Atmore Community Hospital

“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: 39098 Based on observations during facility tour with hospital staff by the Life Safety Surveyor and staff interviews, it was determined the facility was not constructed, arranged and maintained to ensure patient safety. This had the potential to negatively affect all patients served by the hospital. Findings include: Refer to Life Safety Code violations at K 0133, K 0211, K 0226, K 0324, K 0355, K 0363, K 0511, K 0781, K 0918, K 0920, K 00353 and K 0929.”

“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: 30952 Based on review of facility Suicide Precaution policy and procedure, ED (Emergency Department) medical record (MR), and interview with staff, it was determined the facility failed to: 1. Develop a policy for suicide precautions that included the frequency of monitoring for patients identified as high risk for suicide. 2. Follow the facility suicide precaution policy, document PI (Patient Identifier) # 25, one of one ED patients identified as high risk for suicide, was in direct line of sight of ED staff at all times while at the ED. 3. Document the patient/family were informed of suicide precautions and restrictions per the facility policy. Findings include: Facility Policy: Suicidal Precautions Policy Number: NGEN-SAF-7 Date Revised: 10/2023 ...Purpose: To guide staff in caring for the patient experiencing suicidal ideation...for providing safe nursing care for the suicidal patient. Policy: All adult patients treated in the ED...will be assessed for suicidal risk. Patients...identified...at risk will be placed on Suicide Precautions. Patients with physician orders for “suicide precautions”...should have an environmental assessment and room search for potentially dangerous items conducted.... ...suicide precautions may be initiated by the Registered Nurse (RN). 1. A staff member should have direct line of sight at all times, including when toileting. 2. The physician...should be contacted immediately (for) consideration for a psychiatric consult. Procedure: 1. Contact Director...to evaluate available resources. 2. Explain precautions to patient and family...Inform them of the restrictions and rationale for the precautions...removal of personal belonging and medications. Family should be informed of the necessity to limit items from outside...and some items may be restricted...Nurse should check any items brought from the outside. Suggested items to look for/remove... 4...personal belongings should be removed from the room... 5. Meals shall be served on disposable products. Definitions: Suicide Precautions include the following: Environmental assessment Room search Search of personal belongings Staff have direct line of sight with patient Psychiatric consult... Securing the Environment Sitter should be aware of...items...used...to harm one-self therefore patient should be constantly observed, even in the restroom and while sleeping... ...a complete list of personal items temporarily held...by staff should be documented in the MR... 1. PI # 25 presented to the ED on 10/16/23 at 10:28 AM, family present, the cc (chief complaint) was Suicidal Ideations (SI). MR review revealed the nurse triage assessment performed at 10:41 AM included documentation of pediatric behavioral health concerns, and multiple lacerations to the left arm. Review of the CSSRS (Columbia Suicide Severity and Risk Screen-a standardized tool used to screen for risk of self-harm) revealed PI # 25’s level of suicide risk, high risk. Record review revealed PI # 25 was seen by the ED physician at 10:49 AM, assessment was suicidal ideation and a plan to set self on fire. The treatment was transfer to a mental health facility for further care. Review of the ED nurse documentation dated 10/16/23 at 11:17 AM revealed PI # 25 was in paper scrubs, room in direct view of “this” nurse, all extra cords removed from room, suicidal precautions in place. There was no documentation the ED staff explained precautions to the patient and family member, informed them of the restrictions/rationale for the precautions, the necessity to limit items from outside and some items restricted, and the need for the nurse to check items brought from the outside. MR review revealed at 1:41 PM, family at bedside, staff updated the family member on the current plan of care. Further MR review revealed at 4:55 PM, family member returned with requested paperwork requested from the receiving facility. There was no documentation of the time the family member left the hospital. There was no documentation ED staff ensured PI # 25’s safety from 1:41 PM to 4:55 PM, which was 2 hours and 11 minutes. There was no documentation staff offered toileting and/or accompanied PI # 25 during the greater than 8 hours ED stay. An interview was conducted on 11/30/23 at 2:13 PM with Employee Identifier (EI) # 3, ED Manager who stated ED staff had additional patients assigned while caring for PI # 25. EI # 3 confirmed ED staff failed to document an explanation of suicide precautions/restrictions were provided and there was no documentation PI # 25 was in direct line of sight at all times while in the ED.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(i) The use of restraint or seclusion must be-- (i) in accordance with a written modification to the patient’s plan of care. This Standard is not met as evidenced by: 41623 Based on medical record (MR) reviews, hospital policy and staff interview it was determined the hospital failed to document a written modification to the patient’s Plan of Care (POC) with the use restraints. This deficient practice affected one of two MR’s reviewed of restrained patients including Patient Identifier (PI) # 20, and had the potential to affect all patients restrained at this facility. Findings include: Facility policy: Restraint Policy Policy number: NGEN-LEG-7 Date reviewed: 4/2022 ...Non-Violent/Non-Self Destructive Management... Revise Plan of Care, including goals and release criteria... ...Violent/Self Destructive Management Restraint... Revise Plan of Care, including goals and release criteria... 1. PI # 20 was admitted on 5/3/23 with diagnoses including Acute Exacerbation of Psychosis, Methamphetamine Abuse, Rhabdomyolosis, and UTI (Urinary Tract Infection). Review of the Care Plan dated 5/3/23 at 11:50 PM revealed Care Plans including, monitor sleep patterns, encourage adequate nutritional intake, convey acceptance of feelings, assess for suicidal ideations, provide opportunities for patient to succeed, make frequent contact with patient early, assist patient with ADL’s (activities of daily living), administer medications as ordered, provide constant structured environment, evaluate patient tolerance for interaction, implement risk for injury, encourage patient to discuss situation, facilitate grieving process. Review of the Physician’s Orders dated 5/4/23 at 12:03 AM revealed a telephone order for non-violent restraint monitoring. Review of the Nursing Narrative Note dated 5/4/23 at 12:36 AM revealed the nurse documented PI # 20 indicated he/she was going to bite another nurse in the room and orders were given for soft, non-violent restraints and indwelling Foley catheter. Further review of the Care Plan revealed no updates to the Care Plan after application of the restraints. An interview was conducted on 11/30/23 at 1:50 PM with Employee Identifier (EI) # 8, Registered Nurse (RN), Team Leader, who confirmed there were no changes made to the Care Plan after the application of the restraints.