Wiregrass Medical Center

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 39098 Based on review of medical records, hospital policy and procedure, Medical and Dental Staff Bylaws and Rules and Regulations, hospital psychiatric order set, observations, and interviews, it was determined the facility failed to ensure: 1. An appropriate medical screening examination was provided. 2.. All individuals who presented to the ED received necessary stabilizing treatment. This had the potential to affect all patients presenting to the ED. Findings include: Refer to Tags A 2406, and A 2407.”

“POSTING OF SIGNS CFR(s): 489.20(q) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to post conspicuously in any emergency department or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than traditional emergency departments (that is, entrance, admitting area, waiting room, treatment area) a sign (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; and to post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital or rural primary care hospital (e.g., critical access hospital) participates in the Medicaid program under a State plan approved under Title XIX. This Standard is not met as evidenced by: 39098 Based on review of hospital policy and procedure, observations and interview, it was determined the hospital failed to ensure signs specifying the rights of individuals regarding Emergency Medical Treatment and Labor Act (EMTALA), and signs indicating whether the hospital participates in the Medicaid program were posted in places likely to be noticed by all individuals entering the emergency department via the ambulance/ side entrance. This deficient practice had the potential to affect all patients arriving at this hospital for emergency care via the ambulance/ side entrance. Findings include: Hospital Policy: EMTALA Policy Number: None listed Date Reviewed: 3/3/2021 ...VII. Additional Requirements A. Signage: WMC (Wiregrass Medical Center) must post one or more signs conspicuously in the Emergency Department, or in a place or places likely to be noticed by all individuals entering the Emergency Department, and by individuals waiting for examination and treatment in other areas (that is, entrance, admitting area... )... A tour of the Emergency Department (ED) conducted on 4/8/24 at 12:10 PM with Employee Identifier (EI) # 3, Quality Director, revealed there were no signs posted at the ED ambulance/ side entrance. An interview was conducted with EI # 3 during the tour, who confirmed there were no signs posted in the ambulance/ side entrance to the ED regarding the EMTALA laws, or whether the hospital participated in the Medicaid program.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 39098 Based on review of medical records (MR), hospital policy and procedure, City Police Department Incident Report, Emergency Medical Services Report (EMS), Medical and Dental Staff Bylaws and Rules and Regulations, hospital psych (psychiatric) order set, and interviews, it was determined the hospital failed to provide an appropriate Medical Screening Examination (MSE) within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition existed for a patient presenting to the Emergency Department (ED) with Behavioral problems, abnormal blood pressure of 202/108, Systolic (upper number) greater than 120 and Diastolic number (lower number) greater than 80, and Tachycardia (fast heart rate), heart rate of 126 (Normal Heart Rate 60-100). This affected Patient Identifier (PI) # 1, one of three records reviewed of patients designated as Left Without Being Seen, and had the potential to affect all patients presenting to the hospital ED. Findings include: Hospital Policy and Procedure: EMTALA (Emergency Medical Treatment and Active Labor Act) Policy Number: None listed Date Revised: 3/3/2021 ...In general, EMTALA requires that, in the event an individual “comes to the emergency department” at WMC (Wiregrass Medical Center) (the “Emergency Department”), within the meaning of the statute, WMC must provide the individual with an appropriate medical screening examination... ...I. ...A. When an MSE Is Required: ...An individual will be deemed to have “come to the Emergency Department,” within the meaning of EMTALA, in the following circumstances: 1. The individual presents at the Emergency Department and requests, or a request is made on his or her behalf, for examination or treatment for a medical condition. Even if no such request is made, WMC must provide the individual with an MSE if a prudent layperson observer would believe, based on the individual’s appearance or behavior, that the individual needs examination or treatment for a medical condition. ...C. Medical Screening Examination: When an MSE is required, WMC must screen an individual to determine, with reasonable clinical confidence, whether the individual has an EMC (Emergency Medical Condition). WMC must tailor each MSE to the particular individual’s presenting signs and symptoms and utilize any ancillary services that are routinely available to the Emergency Department. ...2. Emergency Medical Condition: ...in the case of a psychiatric emergency, an EMC exists if an individual expresses suicidal or homicidal thoughts or gestures, or if the individual is dangerous to him/herself or others. 3. Ongoing Process: Not Equivalent to Triage. An MSE is not an isolated event; it is an ongoing process that typically begins, but does not end, with triage... Medical and Dental Staff Bylaws and Rules and Regulations Date Approved by Governing Body: 3/13/2019 ...Section 7. Emergency Service Staff The Emergency Service Staff shall consist of those physicians who are secured under arrangement... to provide emergency medical and surgical services for Wiregrass Medical Center. Hospital Order Set: Psych Order Number: None listed Date Reviewed: None listed Set Name ...Psych: ...Medical Urine Drug Screen ... Urinalysis Review of PI # 1’s MR revealed he/she was brought to the ED on 4/1/24 by the Geneva Police Department (PD), with a chief complaint of Behavioral Problem. Triage and Nursing Assessment was documented at 1:55 PM, and included blood pressure 202/108, pulse 126, respiration rate 24, and pulse oximetry 100 %. Triage Acuity was documented as 3 (three) Urgent. Triage Disposition was EX 01 (Exam room 1) and time to room 2:15 PM. Further review of the ED record revealed the five admission documents (consent to treat, advance directive, patient rights and responsibilities, guarantor agreement, and separate bills for services rendered notification) had “pt ams” (patient altered mental status) on the signature line. Review of the Nursing Chart included documentation for General Assessment, Focused Assessment, and Examination. Review of the Nursing Treatment Notes revealed the following documentation by the triage nurse: “1:55 PM: City PD brought patient to ER (Emergency Room) due to behaviors. Officer’s (officers) at bedside. Nurse attempting to triage. 1:58 PM: Patient unable to provide urine sample via urinal at this time. 2:00 PM Procedure: Catheter inserted. 2:07 PM VS (Vital Signs): BP (blood pressure) 202/108... HR (Heart Rate) 126... RR (Respiratory Rate) 24, O2 Sat (Oxygen Saturation) 100 %... 3:10 PM: Police Chief [Name] stated he/she was going to take patient from ER to police department. 3:20 PM: Patient left without being seen at this time. Procedure Details: Urinary Catheter- The catheter was inserted at 4/1/24 2:00 PM. The patient has a need for a catheterization due to urine sample. Notes: Attempted cath (catheter) at this time for urine sample for behavioral clearance protocol. Unable to obtain. ...Disposition: LWBS (Left Without Being Seen) LWBS The patient departed the facility at 4/1/24 3:20 PM. Notes: Patient left without being seen at this time with City Police Dept (Department)...” Review of the Physician Chart notes revealed no documentation by Employee Identifier (EI) # 4, the ED physician, that PI # 1 was provided a medical screening examination for his/her presenting signs and symptoms of psychiatric behavioral problems, and his/her abnormal blood pressure and heart rate. Review of the City Police Department Report (Incident Report) Narrative section, dated 4/2/2024 at 08:19 revealed in part, “PI # 1 (patient name) was advised that we would be taking him/her to Wiregrass Hospital in order to get him/her some help. PI # 1 willingly allowed myself and Officer (name) to put him/her in hand restraints, and we placed him/her in back of my patrol vehicle. On the way to the hospital, PI # 1 randomly became aggressive, yelling things that I could not understand. Once we arrived at the hospital, Officer (name) and I walked him/her in and set him/her on the bed inside the hospital. PI # 1 kept acting as if he/she would lunge at people, so Officer (name) and I held him/her by the shoulders. Once the nurses came in to assist PI # 1, he/she kept yelling at them and calling a “bitch” and saying he /she wasn’t a nice guy/girl. The nurse instructed PI # 1 that he/she would have to pee, ta (to) which they assisted him/her, but he/she would not pee. They advised PI # 1 that they would be doing a catheter. After attempting the catheter, PI # 1 proceeded to kick... the nurse who attempted the catheter, into the wall. PI # 1 was then removed from the hospital and put into an ambulance where they took him/her to another Hospital... where he /her would receive further care.” The EMS report for PI # 1 dated 4/1/2024 at 4:57 PM was reviewed. The section of the note titled, “Patient Care Report Narrative” revealed in part, “Dispatched to the city PD (Police Department) per police chief request for a male/female pt. with AMS (Altered Mental Status). Arrived on scene and was met by the police chief who advised they placed pt under mental health and want him/her transported to Hospital B (receiving hospital). The police chief... advised that they had taken the pt to Wiregrass Medical Center for help when he/she kicked one of the nurses and they advised the police that they were not capable of treating the patient or had the resources to treat him/her per chief... The chief states that they signed him/her out of the hospital and brought him/her back to the PD and called EMS for transport. Chief... states that a police officer will accompany him /her and he/she will be in handcuffs for the transport due to his/her random moments of violence he /she has displayed several times throughout the day. One of the city... PD officers advised that he/she is diagnosed with schizophrenia but do not believe he/she has taken any medications. Pt was assisted into the ambulance where he /she was secured to the stretcher. City... PD Officer... remained in custody of the pt. Pt was alert but very confused. Pt appeared to be in psychosis state of mind. The pt displayed multiple emotions throughout transport. The pt’s speech was incoherent majority of the time. Pt vitals were assessed and monitored during transport. Pt was monitored for any further changes en route. On arrival at Hospital B, report to nursing staff. Report given to RN (Registered Nurse). Witnessed... PD sign for transport since he/she is a mental health pt. of law enforcement. Witness nurse sign receiving care.” The medical record for PI # 1 from Hospital B was reviewed. The medical record revealed the Physician Assistant (PA) documented in part, “HPI (History of the Present Illness) Chief Complaint: Patient presents with Psychiatric Evaluation. EMS states, “He was just released from the jail... PD took him to Wiregrass for mental health eval (evaluation) and he kicked one of their nurses, they said they didn’t have the resources there and sent him back with PD to bring him here. The police officer (name) with EMS (name of EMS company) accompanied pt back to the PD where he and the patient were picked up by EMS and brought here... he is not aggressive on evaluation, but he speaks flight of ideas and is delusional on questioning... Glasgow Coma Scale (tool used to objectively describe extent of impaired consciousness) Score 13 (mild brain injury)... Review of Systems: Psychiatric Behavioral: Positive for agitation, behavioral problems and confusion... Physical Exam... Neurological: Mental Status: He is alert. He is disoriented... Psychiatric: Mood and Affect: Affect is flat. Speech: Speech is rapid and pressured. Behavior: Behavior is withdrawn. Thought Content: Thought content is delusional. Cognition and Memory: Cognition is impaired, ED Course: ED Course... Clinical Impressions as of 4/1/24 7:33 PM Psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality)... Medical Decision Making: Spoke with Psychiatrist (MD Name) who will accept pt to BMU (Behavioral Medicine Unit) for evaluation... will treat UTI (Urinary Tract Infection) in ED... Attending Physician: (Physician Name), MD Psychiatrist...History of present illness: ...30 y.o. (year old) with past history of schizoaffective disorder, PTSD (Post Traumatic Stress Disorder), and medication noncompliance... In the ED, patient received ceftriaxone for UTI, Hydroxyzine (medication used to help control anxiety and tension caused by nervous emotional conditions) and Zyprexa (medication used to treat several