automatic sprinkler system. During a routine recertification survey conducted on this date, the requirements of 42 CFR, Subpart 482.41 were not met as evidenced by the following deficiencies of the 2012 NFPA 101 Life Safety Code (LSC), the 2012 NFPA 99 Health Care Facilities Code and the standards referenced by these codes, as observed by the LS Surveyor while accompanied by the facility maintenance personnel. .”

“Means of Egress - General CFR(s): NFPA 101 Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11. 18.2.1, 19.2.1, 7.1.10.1 This Standard is not met as evidenced by: 41792 . Based on observation, the facility failed to maintain the means of egress per the requirements of: 2012 NFPA 101, 19.2.1, 7.1.10.1, and 7.2.1.5.1 This deficiency affects 1 of 2 loading dock doors. Findings include: During a tour of the facility, the surveyor observed a hasp with a a keyed padlock on the outside of the loading dock Kitchen Storage Room door. A member of the maintenance staff was present when this deficiency was identified. .”

“Exit Signage CFR(s): NFPA 101 Exit Signage 2012 EXISTING Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system. 19.2.10.1 (Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.) This Standard is not met as evidenced by: 42853 . Based on observation, the facility failed to provide an exit sign per the requirements of: 2012 NFPA 101, 19.2.10.1, 7.10.1.2.1, 7.10.1.3, and 7.10.1.5.1 This deficiency affects the Central Purchasing Storage Room. Findings include: During a tour of the facility, the surveyor observed the facility failed to provide an exit sign for the rear exit door of the Central Purchasing Storage Room. A member of the maintenance staff was present when this deficiency was identified. .”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 42853 . Based on review of documentation, the facility failed to provide documentation on the testing and inspection of the automatic sprinkler system per requirements of: 2012 NFPA 101, 19.3.5.1, 9.7.5, and 9.7.8 2011 NFPA 25, 5.1.1.2, Table 5.1.1.1.2, and 5.3.1.1.1 This deficiency affects entire facility. Findings include: During a tour of the facility, the facility failed to provide the following documentation: 1. The 2003 quick-response sprinkler heads found throughout the facility had been replaced or had a representative sample test completed within 20 years of installation. 2. The first quarterly automatic sprinkler inspection that was due in January of 2024 A member of the maintenance staff was present when this deficiency was identified. .”

“Portable Space Heaters CFR(s): NFPA 101 Portable Space Heaters Portable space heating devices shall be prohibited in all health care occupancies, except, unless used in nonsleeping staff and employee areas where the heating elements do not exceed 212 degrees Fahrenheit (100 degrees Celsius). 18.7.8, 19.7.8 This Standard is not met as evidenced by: 41792 . Based on observation, the facility failed to prohibit a portable space heating device per the requirements of: 2012 NFPA 101, 19.7.8 This deficiency affects 1 of 3 first floor smoke compartments. Findings include: During a tour of the facility, the surveyor observed a portable space heating device that was on the tile floor and not turned on. This device not was located in a sleeping smoke compartment. The facility was unable to provide documentation that the heating element did not exceeding 212 degrees. A member of the maintenance staff was present when this deficiency was identified. .”

“Gas Equipment - Cylinder and Container Storag CFR(s): NFPA 101 Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum “CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING.” Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99) This Standard is not met as evidenced by: 42853 . Based on observation, the facility failed to provide protection for the outside oxygen cylinder storage area per the requirements of: 2012 NFPA 99, 11.6.2.3 (11), 11.3.2.3, and 11.6.5.4 This deficiency affects the outside oxygen cylinder storage area. Findings include: During a tour of the facility, the surveyor obsrved the facility failed to provide protection for the outside oxygen cylinder storage area, against continuous exposure to direct rays of the sun where extreme temperatures prevail. A member of the maintenance staff was present when this deficiency was identified.”