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(8) Unless superseded by State law that is more restrictive-- (i) Each order for restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others may only be renewed in accordance with the following limits for up to a total of 24 hours: (A) 4 hours for adults 18 years of age or older; (B) 2 hours for children and adolescents 9 to 17 years of age; or (C) 1-hour for children under 9 years of age; This Standard is not met as evidenced by: 41623 Based on Medical Record (MR) review, facility policy, and staff interview, it was determined the facility failed to obtain and/or document an appropriate physician’s order every four hours for the use of restraints for the management of violent or self-destructive behavior in an adult above the age of 18. This deficient practice affected one of two MR’s reviewed of restrained patients including Patient Identifier (PI) # 20 and had the potential to affect all patients requiring restraints at this hospital. Facility policy: Restraint Policy Policy number: NGEN-LEG-7 Date reviewed: 4/2022 ...Physician Orders: Can be initiated by RN (Registered Nurse) in an emergency with immediate notification of the Physician/LIP (Licensed Independent Practitioner)... Re-evaluation: Renewal of the original order is based on established time frames... Every 4 (four) hours for adults 18 years and older... 1. PI # 20 was admitted on 5/3/23 with diagnoses including Acute Exacerbation of Psychosis, Methamphetamine Abuse, Rhabdomyolosis, and UTI (Urinary Tract Infection). Review of the Physician’s Orders dated 5/4/23 at 12:03 AM revealed a telephone order for non-violent restraint monitoring. Review of the Nursing Narrative Note dated 5/4/23 at 12:36 AM revealed the nurse documented “...In trying to calm the pt. (patient), (he/she) began to indicate (he/she) was going to bite another nurse in the room. Orders given for soft, non-violent restraints...). Review of the nursing documentation, Restraints Information, revealed PI # 20 was in constant restraints on 5/4/23 at 12:38 AM until 5/5/23 at 6:07 AM, which was 30 hours. In an interview on 11/30/23 at 1:50 PM with Employee Identifier (EI) # 8, RN, Team Leader, EI # 8 confirmed PI # 20 was displaying violent behavior and the orders should have been written for Violent/Self Destructive Management and the orders were not renewed every four hours per facility policy.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(9) Restraint or seclusion must be discontinued at the earliest possible time, regardless of the length of time identified in the order. This Standard is not met as evidenced by: 30952 Based on review of medical records, hospital policy, and interviews it was determined the hospital failed to ensure restraint justification and rationale for continued use of the restraint were documented. This deficient practice affected one of two patients reviewed with restraints including Patient Identifier (PI) # 24 and had the potential to affect all patients requiring restraints admitted to this hospital. Findings include: Facility policy: Restraint Policy Policy Number: NGEN-LEG-7 Date Reviewed: 4/2022 Purpose: To provide guidelines on appropriate and safe use of restraints...with adequate clinical justification...The safest, most least-restrictive restraint method should be used. ...Registered Nurse (RN): ...Employs the use of alternatives and interventions to avoid the use of restraint. ...Documents criteria present, nursing assessment, and attempted alternative measures to prevent the use of restraint. Initiates, assesses, and ensures safe monitoring of the restrained patient for the duration of the restraint episode... Procedure: Non-Violent/Non-Self Destructive Management Restraint ...Re-evaluation: 1. RN will re-evaluate the patient at least every 2 hours for the continued use of restraint... RN Assessment/Monitoring and Documentation every 2 hours for... 7. Readiness for discontinuation of use of restraint... Discontinuance and Removal of Restraint: As soon as the patient’s behavior no longer meets the criteria, the RN may discontinue the restraint...physician order is not required... 1. PI # 24 presented to the ED (Emergency Department) on 9/30/23 at 3:00 PM via emergency medical transport (EMT), combative, screaming, not following commands, and unconsolable. Review of the ED record included Restraints Information documentation dated 9/30/23 at 3:00 PM, patient attempting to climb out of bed, soft restraint initiated to left upper and right upper limb, and Patient Care Orders dated 9/30/23 at 3:11 PM, restraint initiate non violent (behavior), reduce injury, soft limb valid for 1 calendar day, restraint monitoring non violent every 2 hours (hrs). Record review revealed Medication Orders for Geodon 20 mg (milligram) IM (intramuscular) was administered on 9/30/23 at 3:31 PM, and Lorazepam 2 mg IVP (intravenous push), was administered on 9/30/23 at 3:37 PM. Further review of ED Restraint Information documentation dated 9/30/23 at 5:00 PM revealed behavior unchanged, does not respond to other interventions, continue restraint episode, and at 7:00 PM, behavior interfering with medical care, continue restraint activity. Record review revealed no order to discontinue restraint use and no documentation PI # 24 was evaluated for the need for continued restraints, no criteria for continued restraint use, no nursing assessment, and no attempted alternative measures to prevent restraint use were documented after 7:00 PM. Record review revealed transfer documentation dated 9/30/23 at 10:43 PM, PI # 24 was transferred to a higher level of care. An interview was conducted on 11/30/23 at 1:56 PM with Employee Identifier (EI) # 3, ED Manager who stated PI # 24 was transferred in restraints. EI # 3 confirmed staff failed to document clinical justification and rationale for continued use of the restraint.