mental health conditions). Patient was admitted to the BMU for further evaluation and treatment. The facility failed to ensure their EMTALA policy was followed as evidenced by failing to provide an appropriate medical screening examination, when a request was made on PI # 1’s behalf by the city’s police officers when presented to hospital’s ED on 4/1/2024, for an examination and treatment of his medical conditions. An interview was conducted on 4/8/24 at 12:26 PM with EI # 4, ED contract physician, who was working in the ED when PI # 1 presented to the ED on 4/1/24. The surveyor asked the ED physician if he/she remembered PI # 1. EI # 4 stated yes, but was not involved, and was busy with other patients. EI # 4 stated that he /she remembered that Police were at the back door with PI # 1, and heard cursing and noise outburst. The nurse went to do the triage, and the nurse came out and said she/he was kicked. EI # 4 further stated, “I could hear screaming, I knew he/she was breathing and had a heartbeat. I knew he /she was OK.” The surveyor asked the ED physician if PI # 1 received a medical screening examination, and the ED physician reported that no screening was done. The question was asked by the surveyor if PI # 1 should have received a medical screening examination? The ED physician indicated he/she did not know; and once the police said they were taking PI # 1, that was LWBS (Left Without Being Seen). EI # 4 stated, “They have the right to leave if they don’t want to be seen, and no orders were written.” EI # 4 stated he /she was unaware no paperwork was signed. The physician was also asked if he/she knew the intentions of the police when they left the hospital with PI # 1. The physician answered he/she was told they were taking the patient back to the precinct. EI # 4 knew the police were going to leave with PI # 1, and failed to perform medical screening exam. An interview was conducted on 4/9/24 at 5:15 PM with the EI # 5, triage nurse, who was also in the ED when the patient presented to the ED on 4/1/24. EI # 5 verbalized that she/he remembered PI # 1, a psychiatric patient, as it was the first time EI # 5 had been assaulted. The City Police department brought him/her straight into the exam (examination) room in handcuffs. Three (3) police officers were there including the Chief. The patient was talking out of his/her head and could tell me his/her name, but not where he/she was. The medic got VS (Vital Signs) while I was trying to do questions. I went to get a urine, which is part of our psychiatric screening, the patient tried to urinate for approximately ten minutes, but could not. I then asked the patient if I could try obtaining the urine another way, and the patient was catheterized, but no urine was obtained. I turned around to de-glove and he /she kicked me in the shoulder, and I left the room. I called the Supervisor, Chief Nursing Officer (CNO). The Tech (Technician) called around looking for a bed, and the Medic stated to the chief, “You will need to leave an officer here.” Chief said I am going to take him/her to the police station. The surveyor asked the question did the patient receive a medical screening examination, and EI# 5’s answer was that no doctor saw the patient. The question also asked by the surveyor was “Where were the police going to the take the patient when they left the ED?” The nurse’s answer was, “I don’t know, just said he/she was going to the police station, and they were talking about several things, arrest, and another facility. So, the patient left without being seen.” EI # 5 revealed that the protocol for psychiatric patients is a urine drug screen, UA (Urinalysis), CXR (Chest X-ray), CMP (Comprehensive Metabolic Panel -measures blood level of glucose and other elements), CBC (Complete Blood Count, measures red blood cells, white blood cells and platelets in the blood), COVID test, and if HR (heart Rate) is up a cardiac screen. EI # 5 stated, “It’s not an order set, our old system had one. The orders are usually verbal orders, then the Medical Doctor signs the chart.” Despite this patient’s presentation of abnormal heart rate and elevated blood pressure there was no cardiac screen order, and no medical interventions related to the patient’s abnormal vital signs. A telephone interview was conducted on 4/10/2024 at 1:13 PM with the City’s Chief of Police. The surveyor asked the Chief did he/she remember PI #1, and he/she stated “Yes,” and the reason for bringing him/her in was because they were called due to his/her irrational behavior, and he/she was transported to the hospital because he/she was violent. The surveyor asked if the physician had any interaction with PI # 1, the Chief answered that it did not get that far. The Chief was also asked if the hospital encouraged them to stay and have PI # 1 examined? The Chief answered, once that happened (kicked the nurse) and couldn’t do a drug screen, I knew he/she couldn’t get in anywhere, so I asked would I get in trouble just taking him/her to the station. They said no. The next question was did you tell anyone in the ED that you may take PI # 1 somewhere else? The Chief of Police answered that he/she was not sure, “...I just knew they couldn’t keep him/her without a doing a drug screen. We deal with is all the time.” The Chief of Police also stated he/she never talked to the physician. After the patient assaulted the nurse, he/she stated he/she asked the CNO if he/she would get in trouble if they took the patient to the police station, and he/she stated she/he responded, “No.” The Chief denied being asked to sign any paperwork before leaving and doesn’t remember being asked to stay and let the doctor examine the patient first. Further review revealed that after arriving at the PD, the police called an ambulance to pick up the patient and transport to Hospital B. An officer accompanied the patient in the ambulance. The patient was admitted to Hospital B for treatment. An interview was conducted on 4/10/24 at 10:00 AM with EI # 2, CNO, who was at the hospital working on 4/1/24 when PI # 1 presented to the ED. The CNO indicated during the interview that she/he remembered PI # 1 because EI # 1 and EI #5 and the Police Chief were talking at the nurse’s station. She/he was informed that EI # 5 had been kicked by PI # 1. She/he also stated the Chief stated they were going to take the patient back to the station. The surveyor asked the question did PI # 1 receive a medical screening examination on 4/1/2024 when he/she presented to the ED? The CNO stated the patient did not get a MSE by the ED physician. A telephone interview was conducted on 4/10/24 at 9:30 AM with EI # 6, ED paramedic. EI # 6 verified that he/she was working in the ED on 4/1/2024 when PI # 1 presented to the ED. EI # 6 stated that he/she remembered PI # 1 because Law Enforcement brought him/her in handcuffs for us to evaluate and clearance for mental health. EI # 6 stated, “...While I was on the phone, he/she assaulted the nurse, I heard her/him scream and I ran in there I told the Chief, Y’all will have to have an officer here at all times for safety now, they said ok. They ended up leaving with PI # 1 in handcuffs.” An interview was conducted on 4/10/24 at 10:15 AM with EI # 8, ED technician, who was on duty when PI # 1 came to the ED on 4/1/24. EI # 8 stated that she/he remembered the Cops (Police) brought him/her in, but I was not involved in PI # 1’s care. PI # 1 was put in an examination room. EI # 8 stated she/he remembered EI # 5 coming out and talked about being kicked, and the cops taking the patient back to the police station. EI # 8 also said that she/he did not remember and did not know if the patient received a medical screening examination. An interview was conducted on 4/10/24 at 12:58 PM with EI # 2, who confirmed there was no MSE conducted by the physician on duty, and there was no documentation the patient, or the individuals acting on his/her behalf were informed of the risks and benefits associated with further examination and treatment. EI # 2 confirmed staff failed to obtain a signed refusal of exam and treatment, and the staff failed to document the refusal per policy. EI # 2 further confirmed only physicians may perform the MSE at WMC, per the Bylaws and Rules and Regulations.”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 39098 Based on review of medical records (MR), hospital policy and procedure, and staff interviews, it was determined the hospital failed to offer the persons acting on behalf of the individual (Patient # 1) the risks and the benefits to the individual of the examination and treatment. Additionally, the facility failed to take all reasonable steps to secure a written informed refusal of the person acting on his/her behalf. This affected Patient Identifier (PI) # 1, one of three records reviewed of patients designated as Left Without Being Seen, and had the potential to affect all patients presenting to the hospital ED. Findings include: Hospital Policy: EMTALA (Emergency Medical Treatment and Labor Act) Policy Number: None Listed Date Revised: 3/3/21 ...In general, if WMC (Wiregrass Medical Center) determines that the individual has an EMC (Emergency Medical Condition), WMC must either provide necessary examination and treatment, within its capabilities, to stabilize the EMC, or provide for an appropriate transfer... F. ...2. Leaving after Triage but before an MSE: In the event that, following triage but prior to receiving an MSE, an individual who has come to the Emergency Department attempts or demands to leave the hospital, or the individual (or if the individual is not capable of making an informed decision for him/herself, a person acting on the individual’s behalf) refuses to consent to further examination or treatment, WMC personnel must (i) if possible, do a complete registration on the individual and chart relevant information; (ii) offer to provide the individual further examination and treatment as may be necessary to identify and stabilize an EMC; (iii) inform the individual (or the person acting on the individual’s behalf) of the risks and benefits associated with further examination and treatment; (iv) if the individual (or the person acting on the individual’s behalf) still refuses to consent to further examination and treatment, take all reasonable steps to obtain a signed, informed refusal of examination or treatment form from the individual (or the person acting on the individual’s behalf), which form must indicate, at a minimum, that WMC personnel informed the individual (or the person acting on the individual’s behalf) of the benefits or risks of examination and treatment, or both, if applicable; and (v) document the refusal accordingly... Review of PI # 1’s MR revealed he was brought to the ED on 4/1/24 by the Geneva Police Department (PD), with a chief complaint of Behavioral Problem. Triage and Nursing Assessment was documented at 1:55 PM, and included blood pressure 202/108, pulse 126, respiration rate 24, and pulse oximetry 100 %. Triage Acuity was documented as 3 (three) Urgent. Triage Disposition was EX 01 (Exam room 1) and time to room 2:15 PM. Review of the Nursing Chart included documentation for General Assessment, Focused Assessment, and Examination. Review of the Nursing Treatment Notes revealed the following documentation by the triage nurse: “1:55 PM: Geneva PD brought patient to ER (Emergency Room) due to behaviors. Officer’s (officers) at bedside. Nurse attempting to triage. 1:58 PM: Patient unable to provide urine sample via urinal at this time. 2:00 PM Procedure: Catheter inserted. 2:07 PM VS (Vital Signs): BP (blood pressure) 202/108... HR (Heart Rate) 126... RR (Respiratory Rate) 24, O2 Sat (Oxygen Saturation) 100 %... 3:10 PM: Police Chief [Name] stated he/she was going to take patient from ER to police department. 3:20 PM: Patient left without being seen at this time. Procedure Details: Urinary Catheter- The catheter was inserted at 4/1/24 2:00 PM. The patient has a need for a catheterization due to urine sample. Notes: Attempted cath (catheter) at this time for urine sample for behavioral clearance protocol. Unable to obtain. ...Disposition: LWBS (Left Without Being Seen) LWBS. The patient departed the facility at 4/1/24 3:20 PM. Notes: Patient left without being seen at this time with Geneva Police Dept (Department)...” Review of the Physician Chart notes revealed no documentation by hospital staff that the persons acting on PI # 1’s behalf (Law Enforcement) were explained the risks and benefits of the examination and treatment. On 4/9/23 at 12:26 PM, an interview was conducted with the ED physician EI # 4. The surveyor asked EI # 4, was PI # 1 or the officers advised of the risks and benefits of leaving without a medical screening examination. EI # 4 replied, not by me. An interview was conducted on 4/10/24 at 12:58 PM with EI # 2, who confirmed there was no MSE, no documentation the patient, or the individuals acting on his/her behalf were informed of the risks and benefits associated with further examination and treatment. EI # 2 confirmed staff failed to obtain a signed refusal of exam and treatment, and the staff failed to document the refusal per policy.”