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 41623 Based on review of medical records (MR), facility policies, and interview, it was determined the facility failed to ensure patients in restraints due to violent/self destructive behavior and non-violent/non-destructive behavior were monitored per facility policy. This deficient practice affected two of two MR’s reviewed of patients in restraints including Patient Identifier (PI) # 20, PI # 24 and had the potential to affect all patients requiring restraints at this facility. Findings include: Facility policy: Restraint Policy Policy number: NGEN-LEG-7 Date reviewed: 4/2022 Purpose: To provide guidelines on appropriate and safe use of restraints... Registered Nurse (RN): ...Initiates, assesses, and ensures safe monitoring of the restrained patient for the duration of the restraint episode... ...Non-Violent/Non-Self Destructive Management Restraint... Re-evaluation: RN (Registered Nurse) will re-evaluate the patient at least every 2 hours for the continued use of restraint... Procedure: Violent/Self Destructive Management Restraint and/or Seclusion... Re-evaluation: ... The RN will assess at a minimum of every 2 hours for the continued use of restraint... RN Assessment/Monitoring and Documentation every 2 hours for signs of injury...level of distress...readiness for discontinuation... At a minimum of every 15 minutes the following assessment criteria should be collected. This function may be delegated to direct care staff: Assessment of need for restraint placement...(Readiness for discontinuation of use of restraint). 1. PI # 20 was admitted on 5/3/23 with diagnoses including Acute Exacerbation of Psychosis, Methamphetamine Abuse, Rhabdomyolosis, and UTI (Urinary Tract Infection). Review of the Physician’s Orders dated 5/4/23 at 12:03 AM revealed a telephone order for non-violent restraint monitoring. Review of the Nursing Narrative Note dated 5/4/23 at 12:36 AM revealed the nurse documented “...In trying to calm the pt. (patient), (he/she) began to indicate (he/she) was going to bite another nurse in the room. Orders given for soft, non-violent restraints...” Review of the Nursing documentation, Restraints Information, revealed the RN documented every two hours the continued use of restraints from 5/4/23 at 12:38 AM through 5/5/23 at 6:07 AM. There was no documentation of every 15 minute checks. An interview was conducted on 11/30/23 at 1:50 PM with Employee Identifier (EI) # 8, RN, Team Leader, who confirmed PI # 20 was exhibiting violent behavior and the physician’s orders should have been for Violent/Self Destructive management. EI # 8 further confirmed there was no documentation of every 15 minute patient checks for a patient in restraints for violent/self destructive behavior. 30952 2. PI # 24 presented to the ED on 9/30/23 at 3:00 PM combative, screaming, not following commands, unconsolable. ED documentation revealed via emergency medical transport (EMT) administered Valium 10 mg (milligram) IM (intramuscular) prior to arrival. Review of the ED record documentation revealed Patient Care Orders dated 9/30/23 at 3:11 PM, restraint initiate non violent (behavior), reduce injury, soft limb valid for 1 calendar day, restraint monitoring non violent every 2 hours (hrs). Further review of ED Restraint Information documentation dated 9/30/23 at 7:00 PM, behavior interfering with medical care, continue restraint activity. Record review revealed transfer documentation dated 9/30/23 at 10:43 PM, PI # 24 was transferred to a higher level of care. There was no documentation the RN assessed and monitored PI # 24 every 2 hours from 7:00 PM to 10:43 PM for signs of injury, distress, and readiness for restraint discontinuation. There was no documentation the restraints were discontinued. An interview was conducted on 11/30/23 at 1:56 PM with EI # 4, ED Manager who reported PI # 24 was transferred in restraints. EI # 4 confirmed staff failed to document clinical justification and rationale for continued use of the restraint.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1-hour after the initiation of the intervention -- o By a-- - Physician or other licensed practitioner; or - Registered nurse who has been trained in accordance with the requirements specified in paragraph (f) of this section. This Standard is not met as evidenced by: 41623 Based on medical record (MR) review, facility policy, facility Medical Staff Rules and Regulations, and interview, it was determined the facility failed to ensure a one hour face to face was conducted. This affected one of two MR’s reviewed of restrained patients including Patient Identifier (PI) # 20, and had the potential to affect all patients restrained at this facility. Findings include: Facility policy: Restraint Policy Policy number: NGEN-LEG-7 Date reviewed: 2/2022 ...Physician/Licensed Independent Practitioner (LIP): Evaluates need for patient restraint... Conducts a face to face evaluation of the patient restrained based on the criteria for non-violent...verses violent/self destructive management restraint criteria and reassesses need within appropriate time frame per age specific criteria... Violent/Self Destructive Management Restraint and/or seclusion... A required face to face evaluation by the Physician/LIP within 1 hour of restraint application... Atmore Community Hospital Rules & Regulations Revised: 12/2/21 ...Article X. Restraints... 1. If restraints are necessary for Behavior Management (the patient has abusive/aggressive behaviors that are harmful to themselves or others). The physician must physically see the patient within 1 (one) hour of restraint application and may verbally renew this after the first four hours for an additional 4 (four) hours for an additional 4 hours. Then, the physician must physically see and assess the patient every 8 hours... 1. PI # 20 was admitted on 5/3/23 with diagnoses including Acute Exacerbation of Psychosis, Methamphetamine Abuse, Rhabdomyolosis, and UTI (Urinary Tract Infection). Review of the Physician’s Orders dated 5/4/23 at 12:03 AM revealed a telephone order for non-violent restraint monitoring. Review of the Nursing Narrative Note dated 5/4/23 at 12:36 AM revealed the nurse documented “...In trying to calm the pt. (patient), (he/she) began to indicate (he/she) was going to bite another nurse in the room. Orders given for soft, non-violent restraints...” Review of the History and Physical dated 5/4/23 at 9:30 AM revealed the physician documented PI # 20 was displaying signs of acute psychosis, hallucinating, agitated and fighting with staff and was verbally and physically abusive to staff. Further review of the MR and physician documentation revealed no documentation a face to face was conducted within one hour of the restraint application and no documentation the physician or LIP assessed the patient every eight hours while in restraints. An interview was conducted on 11/30/23 at 1:50 PM with Employee Identifier (EI) # 8, Registered Nurse (RN) Team Leader, who stated the restraint order should have been for violent behavior and confirmed there was no documentation of a face to face by the physician or LIP.”

“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 hospital QAPI program failed to include reporting data for each department of the hospital. This deficient practice had the potential to affect all patients admitted to this hospital. Findings include: Facility policy: Performance Improvement Plan Policy number: Not provided Date reviewed: 1/2023 ...The purpose of the plan for improving organizational performance is to provide the framework for ensuring the involvement for the entire organization’s performance... Objectives: ... e. Ensure coordination of efforts and collaboration among departments, services, patient care and areas and professional teams. f. Improve patient care processes and outcomes through continually monitoring and evaluating the quality and appropriateness of patient care, clinical performance and other patient related processes... Each clinical area and support service department defines the scope of care and services which is provided...All performance improvement activities are coordinated and communicated through the PI (Performance Improvement) Committee... 1. A review of the QAPI data was conducted on 11/30/23 at 2:00 PM. There was no documentation of data submitted for Dietary or for Dialysis services. An interview was conducted on 11/30/23 at 2:40 PM with Employee Identifier (EI) # 1, Registered Nurse (RN) Manager, who stated the Dietary and the Dialysis departments were contract services and neither had submitted any QAPI data and were not included in the overall QAPI plan. 30952 2. During a review of the Swing Bed program services on 11/29/23 from 9:22 AM until 9:50 AM with EI # 4, Case Management, the surveyor asked, “What data is the Swing Bed unit collecting, and reporting to the hospital quality assurance improvement committee? EI # 4 stated, “the Swing bed unit is not reporting data to the hospital quality committee. The surveyor then asked EI # 4, “Does the Swing bed unit report any quality indicators that are integrated into the hospital quality program? EI # 4 responded, “No”. In an interview conducted on 11/29/23 at 9:22 AM, EI # 4 confirmed the Swing Bed unit failed to collect, analyze, and submit quality data to the hospital quality improvement committee.”

“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: 30952 Based on review of facility policy and procedure, medical records (MR), and interviews, it was determined the facility failed to ensure: 1. Wounds were assessed per facility policy. 2. Wound care was provided as ordered. This affected two of three MR’s reviewed with wounds, including PI (Patient Identifier) # 19, PI # 1, and had the potential to affect all patients with wounds. Findings include: Facility Policy: Pressure Ulcer/Wound/Skin Assessment and Care Policy Number: NGEN-SKI-2 Date Revised: 3/2019 ...Policy: The nurse shall assess and document the condition of the skin upon admission, daily...and prior to the discharge. ...The nurse shall assess changes in existing dermal lesions or pressure ulcers at the time of each treatment or dressing change. ...Pressure ulcer/Wound Documentation Assess/documentation of wound(s) should be done within 24 hours of admission. Change in status (...acute to swing bed)-Admission assessment/weekly measurements... Documentation of wound appearance should include... Location. ...Shape. Tunneling/undermining/margins. Description of surrounding tissue. Description of exudates (drainage) Wound care provided including dressing... 1. PI # 19 was admitted to the Swing Bed unit on 11/9/23 with diagnoses including Sepsis and Generalized Weakness and was discharged on 11/22/23. Record review revealed Medication Reconcilation documentation dated 11/9/23 at 10:44 AM, revealed orders, left inner buttock apply triad cream daily and as needed. MR review revealed a nutritional assessment completed by the Registered Dietician on 11/20/23 revealed PI # 19 had a left inner buttock wound. Further MR review revealed no wound assessment documentation, and no documentation triad cream was applied daily from admission to discharge. An interview was conducted on 11/30/23 at 10:44 AM with EI (Employee Identifier) # 4, Case Management, who confirmed there were no wound assessments and no wound care documentation. 40119 2. PI # 1 was admitted to the hospital on 11/16/23 with diagnoses including Adult Neglect, Heart Failure, Multiple Wounds, Necrotic Toes and Protein Calorie Malnutrition. Review of the physicians order dated 11/17/23 revealed wounds to the right lateral ankle, left lateral ankle, right hip, left lateral elbow, left hip, and sacrum were to be cleaned with 0.25% acetic acid, patted dry, covered with a nickel thick layer of Santyl, a 0.25% acetic acid moistened gauze applied, over the Santyl, within the confines of the wound edges, then a dry gauze and either Mepilex or tape applied to create a pressure dressing daily. Review of the nursing notes documentation for the wounds to the right lateral ankle, left lateral ankle, right hip, left lateral elbow, left hip, and sacrum revealed the following: On 11/17/23 there was no documentation of a wound assessment for the six wounds. On 11/18/23 there was no documentation of the tunneling/undermining/margins, surrounding tissue, and exudates for the six wounds. On 11/19/23 there was no documentation of a wound assessment for the six wounds. On 11/20/23 there was no documentation of the tunneling/undermining/margins, surrounding tissue, and exudates for the six wounds. Further review revealed the six wounds were cleaned with Normal Saline instead of the 0.25% acetic acid as ordered during the daily wound care. On 11/21/23 there was no documentation of the surrounding tissue and exudates for the six wounds. Further review revealed the six wounds were cleaned with Normal Saline instead of the 0.25% acetic acid as ordered during the daily wound care. On 11/22/23 and 11/23/23 there was no documentation of the tunneling/undermining/margins, surrounding tissue, and exudates for the six wounds. Further review on 11/23/23 revealed the six wounds were cleaned with Normal Saline instead of the 0.25% acetic acid as ordered during the daily wound care. On 11/24/23 there was no documentation of a wound assessment and wound care for the six wounds. On 11/26/23 there was no documentation of a wound assessment and wound care for the six wounds. On 11/27/23 there was no documentation of a wound assessment for the six wounds and no documentation of wound care to the left lateral ankle, right hip, left lateral elbow, left hip, and sacrum