“FOOD AND DIETETIC SERVICES CFR(s): 482.28 The hospital must have organized dietary services that are directed and staffed by adequate qualified personnel. However, a hospital that has a contract with an outside food management company may be found to meet this Condition of Participation if the company has a dietitian who serves the hospital on a full-time, part-time, or consultant basis, and if the company maintains at least the minimum standards specified in this section and provides for constant liaison with the hospital medical staff for recommendations on dietetic policies affecting patient treatment. This Condition is not met as evidenced by: 40119 Based on review of the hospital policies, dietary consultant agreement, hospital diet manual, observations, and interviews, it was determined the hospital failed to ensure: 1. The kitchen was maintained in a clean, safe, sanitary manner and free of rodents. 2. Dietary Services were incorporated into the hospital Quality Assessment and Performance Improvement (QAPI) program. 3. A Registered Dietitian was available to supervise the nutritional aspects of patient care. 4. Diet menus were available to meet the needs of patients requiring special diets. 5. The dietary manual was reviewed by the medical staff and a Registered Dietitian. This did affect Patient Identifier (PI) # 10 and had the potential to negatively affect all patients served by the facility. Findings: Refer to tags A 0620, A 0621, A 0629, and A 0631.”

“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: 40119 Based on observations, review of hospital policies and interviews it was determined the hospital failed to ensure the facility was clean, safe, sanitary, and free of rodents. This had the potential to affect all persons served by the hospital. Findings include: Refer to tag A 0701.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 40119 Based on review of medical records (MR), hospital policy and procedure, and staff interview, it was determined the facility failed to ensure two of four swing bed patients were informed of the patient’s rights prior to receiving care at the facility. This affected Patient Identifier (PI) # 17 and PI # 18 and had the potential to affect all patients served by this facility. Findings include: Hospital Policy: Patient Rights and Responsibilities Policy Number: Not documented Date Issued: Not documented ...Procedure: 1. As a part of the orientation process, patients or family members, significant and/or concerned others will be informed both orally and in writing of their rights by the Admission Nurse and/or the Care Manager. ...3. A copy of the Patient’s Rights form will be given to the patient, family member, significant others, and/or concerned others as part of the orientation packet. 1. PI # 17 was admitted to the hospital swing bed unit on 1/6/24 with diagnoses including Cerebral Infarction/Multiple Brain Lesions with Hemorrhage into at Least One of these Lesions and Poor Balance with Diminished Mentation. Review of the MR revealed no documentation the patient, family member, significant and/or concerned others were informed orally and in writing of the patient rights. An interview was conducted on 1/11/24 at 9:18 AM with Employee Identifier (EI) # 2, Case Management Director, who confirmed there was no documentation the patient, family member, significant and/or concerned others were informed orally and in writing of the patient rights. 2. PI # 18 was admitted to the hospital swing bed unit on 1/9/24 with diagnoses including Pneumonia and Congestive Heart Failure. Review of the MR revealed no documentation the patient, family member, significant and/or concerned others were informed orally and in writing of the patient rights. An interview was conducted on 1/11/24 at 9:36 AM with EI # 2 who confirmed there was no documentation the patient, family member, significant and/or concerned others were informed orally and in writing of the patient rights.”

“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: 41623 Based on observations and staff interviews, it was determined the hospital failed to ensure the Senior Care Unit was free of ligature risks. This deficient practice had the potential to negatively affect all patients admitted to the Senior Care Unit. Findings include: 1. During a tour of the Senior Care Unit on 1/9/24 at 10:30 AM with Employee Identifier (EI) # 3, Chief Nursing Officer, the following ligature risks were identified: The activity room bathroom door was lockable from the inside. In the bathroom, the toilet and sink plumbing were exposed and the grab rail was not enclosed, creating ligature risks. An interview was conducted on 1/9/24 at 11:00 AM with EI # 3 who confirmed the bathroom was used by all patients on the unit and the items identified could be used to attach ligature.”

“DATA COLLECTION & ANALYSIS CFR(s): 482.21(a), (b)(1),(b)(2)(i), (b)(3) (a) Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes ... (2) The hospital must measure, analyze, and track quality indicators ... and other aspects of performance that assess processes of care, hospital service and operations. (b)Program Data (1) The program must incorporate quality indicator data including patient care data, and other relevant data such as data submitted to or received from Medicare quality reporting and quality performance programs, including but not limited to data related to hospital readmissions and hospital-acquired conditions. (2) The hospital must use the data collected to-- (i) Monitor the effectiveness and safety of services and quality of care; and .... (3) The frequency and detail of data collection must be specified by the hospital’s governing body. This Standard is not met as evidenced by: 41623 Based on review of the facility QAPI (Quality Assurance and Performance Improvement) program documentation, facility policy and interviews, it was determined the facility QAPI program failed to include reporting data for each department of the facility. This deficient practice had the potential to affect all patients admitted to this facility. Findings include: Facility Policy: Performance Improvement Plan Policy Number: not documented Policy Date: 1/12/23 I. Purpose: The Performance Improvement Plan for Wiregrass Medical Center establishes a planned, systemic, organization-wide approach to process design and performance measurement, analysis, and improvement for the health care services we provide. ...Objectives: ...B. To collect data to monitor the stability of existing processes, identify opportunities for improvement, identify changes that will lead to improvement, and sustain improvement. C. To aggregate and analyze data on an ongoing basis... F. To educate leaders and staff regarding responsibilities and effective participation in performance improvement activities... XII. Unit/Program Activities: Units and/or programs will monitor, evaluate and improve functions and or services provided. 1. The Director/Manager is responsible for and actively participates in monitoring, evaluation and improvement activities for it’s unit or program... 3. All departments shall implement a plan for improving performance for their assigned areas... Report findings to Performance Improvement Committee on quarterly basis... 1. Review of the QAPI data for the year 2023 revealed no documentation of QAPI data from all hospital departments including Dietary, Rehabilitation Services and the inpatient Detox Program. An interview was conducted on 1/9/24 at 1:50 PM with Employee Identifier (EI) # 6, Quality Director, who confirmed there was no data submitted for Dietary, Rehabilitation Services, and the Detox program and the three departments did not participate in the hospital QAPI program.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 41623 Based on review of medical records (MR), Potter and Perry Fundamentals of Nursing, facility policies and procedures, and interviews, it was determined the facility failed to ensure: 1. Wound care was provided as ordered by the physician. 2. Wounds were assessed daily to include measurement and a description as directed per policy. 3. Nursing staff documented a pain assessment and re-assessment after PRN (as needed) medications were administered for pain. 4. Daily weights were obtained as ordered by the physician. 5. Vital signs were assessed every five minutes times three, as directed per facility policy, for blood administration. 6. Nursing staff followed the physician’s orders and drained the correct amount of fluid following a Paracentesis. 7. PRN (as needed) medications for elevated blood pressure were administered as ordered. These deficient practices affected two of four MR’s reviewed of patients with wounds including Patient Identifier (PI) # 24 and PI # 26, two of five inpatient MR’s reviewed requiring a surgical procedure including PI # 28 and PI # 22 and had the potential to affect all patients treated at this facility. Findings include: Facility Policy: Wound Care/Treatment Guidelines Policy Number: Not documented Date Revised/Reviewed: 2/2019 ...Purpose: To provide excellent wound care to promote healing. Guidelines: 1. A daily assessment should be done on all wounds requiring treatment. This should include measurement and a description.... Potter and Perry Fundamentals of Nursing Fifth Edition Copyright 2001 ...Chapter 47. Skin Integrity and Wound Care ...Acute Care. Management of Pressure Ulcers. ...When treating a pressure ulcer, the wound should be reassessed for location, stage, size, sinus tracts, undermining, tunneling, exudate, necrotic tissue, and the presence or absence of granulation, tissue and epithelialization...Pressure ulcers should be reassessed at least daily... Hospital Policy: Pain Assessment Policy Number: Not documented. Review Date: 10/23 ...Statement of Purpose: To develop a procedure to follow for assessment and treatment of pain. Text: When (a) patient complains of pain, the licensed nurse will assess the patient. The nurse will document on the PRN Pain Assessment MAR (Medication Administration Record): ...4. Origin of pain or location of pain. 5. Severity (rate on scale of 0 - 10). 6. Response to treatment. The above should be documented for each PRN pain medication given. PRN pain medications should be re-assessed within 1 (one) to 4 (four) hours depending on route of administration. Hospital Policy: Blood Administration Policy Number: Not documented. Review Date: 3/21 ...Statement of Purpose: To administer blood in the safest and most efficient way to obtain the greatest patient benefit possible. ...Vital signs: ...3. Vital signs will be checked and recorded every 5 minutes x (times) 3... 1. PI # 24 was admitted on 11/9/23 with diagnoses including Acute UTI (Urinary Tract Infection) with Leukocytosis, Dehydration, Diabetes Mellitus Type II with Hyperglycemia, Multiple Decubiti, and Failure to Thrive. Review of the Initial Nursing Interview and Assessment dated 11/9/23 revealed documentation of a Stage 3 pressure ulcer to the right heel measuring 5.5 cm (centimeters) by 5.75 cm and a Stage 2 pressure ulcer to buttocks measuring 1.25 cm by 2.5 cm. There was no depth of the wounds documented. Review of the physician’s order dated 11/9/23 at 6:56 PM revealed orders for Bactroban ointment BID (twice daily). There was no location for the ointment application on the order. Review of the physician’s order dated 11/10/23 at 9:30 AM, post debridement of right heel, revealed orders to clean right heel with saline, pat dry, apply one half strength (Dakin’s Solution) soaked 4 x 4 (four by four) to wound bed, dry four by fours, Kerlix, and tape BID. Review of the physician’s order dated 11/10/23 at 10:06 PM revealed orders for Dakin’s Solution full strength, apply to right heel with dressing change BID. Review of the Patient Progress Note (PPN) dated 11/11/23 at 9:40 AM and 9:30 PM revealed the nurse documented wound care to the right heel with 1/2 strength Dakin’s solution and not the full strength Dakin’s solution ordered. Review of the PPN dated 11/12/23 at 10:30 AM revealed the nurse documented wound assessment and care to the right heel with 1/2 strength Dakin’s solution and not the full strength Dakin’s solution ordered. Further review of the PPNs dated 11/12/23 revealed no measurements of the pressure ulcer to the buttocks. Review of the PPN dated 11/13/23 at 9:45 AM and 9:14 PM revealed the nurse documented wound assessments and wound care to the right heel with 1/2 strength Dakin’s solution and not the full strength Dakin’s solution ordered. Further review of the PPNs dated 11/13/23 revealed no documentation of an assessment of the pressure ulcer to the buttocks. Review of the PPNs dated 11/14/23 at 10:55 AM and 9:10 PM revealed the nurse documented wound care to right heel with 1/2 strength Dakin’s solution and not the full strength Dakin’s solution ordered. Further review of the PPNs dated 11/14/23 revealed no documentation an assessment of the pressure ulcer to the buttocks and no documentation of wound measurements of the pressure ulcer to the right heel. Review of the PPN dated 11/15/23 at 10:00 AM revealed the nurse documented wound care to right heel with 1/2 strength Dakin’s solution and not the full strength Dakin’s solution ordered. Further review of the 11/15/23 PPNs revealed no documentation of measurements of the pressure ulcer to the right heel and no documentation of an assessment of the pressure ulcer to the buttocks. In an interview conducted on 1/11/24 at 3:40 PM, EI # 7, Director of Nursing, confirmed the staff failed to follow the physician’s orders for wound care and failed to assess all wounds daily. 40119 2. PI # 28 was admitted to the hospital on 1/4/24 with a diagnosis of Cellulitis and Abscess of the Left Axilla Extending into the Left Chest Wall and Left Breast. Review of the Physician Admission Orders dated 1/4/24 revealed an order for IV (Intravenous) Morphine 4 mg (milligrams) every four hours prn for pain. Review of the PPN dated 1/4/24 revealed at 10:12 PM, the nurse documented the patient was administered Morphine 4 mg PRN for pain. There was no documentation of the location of the pain and pain severity. Review of the Physician Orders dated 1/5/24 revealed an order for Norco (Hydrocodone and Acetaminophen) 5 mg/325 mg 1 tablet every four hours prn for pain and to only use Morphine if severe pain. Review of the PPN dated 1/5/24 revealed: At 3:11 AM, the nurse documented the patient was administered Morphine 4 mg PRN for pain. There was no documentation of the location of the pain and pain severity. At 11:36 AM, the nurse documented the patient was administered Morphine 4 mg PRN for pain. There was no documentation of the location of the pain and pain severity. At 1:55 PM, the nurse documented the patient was administered Norco 5 mg/ 325 mg PRN for pain. There was no documentation of the location of the pain and pain severity. At 8:24 PM, the nurse documented the patient was administered Norco 5 mg/ 325 mg PRN for pain. There was no documentation of the location of the pain and pain severity. At 10:12 PM, the nurse documented the patient was administered Morphine 4 mg PRN for pain. There was no documentation of the location of the pain and pain severity. Review of the PPN dated 1/6/24 revealed: At 2:26 AM, the nurse documented the patient was administered Norco 5 mg/ 325 mg PRN for pain. There was no documentation of the location of the pain and pain severity. At 12:07 PM, the nurse documented the patient was administered Norco 5 mg/ 325 mg PRN for pain. There was no documentation of the location of the pain and pain severity. At 2:46 PM, the nurse documented the patient was administered Morphine 4 mg PRN for pain. There was no documentation of the location of the pain and pain severity. At 6:14 PM, the nurse documented the patient was administered Norco 5 mg/ 325 mg PRN for pain. There was no documentation of the location of the pain and pain severity. At 7:46 PM, the nurse documented the patient was administered Morphine 4 mg PRN for pain. There was no documentation of the location of the pain and pain severity. At 11:19 PM, the nurse documented the patient was administered Norco 5 mg/ 325 mg PRN for pain. There was no documentation of the location of the pain and pain severity. Review of the Physician’s Orders dated 1/7/24 revealed an order for Toradol 30 mg IV every eight hours prn for pain. Review of the PPN dated 1/7/24 revealed: At 12:42 AM, the nurse documented the patient was administered Morphine 4 mg PRN for pain. There was no documentation of the location of the pain and pain severity. At 3:24 AM, the nurse documented the patient was administered Norco 5 mg/ 325 mg as needed for pain. There was no documentation of the location of the pain and pain severity. The nurse documented a pain reassessment of “effective” at 3:24 AM, the same time the Norco was administered. At 10:47 AM, the nurse documented the patient was administered Toradol 30 mg PRN for pain. There was no documentation of the location of the pain and pain severity. At 1:09 PM, the nurse documented the patient was administered Norco 5 mg/ 325 mg PRN for pain. There was no documentation of the location of the pain and pain severity. At 5:44 PM, the nurse documented the patient was administered Norco 5 mg/ 325 mg PRN for pain. There was no documentation of the location of the pain and pain severity. At 9:11 PM, the nurse documented the patient was administered Toradol 30 mg PRN for pain. There was no documentation of the location of the pain and pain severity. Review of the PPN dated 1/8/24 revealed: At 12:15 AM, the nurse documented the patient was administered Norco 5 mg/ 325 mg PRN for pain. There was no documentation of the location of the pain and pain severity. At 11:09 AM, the nurse documented the patient was administered Norco 5 mg/ 325 mg PRN for pain. There was no documentation of the location of the pain and pain severity. At 6:00 PM, the nurse documented the patient was administered Morphine 4 mg PRN for pain. There was no documentation of the location of the pain and pain severity. At 9:20 PM, the nurse documented the patient was administered Norco 5 mg/ 325 mg PRN for pain. There was no documentation of the location of the pain and pain severity. An interview was conducted on 1/11/24 at 2:59 PM with EI # 2, Case Management Director, who confirmed there was no documentation of a comprehensive pain assessment and/or reassessment for the above dates and times. EI # 2 confirmed a pain reassessment should not be performed at the same time of medication administration. 3. PI # 22 was admitted to the hospital on 12/19/23 with diagnoses including Ascites Secondary to Cirrhosis of the Liver, Symptomatic and Anasarca. Review of the Physician Admission Orders dated 12/19/23 revealed an order for daily weights and Tylenol 650 mg every six hours prn headache or pain. Review of the Physician’s Orders dated 12/20/23 at 9:47 AM revealed an order to drain 6 liters of fluid post Paracentesis, then pull the drain. Review of the Graphic Form dated 12/20/23 to 12/24/23 revealed a documented weight of 251 pounds on 12/20/23 and no documentation a weight was obtained on 12/21/23 through the discharge date of 12/24/23. Review of the PPN dated 12/20/23 revealed the following: At 10:15 AM, 1500 milliliters (ml) was drained from the “Paracentesis”. At 10:23 AM, 750 ml was drained from the “Paracentesis”. At 10:32 AM, 700 ml was drained from the “Paracentesis”. At 11:01 AM, 750 ml was drained from the “Paracentesis”. At 11:38 AM, 1000 ml was drained from the “Paracentesis”. At 11:55 AM, 700 ml was drained from the “Paracentesis” and the physician was contacted regarding the amount and color of the fluid. The physician verbalized to continue order to remove 6 liters. At 12:44 PM, 200 ml was drained from the “Paracentesis” then the drain was removed from the right lower abdomen. A total of 5600 ml of fluid was drained which was 400 ml less than the physician ordered 6 liters. Further review of the PPN dated 12/20/23 revealed at 9:18 PM, the nurse documented the patient was administered Tylenol 650 mg PRN for pain. There was no documentation of the location of the pain and pain severity. Review of the Physician Progress Note dated 12/21/23 revealed the patient continued to have a “fluid wave” in the abdomen, decreased airflow with bibasilar rales and wheezing in the lungs, edema to the lower extremities, and the surgeon was to be reconsulted for a possible repeat paracentesis. Review of the Physician Orders dated 12/21/23 revealed an order to transfuse 2 Units of PRBC (Packed Red Blood Cells). Review of the PPN dated 12/21/23 revealed a blood transfusion of one unit of PRBC was started at 5:25 PM. Further review revealed the first vital signs (blood pressure, pulse, respirations, and temperature) was completed at 5:35 PM, which was 10 minutes after the transfusion was started. At 5:40 PM and 5:43 PM a temperature was documented. There was no documentation of the patient’s blood pressure, pulse, and respirations. The nursing staff failed to perform vital signs every five minutes x 3 per the hospital policy. Further review of the PPN dated 12/21/23 revealed at 6:35 PM, the nurse documented the patient was administered Tylenol 650 mg PRN for pain. There was no documentation of the location of the pain and pain severity. Review of the PPN dated 12/22/23 revealed at 12:39 AM, the nurse documented the patient was administered Tylenol 650 mg PRN for pain. There was no documentation of the location of the pain and pain severity. Review of the PPN dated 12/22/23 revealed at 5:46 AM, the nurse documented the patient was administered Tylenol 650 mg PRN for pain. There was no documentation of the location of the pain and pain severity. An interview was conducted on 1/11/24 at 11:34 AM with EI # 2 who confirmed the staff failed to perform a comprehensive pain assessment and/or reassessment for the above dates and times, obtain daily weights as ordered, assess vital signs every five minutes x 3 per policy for blood administration, and failed to follow the physician’s order to drain a total of 6 liters of fluid from a patient that had a Paracentesis. 49797 4. PI # 26 was admitted on 12/27/23 with Acute on Chronic Systolic Congestive Heart Failure. Review of the MR revealed PI # 26 had a stage II pressure wound to the left buttock measuring 0.9 cm length (L) by 0.6 cm width (W) by 0.1 cm depth (D) and a stage II pressure wound to the right buttock measuring 2.0 cm L by 1.0 W by 0.1 D on admission. Review of the PPNs from 12/28/23 to 1/6/24 revealed no documentation the wounds were measured and described. The facility failed to ensure the staff assessed wounds daily per policy. Review of the physicians orders dated 12/29/23 revealed an order for Clonidine 0.1 mg PRN every four hours for systolic blood pressure greater than 170 or diastolic blood pressure greater than 105. Review of Vital Sign Graph dated 12/31/23 revealed a blood pressure of 200/115 at 4:00 AM. Further review of the MR revealed no documentation Clonidine was administered as ordered by the physician. An interview was conducted on 1/11/24 at 1:15 PM with EI # 7 who confirmed the staff failed to assess and document wounds per policy and failed to administer PRN medications per physician order for elevated blood pressure.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 40119 Based on review of medical records (MR), hospital policy and procedure and interviews with the staff it was determined the hospital failed to ensure a nursing care plan was developed and updated for each patient admitted to the hospital. This did affect Patient Identifier (PI) # 17, PI # 18, PI # 21, three of four swing bed patients, PI # 28, and PI # 22, two of five inpatient MR’s review requiring a surgical procedure, and had the potential to negatively affect all patients admitted to the hospital. Findings include: Hospital Policy: Assessment of Patients and Care Plans Policy Number: Not documented Revised Date: 9/23 ...Text: An RN (Registered Nurse) will assess the patient within the first four hours of admission... Re-assessment will be done when the patient’s condition changes or upon patient or family request, but at least once a shift... The goals in the care plan will be based on the nursing assessment and be realistic, measurable, and consistent with the therapy prescribed by the physician, include the patient education needs identified in the assessment or re-assessment. 1. PI # 17 was admitted to the hospital swing bed unit on 1/6/24 with diagnoses including Cerebral Infarction/Multiple Brain Lesions with Hemorrhage into at Least One of these Lesions and Poor Balance with Diminished Mentation. Review of the MR revealed no documentation a nursing care plan was developed on admission and updated as needed with changes in the patient’s condition. An interview was conducted on 1/11/24 at 9:18 AM with Employee Identifier (EI) # 2, Case Management Director, who confirmed the staff failed to complete a nursing care plan on PI # 17. 2. PI # 18 was admitted to the hospital swing bed unit on 1/9/24 with diagnoses including Pneumonia and Congestive Heart Failure. Review of the MR revealed no documentation a nursing care plan was developed on admission and updated as needed with changes in the patient’s condition. An interview was conducted on 1/11/24 at 9:36 AM with EI # 2 who confirmed the staff failed to complete a nursing care plan on PI # 18. 3. PI # 21 was admitted to the hospital swing bed unit on 8/17/23 with a diagnosis of Right-sided CVA (Cerebral Vascular Accident). Review of the MR revealed no documentation a nursing care plan was developed on admission and updated as needed with changes in the patient’s condition. An interview was conducted on 1/11/24 at 2:25 PM with EI # 2 who confirmed the staff failed to complete a nursing care plan on PI # 21. 4. PI # 28 was admitted to the hospital on 1/4/24 with a diagnosis of Cellulitis and Abscess of the Left Axilla Extending into the Left Chest Wall and Left Breast. Review of the MR revealed PI # 28 required the administration of as needed pain medications once on 1/4/24, six times on 1/5/24, nine times on 1/6/24, seven times on 1/7/24, and eight times on 1/8/24. Review of the Nursing Care Plan dated 1/11/24 revealed documentation of skin integrity-actual impairment as the problem. There was no documentation of a nursing care plan for pain interventions and goals. An interview was conducted on 1/11/24 at 2:59 PM with EI # 2 who confirmed there was no documentation of a nursing pain intervention and goal on the nursing care plan for PI # 28. 5. PI # 22 was admitted to the hospital on 12/19/23 with diagnoses including Ascites Secondary to Cirrhosis of the Liver, Symptomatic and Anasarca. Review of the Nursing Care Plan dated 1/11/24 revealed documentation of ineffective peripheral tissue perfusion related to decreased blood flow. Further review revealed no nursing interventions and goals for the problem of ineffective peripheral tissue perfusion related to decreased blood flow. An interview was conducted on 1/11/24 at 11:34 AM with EI # 2 who confirmed there was no documentation of a nursing intervention and goals on the nursing care plan for PI # 22.”