wounds. An observation was conducted on 11/29/23 to observe wound care to the right lateral ankle, left lateral ankle, and left lateral elbow with EI # 12, Registered Nurse and EI # 11, Medical-Surgical Manager. During the observsation, EI # 12 failed to apply the 0.25% acetic acid moistened gauze, over the Santyl, prior to the placement of Mepilex to cover the three wounds. Review of the physicians order dated 11/20/22 revealed wounds to the left shoulder, right shoulder, left hip, right lateral lower thigh, right lateral upper calf, left lower lateral thigh, left lateral knee, and left upper lateral calf were to be cleaned with normal saline, patted dry, and Mepilex applied every three days and as needed. Review of the nursing notes from 11/23/23 to 11/27/23 revealed care was performed to the eight wounds on 11/23/23. There no documentation wound care was performed right shoulder, right lateral lower thigh, right lateral upper calf, left lower lateral thigh, left lateral knee, and left upper lateral calf wounds after care performed on 11/23/23. Review of the nursing notes dated 11/25/23 revealed documentation wound care was performed to the the left shoulder and left hip wounds with the use of 0.25% acetic acid instead of the normal saline as ordered. An interview was conducted on 11/30/23 at 2:17 PM with EI # 11, Medical-Surgical Manager, who confirmed the hospital staff failed to perform wound assessments per the hospital policy and wound care per the physician’s orders. EI # 11 also confirmed EI # 12 failed to apply the 0.25% acetic acid moistened gauze to the three wounds during the observation of wound care on 11/29/23.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of 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. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 30952 Based on review medical records (MR) and interview, it was determined the nursing staff failed to administer sliding scale insulin as ordered by the physician. This deficient practice affected two of fourteen current inpatient MR reviews including, Patient Identifier (PI) # 14 and PI # 4, and had the potential to affect all patients served by the facility. Findings Include: 1. PI # 14 was admitted to the facility on 11/27/23 with diagnoses including intractable nausea and vomiting, abdominal cramping, and hypokalemia (low potassium level). Record review revealed an insulin Regular sliding scale order modification dated 11/27/23 at 11:14 PM for the following: Equal to or < (less than) 50 institute hypoglycemic (low blood sugar-BS) protocol 51-149 no coverage 150-200 10 U (units) sq (subcutaneously) 201-250 12 U sq 251-300 14 U sq 301-350 16 U sq 351-400 20 U sq > 400 20 U sq, recheck BS (blood sugar/blood glucose) in one hour, if greater than 350, call M.D. (medical doctor). Record review revealed the Point of Care (POC) Blood Glucose (BG) level documentation dated 11/28/23 at 11:33 AM, the BG was 199 (high) and the Medication Administration Summary Report (MASR) documentation revealed 4 units insulin was administered at 11:40 AM. Staff failed to follow the modified sliding scale insulin orders and administer insulin 10 U for BG 150-200. Further review of the POC BG Level documentation dated 11/29/23 at 6:25 AM revealed BG was 195 (H). The MASR documentation revealed insulin 12 U was administered at 6:32 AM. Staff failed to follow the modified sliding scale insulin orders and administer insulin 10 U for BG 150-200. An interview was conducted on 11/30/23 at 10:45 AM with EI (Employee Identifier) # 11, Medical Surgical Unit Manager, who confirmed staff failed to follow physician orders for sliding scale insulin administration. 40119 2. PI # 4 was admitted to the facility on 11/28/23 with diagnoses including Uncontrolled Type 2 DM (Diabetes Mellitus) with Hyperosmolar Nonketotic Hyperglycemia and Benign Essential Hypertension. Record review revealed a physician’s order for NPO (nothing by mouth) dated 11/28/23 at 6:47 PM and discontinued on 11/30/23 at 8:41 AM. Record review revealed a physician’s order for Humalog sliding scale dated 11/29/23 at 8:30 PM for the following: Equal to or < 50 institute hypoglycemic protocol 51-149 no coverage 150-200 4 U sq 201-250 6 U sq 251-300 8 U sq 301-350 12 U sq 351-400 16 U sq > 400 20 U sq, recheck BS in one hour, if greater than 350, call M.D. Record review revealed the POC BG level documentation dated 11/29/23 at 9:14 PM, the BG was 178 and the MAR (Medication Administration Report) documentation revealed the 4 U of Humalog sliding scale insulin was not administered as ordered due to the patient NPO status. An interview was conducted on 11/30/23 at 1:45 PM with EI # 2, Director of Nursing, who verbalized the patient had been NPO since admission, due to being on an insulin drip, and the patient should have received the ordered sliding scale insulin. EI # 2 confirmed the staff failed to follow physician orders for sliding scale insulin administration.”

“DIETS CFR(s): 482.28(b)(2) All patient diets, including therapeutic diets, must be ordered by a practitioner responsible for the care of the patient, or by a qualified dietitian or qualified nutrition professional as authorized by the medical staff and in accordance with State law governing dietitians and nutrition professionals. This Standard is not met as evidenced by: 30952 Based on review of facility policy and procedure, medical record (MR), and interview, it was determined staff failed to follow the RD (Registered Dietician) nutritional recommendations in one of one Swing Bed records reviewed, and did affect PI (Patient Identifier) # 19, and had the potential to affect all patients admitted to the Swing Bed unit. Findings include: Facility Policy: Nutrition Assessment Policy Number NGEN-SWB-7 Date Reviewed: 7/2022 Policy: Based on a patient’s comprehensive assessment, the facility will ensure that a patient maintain in acceptable parameters of nutritional status ... Procedure: ...2. If there is an identified need for dietary consultations, she/he will review the chart and interview the patient/family ...make recommendations for diet type, supplement ... 3. The dietician ...participates in all interdisciplinary team meetings...makes recommendation as needed ... Facility Policy Physician’s Orders Policy Number: None listed Date Revised 6/2021 ...Policy: All orders for treatment shall be in writing. A verbal order shall be considered in writing if dictated to ...to practitioners by an appropriately registered or licensed person ...Nurse ...Dietician ... ...orders may be taken...to those involving performance of the particular professional skills of the person taking the order ... 