“ORDERS FOR DRUGS AND BIOLOGICALS CFR(s): Orders for drugs and biologicals may be documented and signed by other practitioners, not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. This Standard is not met as evidenced by: 41623 Based on observations during a tour of Senior Care Unit, facility policies, and interviews with staff, it was determined the facility failed to ensure all medications dispensed to patients were ordered by the physician. This deficient practice affected one of ten patients in the Senior Care Unit including Patient Identifier (PI) # 2 and had the potential to affect all patients in this facility. Findings include: Facility Policy: Medication Samples Policy Number: Not Documented Revised Date: 12/21 Purpose: To establish guidelines for the use of samples. Policy: Medication samples are prohibited on-site at Wiregrass Medical Center. ...2. If a physician has a request, the representative may order for the physician’s personal use. These should never be left in the hospital department where the physician practices... 3. Physicians may supply patients with sample medications. These medications will be treated as any other patient’s own medication. Facility Policy: Use of Patient’s Own Medication Policy Number: Not Documented Revised Date: 8/14/15 Purpose: To describe a method to safely manage medications brought into the hospital by patients and their families... Patients may use their own medications under the following circumstances: 1. The medication is not on the hospital formulary... 2. A patient prefers to use their own medication rather than taking the hospital formulary substitute. 3. The medication must be verified by a pharmacist. Facility Policy: Distribution of Medication in Wiregrass Hospital Policy Number: Not Documented Revised Date: 9/15 ...Statement of Purpose: To establish a standard system for ordering and dispensing medications to patients... II. Dispensing/Charging A. Medications are dispensed from Pyxis machines... III. Patient Profiles... B. All medications ordered for the patient are to be listed on the profile. No med should be dispensed without an order... 1. A tour of the Senior Care Unit medication room was conducted on 1/9/24 at 11:00 AM with Employee Identifier (EI) # 3, Chief Nursing Officer. In the medicine cart drawer for PI # 2 was a physician’s sample package of Rexulti 2 mg (milligram) tablets. There was no patient label on the package. Review of the physician’s orders revealed no documentation of an order for Rexulti. Review of the MAR (Medication Administration Record) dated 1/9/24 revealed no documentation of the Rexulti medication. During the tour, EI # 3 confirmed the sample medication Rexulti was for PI # 2 and there was no physician order for the medication. An interview was conducted on 1/10/24 at 9:32 AM with EI # 10, Pharmacist, who stated the sample medications were treated as the use of the patient’s own medications and sample medications were to have a label printed on them and placed in the patient’s drawer on the medication cart.”

“UNUSABLE DRUGS NOT USED CFR(s): 482.25(b)(3) §482.25(b)(3) - Outdated, mislabeled, or otherwise unusable drugs and biologicals must not be available for patient use This Standard is not met as evidenced by: 46290 Based on observation, hospital policies and procedures, Centers for Disease Control and Prevention (CDC) Injection Safety, and interview, it was determined the hospital failed to ensure: a. Expired supplies, medications and solutions were not available for patient use. b. Opened multi-dose medication vials were not stored in the anesthesia cart. This deficient practice had the potential to affect all patients receiving care at this hospital. Findings include: Hospital Policy: Anesthesia Rules and Regulations Policy Number: Not Documented Revised: 1/14 Procedures: To maintain ...safety and effective anesthesia care of the patient ... ...All medicines opened and unused are discarded at the completion of the case. CDC Injection Safety Reviewed: 6/20/19 Questions about Multi-dose Vials If a multi-dose vial enters an immediate patient treatment area, it should be dedicated for single patient use only. Example of immediate patient treatment areas include ...anesthesia and procedure carts ... If a ...vial has not been opened or accessed (needle punctured), it should be discarded according to manufacturer’s expiration date. The manufacturer’s expiration date refers to the date after which an unopened...vial should not be used. Facility Policy: Distribution of Medication in Wiregrass Hospital Policy Number: not documented Revised/Reviewed Date: 9/15 ...Purpose: To establish a standard system for ordering and dispensing medications... IV. Stock Medications: ...C. Monthly checks will be done by Pharmacy for expiration dates... 1. During a tour of the Outpatient Surgery unit on 1/9/24 at 11:10 AM, with Employee Identifier (EI) # 8, Certified Registered Nurse Anesthetist (CRNA), the following medications were observed and available for patient use: a. One opened multi-dose vial Neostigmine Methyl Sulfate Injection 10 milligram (mg) per 10 milliliters (ml) in the Operating Room (OR) anesthesia cart. b. Five Hydro Morphine Carpuject syringes 2 mg/ml in the narcotic cabinet expired 10/31/23. c. Seven Cisatracurium vials 2 mg/ml in the OR Supply Room refrigerator expired 7/31/23. An interview was conducted during the tour with EI # 8, who confirmed the above medication vials were opened, expired and available for patient use. 2. During a tour of the Intensive Care Unit (ICU) medication storage room on 1/9/24 at 1:05 PM the following out of date intravenous (IV) supplies were observed: a. Four D5 0.9% NS (Dextrose 5 %, Normal Saline 0.9 %) 500 ml bags with an expiration date of 10/23. b. One D5NS 500 ml bag with an expiration date of 11/22. c. Five D5NS 1000 ml bags with an expiration date of 11/23. d. One 1/2 NS 1000 ml bag with an expiration date of 10/23. e. Two D5W (Dextrose 5 % in Water) 50 ml bags with an expiration date of 10/23. f. Three NS 25 ml bags with an expiration date of 11/23. g. Two NS 50 ml bags with an expiration date of 11/23. h. Three NS 100 ml bags with an expiration date of 11/23. i. Two D5W 50 ml bags with an expiration date of 10/23. j. Four Plasma-Lyte 7.4 pH (percent of hydrogen) 1000 ml bags with an expiration date of 11/23. k. Three Plasma-Lyte 7.4 pH 500 ml bags with an expiration date of 10/23. During the tour EI # 3, Chief Nursing Officer, confirmed the IV medications were expired and available for patient use. 3. During a tour of the Medical Surgical Unit medication storage room on 1/9/24 at 1:30 PM, the following expired IV medications were observed: a. Seven D5W 100 ml bags with an expiration date of 11/23. b. Thirteen D5W 50 ml bags with an expiration date of 11/23. c. Nine D5W 1000 ml bags with an expiration date of 11/23. d. Four D10W 1000 ml bags with an expiration date of 11/23. e. Three Plasma- Lyte 500 ml bags with and expiration date of 10/23. f. One Sodium chloride 500 ml bag with an expiration date of 10/23. g. Three 5% Dextrose and 0.9% Sodium Chloride 500 ml bags with an expiration date of 10/23. h. One 5% Dextrose 1000 ml bag with an expiration date of 2/23. During the tour EI # 3 confirmed the IV medications were expired and available for patient use. 4. A tour of the Emergency Room on 1/10/24 at 9:59 AM revealed the following expired medications and supplies in the crash cart located in the trauma room. a. Lidocaine 2 grams 500 ml vial expired 11/23 b. Angiocath 16 gauge needles two expired 9/23. c. Angiocath 16 gauge needle one expired 9/23. An interview was conducted on 1/10/24 at 10:15 AM with EI # 6, Quality Director, who confirmed the expired medication and supplies were available for patient use. 41623 49797”