1. PI # 19 was admitted to the Swing Bed unit on 11/9/23 with diagnoses of Sepsis and Generalized Weakness. MR review revealed a nutritional assessment completed by the RD on 11/20/23 revealed PI # 19 was on a regular diet, had a left buttock wound, and a history of ulcerative colitis. The dietary recommendations included Ensure (oral nutritional supplementation drink) three times daily, RD follow-up as needed. Further medical record review revealed no order to modify PI # 19’s diet to include Ensure. There was no documentation PI # 19 received Ensure. An interview was conducted on 11/30/23 at 10:44 AM with Employee Identifier # 4, Case Management, who confirmed there was no documentation PI # 19 was provided the recommended nutritional supplementation.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 30952 Based on review of facility policies and procedures, Sani-T-10 Plus Sanitizer manufacturer’s instructions, BNC -15 (disinfectant solution brand) manufacturer’s instructions, Centers for Disease Control and Prevention (CDC) Environmental Cleaning in Healthcare Facilities, observations, and interview it was determined the facility failed to ensure staff: 1. Followed the policy for hand hygiene and glove use. 2. Followed the manufacturer’s instructions to ensure the sanitation of dietary pots and pans. 3. Followed the manufacturer’s guidelines and CDC environmental cleaning procedures to ensure the disinfection of a patient room. 4. Maintained the disinfected status of cleaned patient reusable equipment. This affected PI (Patient Identifier) # 37, and PI # 38 in two of two outpatient care observations, one of one observations for the sanitation of dietary pots and pans, and one of one dietary plating observations and had the potential to affect all patients treated at the facility. Findings include: Facility Policy: Hand Hygiene Guidelines Policy Number: NGEN-INF-27 Date Revised: 01/2023 ...Policy: ...The following are the CDC’s (Centers for Disease Prevention) recommendations for hand washing ... Procedure: B. Hand Hygiene Technique 2. Soap and water wash: b. Apply soap ... d. Rinse hands with water e. Dry ...with a disposable towel f. Use disposable towel to turn off faucet ... Facility Policy: Guideline for Appropriate Glove Use and Glove Technique Policy: None listed Date Revised: 01/23 ...Procedure: ...Hand hygiene must be performed before donning gloves. Hand hygiene must be performed immediately after removing gloves. ...D. Gloves should be changed...between each task (example, after contact with a contaminated surface or environment) Sani-T-10 Plus Sanitizer Manufacturer’s Instructions Date: 12/14 ...3. Sanitize. Fill...sanitizer sink with Sani-T-10 Plus solution...using room temperature water. ...Check to be sure Sani-T-10 Plus is between 150 - 400 ppm (parts per million) with test strips. Immerse the equipment for at least 1 (one) minute, then air dry. Sani-T-10 Plus Sanitizer Test Strip Instructions. ...Test should reach 150-400 ppm, with a target of 200 ppm. CDC Environmental Cleaning in Healthcare Facilities. Date reviewed: 4/21/2020 ...4. Environmental Cleaning Procedures... provides the current best practices for environmental cleaning procedures in patient care areas... 4.1 General environmental cleaning techniques. ...Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. Examples include: ...Clean patient areas...before patient toilets... ...Common high-touch surfaces include: ...doorknobs...light switches. ...4.2.3 Terminal or discharge cleaning of inpatient wards. Terminal cleaning of inpatient areas, which occurs after the patient is discharged...includes the patient zone and the wider patient care area and aims to remove organic material and significantly reduce and eliminate microbial contamination to ensure that there is no transfer of microorganisms to the next patient. ...This is the general terminal cleaning process: ...5. Clean and disinfect all low and high-touch surfaces... BNC-15 Manufacturer’s Instructions Date: Not documented. This product is bactericidal...Contact time...3 minutes... 1. An observation was conducted on 11/28/23 at 9:55 AM with EI # 14, dietary sanitation staff, to observe the cleaning of the dietary pots and pans using a three compartment sink. EI # 14 turned on the cold water faucet over the third sink compartment then turned the knob of the Sani-T-10 Plus Sanitizer to fill the third sink compartment. EI # 14 failed to ensure the water was room temperature per the manufacturer’s instructions. While the third sink compartment continued to fill, EI # 14 dipped the sanitizer test strip into the water in the third sink compartment then compared the test strip to the sanitizer test strip container. The test strip when compared to the test strip container measured the sanitizer at 50 ppm, which was 100 ppm below the recommended ppm of the sanitizer concentration. EI # 14 filled the third sink compartment until approximately two inches below the fill line marked on the outside of the sink failing to fill the sink to the designated fill line. EI # 14 then obtained a second sanitizer test strip and dipped the sanitizer test strip into the water in the third sink compartment then compared the test strip to the sanitizer test strip container. The test strip when compared to the test strip container measured the sanitizer at 50 ppm, which was 100 ppm below the recommended ppm of the sanitizer concentration. EI # 14 filled the other two sink compartments and started to individually clean four pots and two pans. EI # 14 immersed each pot and pan into the sanitizer solution then immediately removed failing to fully immerse each pot and pan for at least one minute per the manufacturer’s instructions. An interview was conducted on 11/28/23 at 2:54 PM with EI # 6, Culinary Director, who confirmed EI # 14 failed to follow the manufacturer’s instructions for the concentration of the sanitizer and ensuring each pot and pan was immersed for one minute in the sanitizing water. 