“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: 40119 Based on observations, review of hospital policies and interviews it was determined the Food Services Director failed to ensure: 1. The kitchen was maintained in a clean, safe, sanitary manner and free of rodents. 2. Dietary Services were incorporated into the hospital Quality Assessment and Performance Improvement (QAPI) program. This had the potential to affect all persons served by the hospital. Findings include: Hospital Policy: Pest Control Policy Number: 032 Revision Date: 5/14 Policy statement: It is the center policy that there is a program established for the control of... rodents for the dining services department. Action Steps: ...The food services director coordinates with the Director of Maintenance to arrange pest control services on a monthly basis, or as needed. Hospital Policy: Equipment Policy Number: 030 Revision Date: 5/14 Policy statement: It is the center policy that all Food service equipment is clean, sanitary, and in proper working order. Action Steps: 1. The Food Services Director will ensure that all equipment is routinely cleaned and maintained... 3. The Food Services Director ensures that all food contact equipment is cleaned and sanitized after every use... Hospital Policy: Environment Policy Number: 031 Revision Date: 5/14 Policy: It is the center policy that all food preparation areas, food service areas...will be maintained in a clean and sanitary condition. Action Steps: 1. The Food Services Director will ensure that the physical plant is maintained in a clean and sanitary manner, including the floors... 3. The Food Services Director will ensure that all food contact surfaces are cleaned and sanitized after each use. Hospital Policy: QAPI Policy Number: 036 Revision Date: 5/14 Policy statement: It is the center policy that dining services department will participate in a QAPI process that includes safety, customer satisfaction, food services operations, clinical care, and regulatory compliance with all applicable local, state, and federal statutes. Action Steps: 1. The Food Services Director will conduct customer satisfaction surveys with residents/patients at a minimum of four times per year. The survey will include, but not limited to, the following: a. Staff responsiveness. b. Menu variety. c. Food quality - taste, temperature, appearance. d. Timeliness of service. e. Cleanliness of environment. 2. The Food Services Director will conduct routine quality audits of the meal service delivery practices, including proper food storage, preparation, and service. 3. The Registered Dietitian will conduct clinical care delivery audits as appropriate. 4. Results of the clinical and operations audits, and customer satisfaction surveys, will be analyzed. Opportunities for process improvement will be identified. 5. An action plan, including appropriate monitoring, will be implemented. 6. Quality improvement plans, including monitoring, will be implemented. 7. The results of the QAPI process will be reported to the center Quality Assurance Committee. 1. A tour of the dietary department was conducted on 1/9/24 at 10:33 AM with Employee Identifier (EI) # 11, Dietary Account Manager (Food Services Director). The following observations were made: An 8-pound opened container of Strawberry Glaze was observed in the Dry Storage Area with a use by date of 10/31/23. The grease in the two kitchen fryers had a layer of a brown substance, with the appearance of corn mill grounds, over the surface of the grease. The sides, front, and back splash of both fryers and oven had brown grease build up. The sides of the gas stove range had brown grease build up. The floor around and under the fryers had brown grease build up. A stack of eight oven sheet pans had brown and black grime on all side of the sheet pans. Two roast pans had brown grime on the bottoms of the pans. The “tea and juice counter” had dark brown grime under the counter. Rodent droppings were observed under the food preparation /chopping counter, beside the tip skillet, and under the dessert counter, garbage disposal, food service line and dishwasher. An interview was conducted during the tour with EI # 11, who confirmed the opened container of strawberry glaze was beyond the use by date, the brown and black grime on the sheet pans and roast pan, the brown grime under the tea and juice counter, and the buildup of grease on the fryers, gas stove range, and oven. EI # 11 also confirmed the droppings found in the kitchen were from a rodent and stated she/he has seen rodents “every day when you turn on the light” since she/he began the position in May 23. EI # 11 further verbalized she/he had reported the rodent issue to maintenance several times. An interview was conducted on 1/11/24 at 3:55 PM with EI # 14, Maintenance Director. EI # 14 verbalized he/she had not been aware of the rodent issue in the dietary department and confirmed there was no documentation of a work order for the rodent issue in the dietary department. 2. An interview was conducted on 1/9/24 at 1:30 PM with EI # 11. EI # 11 was asked what quality indicators were being monitored and reported to the hospital QAPI committee. EI # 11 verbalized there were no quality indicators for the dietary department and the dietary department did not participate in the hospital QAPI. During the interview, EI # 11 walked toward the dishwashing area followed by the surveyor. EI # 11 came to a sudden stop and jumped back with the appearance of being startled by something in the dishwashing area. EI # 11 verbalized he/she had observed a rodent in the dishwashing area approximately three inches in circular width. EI # 11 then directed the surveyor to two wooden boxes with circles approximately one to two inches in width and length in the dishwashing area and three silver rectangular boxes located in the kitchen area all used for rodent pest control. An interview was conducted on 1/9/24 at 1:50 PM with EI # 6, Quality Director, who confirmed there was no documentation of QAPI data for 2023 or 2024 for the dietary department and the dietary department did not participate in the QAPI program. 3. On 1/16/24 at 2:52 PM, EI # 3, Chief Nursing Officer, provided the hospital pest control invoices for 2023 to the surveyor via email. Review of the hospital pest control invoices for 2023 revealed the hospital was provided rodent control pest service monthly. Further review revealed documentation of the following number of rodent bait stations used for rodent pest control measures: “15” bait stations on 2/7/23, “17” bait stations on 3/20/23, and “13 bait stations” used since 4/14/23. The same pest control measures were used with continued evidence of rodents in the dietary department.”

“QUALIFIED DIETITIAN CFR(s): 482.28(a)(2) There must be a qualified dietitian, full-time, part-time, or on a consultant basis. This Standard is not met as evidenced by: 40119 Based on review of hospital policies, dietary consultant agreement provided by the facility, and interviews with staff, it was determined the hospital failed to ensure a dietitian was available to supervise the nutritional aspects of patient care to include: 1. Approving patient menus and nutritional supplements. 2. Patient, family, and caretaker dietary counseling. 3. Performing and documenting nutritional assessments and evaluating patient tolerance to therapeutic diets when appropriate. 4. Collaborating with other hospital services to plan and implement the nutritional needs of the patients. 5. Maintaining pertinent patient data necessary to recommend, prescribe, or modify therapeutic diets as needed to meet the nutritional needs of the patients. This had the potential to negatively affect all patients requiring a dietary consult served by the hospital. Findings include: Hospital Policy: Nutritional Screening Policy Number: Not documented Revised Date: 6/22 ...Statement of Purpose: To assign level of care based on degree of nutritional risk. 1. A preliminary screen is conducted on all patients. The preliminary screen is based on admitting diagnosis, patient diet orders and other information gathered through the admitting process. 2. Preliminary Screens: ...criteria will be used to trigger a dietary consult. Hospital Policy: Professional Staffing Policy Number: 001 Revised Date: 5/14 Policy Statement: It is the center policy that the dining services department operates under the direction of a qualified dietitian. ...Action Steps: 1... the center will employ a Registered Dietitian (RD)... 2. The RD is responsible for ensuring that all food service operations and practices meet current standards of practice and all regulatory requirements... Hospital Policy: Menus Policy Number: 004 Revised Date: 5/14 ...Action Steps: ...5. The RD reviews and approves the menus. The RD will adjust the meal and/or menu plan to meet the individual needs as necessary, including cultural, religious, or ethnic preferences as appropriate... During a tour of the Dietary Department on 1/9/24 at 1:30 PM, Employee Identifier (EI) # 11, Dietary Account Manager, was asked about the supervision and direction by an RD for the dietary department and patient menus. EI # 11 verbalized, she/he has not seen or spoken with the RD since starting her/his position in May 23. When the surveyor asked about setting up an interview with the RD, EI # 11 stated, “I’ll see if the nursing home side can get in contact with (her/him). I’ve never talked to (her/him)” EI # 11 confirmed not having contact information for the RD. Review of the Dietary Consultant Agreement provided by the hospital dated 2/24/2020 revealed documentation the agreement was for the nursing home. There was no documentation an RD was contracted or on staff to provide RD services for the hospital. An interview was conducted with EI # 13, RD on 1/10/24 at 3:49 PM, EI # 13 was asked about providing supervision and direction to the hospital dietary department. EI # 13 stated, “If they have questions, they can ask but other than that I let them do their thing.” EI # 13 confirmed he/she had not provided supervision and direction for the dietary department patient menu planning or therapeutic diets. EI # 13 confirmed, if the hospital had a consult for an RD, they would call but it doesn’t happen often and stated, “I might get one phone call a year.” EI # 13 confirmed the only time spent at the hospital would be for a consult if called.”

“THERAPEUTIC DIETS CFR(s): 482.28(b), (b)(1) §482.28(b) Menus must meet the needs of patients. (1) Individual patient nutritional needs must be met in accordance with recognized dietary practices. This Standard is not met as evidenced by: 40119 Based on review the hospital policy, observation, and interviews with staff, it was determined the hospital failed to ensure patient menus met the needs of the patients. This did affect Patient Identifier (PI) # 10, one of one patient with a physician ordered 1800 calorie ADA (American Diabetic Association) diet and had the potential to negatively affect all patients served by the hospital. Findings include: Hospital Policy: Menus Policy Number: 004 Revised Date: 5/14 ...Action Steps: ...5. The RD reviews and approves the menus. The RD will adjust the meal and/or menu plan to meet the individual needs as necessary, including cultural, religious, or ethnic preferences as appropriate... 1. PI # 10 was admitted to the hospital on 1/4/24 with diagnoses including Pneumonia, Hyperglycemia, and Confusion. Review of the patient diet orders for 1/9/24 revealed documentation an 1800 calorie ADA diet was ordered for PI # 10. An observation of plating the patient lunches was conducted on 1/9/24 at 11:18 AM. During the observation the following foods and amounts were provided for PI # 10 as well as for patients ordered a 2000 calorie ADA diet: One slice of bread, one slice of turkey with gravy, four ounces (oz) of mash potatoes, 4 oz of Brussels sprouts and a prefilled cup with approximately 4 oz of pears. There was no distinguishing difference in the food or amounts of food provided to PI # 10 with an 1800 calorie ADA diet and others with a 2000 calorie ADA diet. Review of the 23-24 Diet Guide Sheet revealed no documentation of a 1800 ADA diet for the dietary meal plan. An interview was conducted on 1/9/24 at 1:30 PM with Employee Identifier (EI) # 11, Dietary Account Manager, who was asked how the dietary staff determined the food and food measurement amounts between the 1800 ADA and the 2000 ADA diet. EI # 11 stated, “we don’t know, we don’t have a printout for the hospital side...” An interview was conducted with EI # 13, RD on 1/10/23 at 3:49 PM, EI # 13 confirmed he/she had not provided supervision and direction for the dietary department patient menu planning or therapeutic diets.”

“THERAPEUTIC DIET MANUAL CFR(s): 482.28(b)(3) A current therapeutic diet manual approved by the dietitian and medical staff must be readily available to all medical, nursing, and food service personnel. This Standard is not met as evidenced by: 40119 Based on review of hospital diet manual and staff interview, it was determined the facility failed to ensure the dietary manual was reviewed by the medical staff and a Registered Dietician (RD). This had the potential to affect all patients served by this facility. Findings include: During a tour of the Dietary Department on 1/9/24 at 1:30 PM with Employee Identifier (EI) # 11, Dietary Account Manager, the surveyor requested the therapeutic diet manual. Review of the hospital diet manual 2019 Edition, revealed documentation the manual had been reviewed and approved by the Director of Nursing on 2/6/23. There was no documentation the hospital diet manual was reviewed and approved by the medical staff and RD. An interview was conducted during the tour with EI # 11, who confirmed there was no documentation the hospital diet manual was reviewed and approved by the medical staff and RD. A second interview was conducted with EI # 13, RD on 1/10/23 at 3:49 PM, who confirmed no documentation the hospital diet manual was reviewed and approved by the medical staff and RD.”