2. An observation was conducted on 11/28/23 at 11:05 AM with EI # 13, dietary staff, to observe the plating of patient lunches. During the observation, EI # 13 donned gloves, removed the containers of green beans, mash potatoes, gravy, and meatloaf from the oven, placed the food containers on the steam table, then obtained the temperature of each food without performing hand hygiene prior to donning gloves. EI # 13 then proceeded to obtain water from the kitchen sink faucet and vegetable base from the walk in refrigerator, then mixed the vegetable base into the water over the stove to prepare vegetable soup without removing gloves and perform hand hygiene prior preparing vegetable soup. EI # 13 removed gloves then donned gloves without performing hand hygiene after removing gloves then donned oven mitts over the gloves, removed a tray of bacon from the oven, used gloved hands to break bacon into small pieces, removed the used parchment paper on the bacon tray, placed the parchment paper in the trash can, and used gloved hand to push the parchment paper down into the trash can. EI # 13 then donned a second pair of gloves over the gloves used for the bacon and cut up green beans and meatloaf on cutting board into small pieces and placed on four patient trays. EI # 13 removed both sets of gloves, removed knife and cutting board used to cut up green beans and meatloaf then donned gloves without performing hand hygiene, and placed covers over the food on the steam table. An interview was conducted on 11/28/23 at 2:54 PM with EI # 6, Culinary Director, who confirmed EI # 13 failed to follow the facility policy for hand hygiene and glove use. Observations of care were conducted on 11/28/23 in the Outpatient infusion and Outpatient Therapy departments with the following hand hygiene observations: 3. At 1:00 PM in the Outpatient infusion department the surveyor observed care during an iron infusion for PI # 38. EI (Employee Identifier) # 9, Outpatient Registered Nurse (RN), cleaned the overbed table with disinfectant wipes, removed gloves, washed hands, and turned off the faucet with bare hands and not a disposable towel. After starting PI # 38’s IV (Intravenous access) EI # 9 washed hands in the sink, turned off the faucet with bare hands and not a disposable paper towel. EI # 9 failed to follow the facility hand hygiene policy. An interview was conducted on 11/29/23 at 2:20 PM with EI # 1, RN Manager who confirmed after hand hygiene staff should turn off the faucet with the disposable paper towel. 4. At 2:00 PM in the Outpatient Therapy department, EI # 10, Licensed Physical Therapy Assistant provided therapy treatment with PI # 37. EI # 10 evaluated PI # 37 during therapy which included patient contact with ungloved hands. Next EI # 10 performed hand washing in the sink, and turned the faucet off with a bare hand. After PI # 37’s treatment was complete, EI # 10 removed the sheet from the treatment table and pillow case from the pillow, discarded the used linens into the linen hamper, and performed hand hygiene at the sink. EI # 10 turned the faucet off with clean bare hands. EI # 10 failed to follow the facility hand hygiene policy. An interview was conducted on 11/29/23 at 2:20 PM with EI # 1 who confirmed after hand hygiene staff should turn off the faucet with the disposable paper towel. 5. An observation was conducted on 11/29/23 at 10:04 AM with EI # 15, Environmental staff, to observe the terminal cleaning of patient room 265. EI # 15 removed used linen from the room bed and proceeded to clean the air mattress pad with BNC-15 solution cloth. As the air mattress pad was cleaned it was then rolled onto itself immediately without allowing a contact time of three minutes per the manufacturer’s instructions. After the air mattress pad was fully rolled onto itself, EI # 15 removed the air mattress pad from the room and laid the mattress pad on the hallway floor outside of the patient room. EI # 15 failed to maintain the disinfected status of the air mattress pad by placing the disinfected mattress pad on the hospital hallway floor. After cleaning the toilet in the patient bathroom, EI # 15 proceeded to clean a patient reusable walker then the room sink with the same gloves used to clean the patient bathroom toilet. EI # 15 failed to clean the bed frame of the hospital bed, the room and bathroom light switches, and the room and bathroom door knobs during the observation. An interview was conducted on 11/30/23 at 2:41 PM with EI # 16, Environmental Director, who confirmed EI # 15 failed to disinfect the air mattress pad per the manufacturer’s instructions, maintain the disinfected status of the air mattress by placing the disinfected mattress pad on the hospital hallway floor, changed gloves per the hospital policy, and cleaned the patient room per CDC guidelines. 40119”

“POST-ANESTHESIA EVALUATION CFR(s): 482.52(b)(3) [The policies must ensure that the following are provided for each patient:] A post-anesthesia evaluation completed and documented by an individual qualified to administer anesthesia, as specified in paragraph (a) of this section, no later than 48 hours after surgery or a procedure requiring anesthesia services. The post-anesthesia evaluation for anesthesia recovery must be completed in accordance with State law and with hospital policies and procedures, which have been approved by the medical staff and which reflect current standards of anesthesia care. This Standard is not met as evidenced by: 41623 Based on medical record (MR) reviews, facility policy, and interview, it was determined the facility failed to ensure a post anesthesia assessment was completed for all patients receiving anesthesia This affected one of six MR reviewed of patients receiving anesthesia including Patient Identifier (PI) # 35 and had the potential to affect all patients receiving anesthesia at this facility. Findings include: Facility policy: Post-Anesthetic Patient Assessment Policy number: ANES-09 Date reviewed: 6/2020 ...All patients who have received anesthesia other than “local only” should be evaluated...prior to discharge from the PACU (Post Anesthesia Care Unit)...each patient should be evaluated by the anesthesia provider and a note should be written on the anesthetic record documenting the patient’s status, including any post-anesthesia complications... 1. PI # 35 was admitted for an outpatient Colonoscopy on 11/21/23. Review of the Anesthesia Record dated 11/21/23 revealed the CRNA (Certified Registered Nurse Anesthetist) administered anesthesia medications including Ketamine 12.5 mg (milligrams), Lidocaine 80 mg, and Propofal 230 mg during the procedure. Review of the Anesthesia Record, Post-Anesthesia Note, revealed no documentation an assessment was completed by the CRNA. In an interview conducted on 11/30/23 at 2:03 PM, Employee Identifier # 5, Operating Room Manager, confirmed the staff failed to document a post-anesthesia note per facility policy.”