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 40119 Based on observations, review of hospital policies and interviews it was determined the hospital failed to ensure the facility was maintained in a clean, safe, sanitary manner and free of rodents. This had the potential to affect all persons served by the hospital. Findings include: Hospital Policy: Pest Control Policy Number: 032 Revision Date: 5/14 Policy statement: It is the center policy that there is a program established for the control of... rodents for the dining services department. Action Steps: ...The food services director coordinates with the Director of Maintenance to arrange pest control services on a monthly basis, or as needed. Hospital Policy: Equipment Policy Number: 030 Revision Date: 5/14 Policy statement: It is the center policy that all Food service equipment is clean, sanitary, and in proper working order. Action Steps: 1. The Food Services Director will ensure that all equipment is routinely cleaned and maintained... 3. The Food Services Director ensures that all food contact equipment is cleaned and sanitized after every use... Hospital Policy: Environment Policy Number: 031 Revision Date: 5/14 Policy: It is the center policy that all food preparation areas, food service areas...will be maintained in a clean and sanitary condition. Action Steps: 1. The Food Services Director will ensure that the physical plant is maintained in a clean and sanitary manner, including the floors... 3. The Food Services Director will ensure that all food contact surfaces are cleaned and sanitized after each use. 1. During a tour of the Senior Care Unit conducted on 1/9/24 at 10:30 AM with Employee Identifier (EI) # 3, Chief Nursing Officer, the following items in need of repair were identified: a. In room 403 the wall material was loose, cracked and could be easily pushed in with the hand. The Baseboards were loose and peeling away from the wall. b. In room 404 an area of paint had peeled from wall measuring approximately 6 inches by 15 inches. c. In room 405 the wall material under the air conditioner unit was loose and could be easily pushed in with the hand. The baseboards were peeling from the wall. During the tour, EI # 3 confirmed the unit had not been maintained to ensure the safety and well being of the patients. 2. A tour of the dietary department was conducted on 1/9/24 at 10:33 AM with EI # 11, Dietary Account Manager (Food Services Director). The following observations were made: The grease in the two kitchen fryers had a layer of a brown substance, with the appearance of corn mill grounds, over the surface of the grease. The sides, front, and back splash of both fryers and oven had brown grease build up. The sides of the gas stove range had brown grease build up. The floor around and under the fryers had brown grease build up. The “tea and juice counter” had dark brown grime under the counter. Rodent droppings were observed under the food preparation /chopping counter, beside the tip skillet, and under the dessert counter, garbage disposal, food service line and dishwasher. An interview was conducted during the tour with EI # 11, who confirmed there was brown grime under the tea and juice counter, and grease buildup on the fryers, gas stove range, and oven. EI # 11 also confirmed the droppings observed in the kitchen were from rodents. An interview was conducted on 1/11/24 at 3:55 PM with EI # 14, Maintenance Director. EI # 14 verbalized he/she had not been aware of the rodent issue in the dietary department and confirmed there was no documentation of a work order for the rodent issue in the dietary department. A second interview was conducted on 1/9/24 at 1:30 PM with EI # 11. During the interview, EI # 11 walked toward the dishwashing area followed by the surveyor. EI # 11 came to a sudden stop and jumped back with the appearance of being startled by something in the dishwashing area. EI # 11 verbalized he/she had observed a rodent in the dishwashing area approximately three inches in circular width. EI # 11 then directed the surveyor to two wooden boxes with circles approximately one to two inches in width and length in the dishwashing area and three silver rectangular boxes located in the kitchen area all used for rodent pest control. 3. Review of the hospital pest control service invoices for 2023 revealed the hospital was provided rodent pest control service monthly. Further review revealed documentation of the following number of rodent bait stations used for rodent pest control measures: “15” bait stations on 2/7/23, “17” bait stations on 3/20/23, and “13 bait stations” used monthly since 4/14/23. The same pest control measures were used with continued evidence of rodents in the dietary department.”

“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: 41623 Based on observations, facility policy and procedure, Clorox disinfect wipe manufacturers instructions, Centers for Disease Control and Prevention (CDC) Best Practices for Environmental Cleaning in Healthcare Facilities, and interviews, it was determined the facility failed to ensure the staff: 1. Wore gloves when administering intravenous (IV) medications and blood products. 2. Performed hand hygiene per the facility policy. 3. Cleaned and disinfected reusable patient equipment per manufacturers instructions and CDC best practices. This deficient practice did affect Unsampled Patient # 1, Unsampled Patient # 2, Unsampled Patient # 3, and had the potential to negatively affect all patients admitted to this hospital. Findings include: Facility Policy: Hand Hygiene-CDC (Centers for Disease Control and Prevention) Guidelines Policy Number: not documented Revised Date: 9/19/23 ...Purpose: To provide guidelines for effective hand hygiene in order to prevent the transmission of bacteria, germs, and infections. ...All staff shall use the hand hygiene techniques, as set forth in the following procedure... Before each patient encounter... Before applying gloves... After coming in contact with the patient’s intact skin... After contact with medical equipment/supplies in patient areas Always after removing gloves... Procedure: Using antimicrobial soap and water or non-antimicrobial soap and water: ...Turn off faucet with used paper towel and discard. Notes: ...Always follow Standard Precautions... Gloves are to be worn when in contact with blood, bodily fluids, mucous membranes, dressings, non intact skin...is anticipated... Clorox Disinfectant Wipes Manufacturers Instructions Copyright Date: 2016 ...Disinfection... To clean and disinfect...wipe surface to be disinfected. Use enough wipes for treated surface to remain visibly wet...let air dry. CDC Best Practices for Environmental Cleaning in Healthcare Facilities Reviewed Date: 4/21/2020 ...4. Environmental Cleaning Procedures... 4.7 Noncritical patient care equipment ...noncritical patient care equipment includes...stethoscopes. These high-touch items are: used by healthcare workers to touch patients (i.e. stethoscopes)...often shared between patients. ...Table 26: Recommended Selection and Care of Noncritical Patient Care Equipment. ...Shared...Frequency...Before and after each use..clean and disinfect... 1. An observation of terminal cleaning was conducted on 1/9/24 at 1:10 PM with EI # 16, Environmental Services. EI # 16 changed gloves 13 times without performing hand hygiene after glove removal and prior to donning clean gloves. An interview conducted on 1/11/24 at 12:50 PM with EI # 13, Infection Preventionist, confirmed the staff failed to follow hospital policy for hand hygiene after glove removal. 2. An observation of IV medication administration was conducted on 1/9/24 at 2:30 PM for unsampled patient # 1 in room 609. Employee Identifier (EI) # 23, Registered Nurse (RN), performed hand hygiene with soap and water, donned gloves, and opened the IV tubing package. EI # 23 stated he/she had the wrong tubing, removed gloves, performed hand hygiene and left the patient room. Upon returning to the room, EI # 23 performed hand hygiene, connected the new tubing to the IV bag, prepped the Heparin Lock device on the patient’s right arm, and connected the IV. EI # 23 failed to follow aseptic technique and apply gloves before administering the IV medication. EI # 23 then donned glove and prepared to assist with changing the patient’s sheets. EI # 23 failed to perform hand hygiene prior to donning gloves. In an interview conducted on 1/11/24 at 12:50 PM with EI # 13, Infection Preventionist, EI # 13 confirmed the staff failed to follow hospital policy and aseptic technique when administering the IV medications and donning gloves. 3. An observation was conducted on 1/9/24 to observe a laboratory (lab) blood collection procedure with EI # 17, Lab Assistant, EI # 18, Lab Assistant, and EI # 19, Registered Nurse for Unsampled Patient # 2. At 3:55 PM, EI # 17, wheeled the patient to the outpatient lab room, gathered supplies, then donned gloves without hand hygiene. After puncture site was cleansed with alcohol, EI # 17 then palpated the site with gloved hand and proceeded to insert a needle. EI # 17 failed to re-cleanse the palpated vein puncture site prior to puncturing with a needle. After the unsuccessful venipuncture attempt, EI # 17 removed gloves, used telephone in the lab room to call for assistance then documented on the medical record. EI # 17 failed to perform hand hygiene after removing gloves. At 4:10 PM, EI # 18 entered the outpatient lab room, donned gloves, and applied tourniquet to the patient’s right arm. EI # 18 failed to perform hand hygiene prior to donning gloves. After EI # 18 was unsuccessful in palpating a vein, EI # 18 removed gloves, obtained clean syringes, and donned gloves without hand hygiene. EI # 18 failed to perform hand hygiene after removing gloves and prior to donning gloves. At 4:17 PM, EI # 19 entered the outpatient lab room. After obtaining and opening sterile supplies with gloved hands, EI # 19 assisted the patient with the placement of the patient’s shirt to give access to infusaport (Implantable Central Venous Access Device). EI # 19 then proceeded to remove Huber needle from paper sleeve, attach normal saline flush, open and don sterile gloves. EI # 19 failed to remove gloves and perform hand hygiene after assisting with the patient’s shirt and prior to connecting the normal saline to the sterile Huber needle and donning sterile gloves. After the infusaport was accessed and flushed, EI # 19 removed gloves and donned sterile gloves to apply the sterile gauze and transparent dressing to the infusaport access site. EI # 19 failed to perform hand hygiene after glove removal and before donning sterile gloves. An interview was conducted on 1/10/24 at 9:01 AM with EI # 22, Lab Director, who confirmed EI # 17, EI # 18, and EI # 19 failed to perform hand hygiene per the hospital policy. 4. An observation of IV medication administration was conducted on 1/10/24 at 9:30 AM on an unsampled patient # 3 in room 514. EI # 24, RN, performed hand hygiene, prepped the IV tubing port, connected the syringe containing Protonix 40 mg and administered the medication. EI # 24 failed to follow aseptic technique and apply gloves before administering the IV medication. In an interview conducted on 1/11/24 at 12:50 PM with EI # 13, Infection Preventionist, EI # 13 confirmed the staff failed to follow hospital policy and aseptic technique when administering the IV medications and donning gloves. 5. An observation was conducted on 1/10/24 at 9:41 AM to observe blood administration with EI # 20, Registered Nurse for Unsampled Patient # 2. EI # 20 performed hand hygiene using soap and water, used bare hand to turn the sink faucet off, then used contaminated bare hand to cleanse the hub site of the infusaport access line, connect a normal saline flush to the access line, aspirate blood return of the infusaport then flush the infusaport access line with normal saline. EI # 20 obtained Clorox disinfectant wipe, cleaned bedside table, then immediately placed IV 500 ml bag of 0.9 % Sodium Chloride and infusion set tubing on bedside table without allowing table to air dry. EI # 20 then proceeded to hang the IV Sodium Chloride bag on the IV pole, open and connect IV infusion set tubing to Sodium Chloride IV bag, prime IV tubing with Sodium Chloride, and connect the IV tubing to the patient infusaport access line without performing hand hygiene after disinfecting bedside table and applying gloves. At 9:41 AM, EI # 20 walked to the blood bank to obtain blood. After entering the blood bank, EI # 20 donned gloves without hand hygiene then removed his/her gloves and exited the blood bank without performing hand hygiene. At 9:47 AM, EI # 20 returned to the blood bank with patient paperwork and donned gloves without hand hygiene. After EI # 20 verified the blood with EI # 21, Medical Lab Technician, EI # 21 removed his/her gloves and without performing hand hygiene, exited the blood bank and entered the lab area to obtain paperwork. EI # 20 exited the blood bank with gloves on, waited for EI # 21 to make copy of the patient’s paperwork, returned to the patient area, stopped IV pump, then verified the blood unit with another nurse. After the blood unit was verified, EI # 20 hung the IV blood unit on the IV pole and a hole was observed in the right glove at the tip of the thumb exposing EI # 20’s fingernail. EI # 20 then continued to use the same gloves with the hole in the right thumb to prime the blood through the tubing, connect the blood to the IV pump, disinfect infusaport access line hub with alcohol, connect IV tubing to the access line hub, and start the blood infusion. EI # 20 removed gloves, removed stethoscope from around his/her neck, listened to the patient’s chest, and returned the uncleaned stethoscope to his/her neck. EI # 20 then performed hand hygiene using soap and water then used bare hand to turn sink faucet off. EI # 20 removed stethoscope from around his/her neck, listened to the patient’s chest, and returned the uncleaned stethoscope to his/her neck two additional times. After the blood was administered, EI # 20 performed hand hygiene using soap and water four times then used bare hand to turn sink faucet off each time hand hygiene was performed. EI # 20 failed to clean the stethoscope before and after each use. An interview was conducted on 1/11/24 at 4:16 PM with EI # 2, Case Management Director, who confirmed EI # 20 failed to use gloves and perform hand hygiene per the hospital policy. EI # 20 also confirmed the stethoscope was not cleaned per CDC best practices. 40119 49797”

“HISTORY AND PHYSICAL CFR(s): 482.51(b)(1) Prior to surgery or a procedure requiring anesthesia services and except in the case of emergencies: (i) A medical history and physical examination must be completed and documented no more than 30 days before or 24 hours after admission or registration, and except as provided under paragraph (b)(1)(iii) of this section. This Standard is not met as evidenced by: 46290 Based on observation, hospital policy and procedure, and interview, it was determined the hospital failed to ensure a medical history and physical (H&P) examination was completed and documented prior to an invasive procedure. This affected one of five outpatient surgical medical records (MR) reviewed including Patient Identifier (PI) # 44, and had the potential to affect all patients served at this hospital. Findings include: Hospital Policy: Content and Timeliness of Completed Patient Record Policy Number: None Documented Date Revised: 2023 Purpose: To ensure timely completion of medical records by physicians... ...A history and physical is required to be completed within 24 hours of admission or prior to an invasive procedure. 1. PI # 44 was admitted on 12/8/23 with chief complaint including Crohns Disease. Review of the medical record revealed Patient Identifier (PI) # 44 had a Colonoscopy Possible Biopsy and or Polypectomy procedure performed on 12/8/23. Further Review of PI # 44’s medical record revealed no documentation of a H&P prior to the invasive procedure. An interview was conducted on 1/10/24 at 3:39 PM with Employee Identifier (EI) # 9, Medical Record Supervisor, who verified no documentation of a H&P was completed prior to the invasive procedure per the hospital’s policy.”

“PRE-ANESTHESIA EVALUATION CFR(s): 482.52(b)(1) [The policies must ensure that the following are provided for each patient:] A pre-anesthesia evaluation completed and documented by an individual qualified to administer anesthesia, as specified in paragraph (a) of this section, performed within 48 hours prior to surgery or a procedure requiring anesthesia services. This Standard is not met as evidenced by: 40119 Based on review of Medical Records (MR), hospital policy, and interview, it was determined the hospital failed to ensure a pre-anesthesia evaluation was completed and documented by an individual qualified to administer anesthesia, within 48 hours prior to surgery or a procedure requiring anesthesia services. This affected one of five inpatient surgical MR’s reviewed including Patient Identifier (PI) # 28 and had the potential to affect all patients requiring surgical services the hospital. Findings include: Hospital Policy: Rules and Regulations Policy Number: None documented Date Revised: 1/14 ... Preanesthetic Care: ...The anesthetist must perform a preoperative evaluation of patients scheduled for surgery. This includes a review of that patient’s chart including consultations, history and physical, lab (laboratory), EKG (Electrocardiogram), and radiology and to determine the physical status of the patient... 1. PI # 28 was admitted to the hospital on 1/4/24 with a diagnosis of Cellulitis and Abscess of the Left Axilla Extending into the Left Chest Wall and Left Breast. Review of the Operative Note dated 1/8/24 revealed the patient underwent a packing removal under sedation with IV (intravenous) anesthesia administered. Review of the MR revealed no documentation of a preoperative anesthesia evaluation within 48 hours of the packing removal operative procedure. An interview was conducted on 1/11/24 at 2:59 PM with Employee Identifier (EI) # 2, Case Management Director, who confirmed there was no documentation of a preoperative anesthesia evaluation within 48 hours of the packing removal operative procedure.”

“. K3 Building: 0102 K6 Plan Approval:1954/1963/1973/1995 K7 Survey Under: 2012 Existing K8 HOSP Generators: Two Generac Diesel: one 175 kW and one 275 kW (both installed 2023) FACP: Harrington HS3200 (installed 2015) Locking Devices: None Beds: 87 Census: 24 Type of Structure: 1954 original building one story unprotected wood frame, Type V(000). 1963 single story addition (500 Hall) protected noncombustible, Type II(111). 1973 single story addition (600 Hall) protected noncombustible, Type II(222). 1995 single story addition protected noncombustible, Type II(222). The facility has a complete 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 Surveyors while accompanied by the facility maintenance personnel. .”

“Sprinkler System - Installation CFR(s): NFPA 101 Spinkler System - Installation 2012 EXISTING Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers. In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems. 19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1) This Standard is not met as evidenced by: 41792 . Based on observation, the facility failed to provide information on the automatic sprinkler system per the requirements of: 2012 NFPA 101, 4.6.12.3, 4.6.12.2, 18.3.5.1, and 9.7.1.1 (1) 2010 NFPA 13, 7.6.1.4, 7.6.1.5, TIA 10-2, 6.2.7.1, 6.2.7.2, 8.3.3.2, and 8.3.3.4 This deficiency affects the complete automatic sprinkler system. Findings include: During a tour of the facility, the surveyor observed the following: 1. The facility failed to have a placard mounted on the wet system riser feeding the remote antifreeze system for the courtyard. This placard shall indicate the following: a. The number of all remote antifreeze systems supplied by that riser b. The location of all remote antifreeze systems supplied by that riser 2. The facility failed to have a placard mounted on the main valve of the courtyard antifreeze system. This placard shall indicate the following: a. The manufacture type and brand of the antifreeze solution b. The volume of anti-freeze solution used in the system 3. During a tour of the facility, the surveyor observed 1 recessed ceiling automatic sprinkler head in Office 253 (100 Hall) with their escutcheon plates not in place. 4. During a tour of the facility, the surveyor observed five quick-response sprinkler heads installed in the same compartment (Radiology Hall) with five standard-response sprinkler heads. 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: 41792 . Based on observation and review of documentation, the facility failed to maintain the automatic sprinkler system per requirements of: 2012 NFPA 101, 4.6.12.3, 4.6.12.2, 18.3.5.1, 9.7.5, and 9.7.8 2011 NFPA 25, 5.3.4, TIA 11-1, TIA 11-2, TIA 11-3, TIA 11-4, 15.3.1, 15.3.2, and 5.2.2.2 This deficiency affects the automatic sprinkler system. Findings include: During a tour of the facility, the surveyors observed the following: 1. The facility failed to provide documentation indicating the existing antifreeze solution had been drained and replaced with the new required premixed antifreeze solution. 45258 2. The facility failed to provide a tag, posted on the valve, indicating the antifreeze system at the Laundry Room (Old Loading Dock) had been removed from service. 3. Seven orange cables and one red cable (external loads) resting on the automatic sprinkler pipe above the ceiling near the 100 Hall Nurses’ Station. A member of the maintenance staff was present when this deficiency was identified. .”

“Utilities - Gas and Electric CFR(s): NFPA 101 Utilities - Gas and Electric Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life. 18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2 This Standard is not met as evidenced by: 45258 . Based on observation, the facility failed to maintain the electrical wiring and equipment per the requirements of: 2012 NFPA 101, 19.5.1.1, and 9.1.2 2011 NFPA 70, 110.26(A)(1), and Table 110.26(A)(1) This deficiency affects 1 of 6 smoke compartments. Findings include: During a tour of the facility, the surveyor observed 2 stacks of cardboard boxes stored within 3’ of the electrical panel in the Diaper Room. The stacks were as follows: broken down boxes - 3’-0” high and cardboard boxes with stuff in them - 4’-0” high and were in front of and to the side of the panel, with oly 18” of work space in between them. 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: 45258 . 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 6 smoke compartments. Findings include: During a tour of the facility, the surveyor observed a portable space heating device under a desk in the Housekeeping Supervisor’s Office. The space heating device was not on or plugged in. The facility was unable to provide documentation that the heating element did not exceed 212 degrees. A member of the maintenance staff was present when this deficiency was identified. .”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) This Standard is not met as evidenced by: 41792 . Based on review of documentation, the facility failed to maintain the testing of the emergency generators per the requirements of: 2012 NFPA 99, 6.5.4.1.1.2, 6.5.4.1.3, 6.5.4.2, 6.4.4.1.1.3, and 6.4.4.1.3 2010 NFPA 110, 8.3.7.1 This deficiency affects 2 of 2 generators. Findings include: During the review of the documentation, the facility failed to provide documentation of performing monthly testing and recording of electrolyte specific gravity or conductance on the facility’s emergency generators’ batteries for the past 12 months. A member of the maintenance staff was present when this deficiency was identified. .”

“Electrical Equipment - Power Cords and Extens CFR(s): NFPA 101 Electrical Equipment - Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5 This Standard is not met as evidenced by: 41792 . Based on observation, the facility failed to maintain the electrical equipment per the requirements of: 2012 NFPA 99, 10.2.3.6, and 10.2.4 2011 NFPA 70, 400.8 S&C: 14-46-LCS This deficiency affects 1 of 2 Operating Rooms. Findings include: During a tour of the facility, the surveyor observed one tourniquet machine and one operating bed (patient care related electrical equipment) plugged into a power strip that was not the CMS approved 1363A power strip for patient care related electrical equipment. This was observed in Operating Room 2. A member of the maintenance staff was present when this deficiency was identified.”