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 30952 Based on review of facility policy, ED (Emergency Department) medical records (MR’s), and interview with facility staff, it was determined the facility failed to ensure the staff: 1. Screened all adult patients for suicide risk assessment, which affected three of four ED records reviewed on ED patients able to be screened for suicide risk and included PI # 21, PI # 23, and PI # 28. 2. Submitted ED records to the receiving facility upon transfer per policy and procedure. This affected six of six ED transfers and included PI # 21, PI # 25, PI # 30, PI # 26, PI # 22, PI # 27. 3. Followed the facility policy, documented orders were received or no order was received after critical lab (laboratory) results were reported to the ED physician in one of ten record reviews that included PI # 30. This had the potential to negatively affect all patients who were treated in the ED. Findings include: Facility Policy: Suicidal Precautions Policy Number NGEN-SAF-7 Date Revised: 10/2023 ...Purpose: To guide staff in caring for the patient experiencing suicidal ideation...for providing safe nursing care for the suicidal patient. Policy: All adult patients treated in the ED...will be assessed for suicidal risk. Patients...identified...at risk will be placed on Suicide Precautions... Facility Policy: Transfer/Discharge of an Unstabilized Patient to Another Acute care/Specialty Facility Policy Policy Number: None listed Date Reviewed: 5/2021 ...Transfer/Discharge of an Unstabilized Patient to Another Acute care/Specialty Facility Procedure. ...3. Continue to provide medical treatment within the hospital’s capacity that minimizes the risk... 7. Send all medical records relating to the emergency medical condition with the patient... 8. Fully complete the transfer to acute care/specialty facility summary form... Facility Policy and Procedure: Panic (Critical) Values and Critical Tests Policy Number: None listed Review Date: 5/21 ...Policy: Critical results are defined as results of tests...that fall significantly outside the normal range and may indicate a life threatening situation...provide the responsible licensed caregiver these results...so...the patient can be promptly treated. Procedure: 1. The critical result...called to the physician...patient’s licensed nurse. ...4. Document in the MR the date, time, who was notified, result given and any orders received, If no new orders are received, note that in the MR also... 1. PI # 21 presented to the ED on 11/23/23, chief complaint (cc), right sided abdominal pain. Review of the ED record documentation failed to reveal PI # 21 was assessed for suicide risk. MR review revealed on 11/23/23 at 5:16 PM PI # 21 was transferred to a higher level of care. There was no documentation ED records were sent to the receiving facility upon transfer. An interview was conducted on 11/30/23 at 3:20 PM with EI (Employee Identifier) # 3, ED Manager, who confirmed there was no documentation PI # 21 was assessed for suicide risk and no documentation ED records were sent to the receiving facility at transfer. 2. PI # 25 presented to the ED on 10/16/23 at 10:28 AM, family present, and the cc was Suicidal Ideations (SI). Record review revealed PI # 25 was seen by the ED physician at 10:49 AM, assessment was SI, and a plan to set self on fire. The treatment plan was transfer to a mental health facility for further care. MR review revealed PI # 25 was transferred on 10/16/23 at 8:15 PM. There was no documentation ED records were sent to the receiving facility. An interview was conducted on 11/30/23 at 3:20 PM, with EI # 3 who confirmed there was no documentation the ED record was provided to the receiving facility at transfer. 3. PI # 23 presented to the ED on 11/26/23, cc was rat bite. MR review revealed no documentation PI # 23 was assessed for suicidal risk. An interview was conducted on 11/30/23 at 3:20 PM with EI # 3 who confirmed there was no documentation PI # 23 was assessed for suicidal risk. 4. PI # 30 presented to the ED on 9/30/23 via Emergency Medical Transport (EMT), combative, screaming, unconsolable, was triaged at 3:00 PM and ED nurse documentation revealed PI # 30 was crying, disruptive, explosive, hostile, and disheveled. MR review revealed a critical glucose level 657 resulted on 9/30/23 at 3:28 AM. Record review revealed the ED physician saw PI # 30 at 3:34 PM, the assessment was psychiatric paranoia, atrial fibrillation with rapid ventricular response. Further record review revealed the glucose level, critical results 657, were called to the ED RN on 9/30/23 at 4:57 PM, and physician communication log documentation completed by the ED RN on 9/30/23 at 5:13 PM revealed the ED physician was notified of the glucose 657. Further record review revealed no order for treatment for the critical glucose, and no repeat glucose testing was completed. There was no documentation of orders received after the physician was notified of the critical glucose per facility policy. Record review revealed PI # 30 was transferred to a facility with an intensive care admission on 9/30/23 at 6:51 PM. There was no documentation ED records were sent to the receiving facility upon transfer. An interview was conducted on 11/30/23 at 1:56 PM with EI # 3 who confirmed there was no documentation treatment was provided for the critical blood glucose. The surveyor asked EI # 3 if he/she asked the ED physician if orders were provided for treatment of the 657 glucose? EI # 3’s response was no. 5. PI # 26 presented to the ED on 5/28/23, cc, 35 weeks pregnant, premature ruptured membranes. Record review revealed PI # 26 was transferred to a higher level of care 5/28/23 at 12:15 PM. There was no documentation the ED records were sent to the receiving facility. An interview was conducted on 11/30/23 at 2:13 PM with EI # 3 who confirmed there was no documentation ED records were sent to the receiving facility at transfer. 6. PI # 22 presented to the ED on 11/9/23, cc was unresponsive, cardiac and/or respiratory arrest, accidental overdose. MR review revealed PI # 22 was transferred to a critical care facility 11/9/23 at 10:00 PM. There was no documentation ED records were sent to the receiving facility. An interview was conducted on 11/30/23 at 2:24 PM with EI # 3 who confirmed there was no documentation the ED record was sent to the receiving facility at transfer. 7. PI # 27 presented to the ED on 6/17/23, cc was unresponsive, overdose. MR review revealed PI # 27 was transferred to a critical care facility 11/9/23 at 11:20 PM. There was no documentation ED records were sent to the receiving facility. An interview was conducted on 11/30/23 at 1:42 PM with EI # 3 who confirmed there was no documentation the ED record was sent to the receiving facility at transfer. 49603 8. PI # 28 presented to the ED on 8/04/23, cc was syncope. MR review revealed no documentation PI # 28 was assessed for suicidal risk. An interview was conducted on 11/30/23 at 3:20 PM with EI # 3 who confirmed there was no documentation PI # 28 was assessed for suicidal risk.”

“EP Training Program CFR(s): §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, “Organizations” under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF’s emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This Standard is not met as evidenced by: 30952 Based on review of the employee files, and interview with the staff it was determined the facility failed to ensure contracted staff completed the initial Emergency Preparedness (EP) training. This deficient practice did affect one of two contract employee files reviewed, including Employee Identifier (EI) # 6, Director of Culinary Services and had the potential to negatively affect all staff and patients served by the clinic. Findings include: 1. A review of employee files conducted on 11/30/23 revealed EI # 6 was hired on 2/20/23. There was no documentation EI # 6 had received initial training in emergency preparedness. An interview was conducted on 11/30/23 at 12:02 PM with EI # 1, Registered Nurse Manager, who confirmed EI # 6 had not received initial emergency preparedness training.”

“. K3 Building: 0204 K6 Plan Approval: 1976 K7 Survey Under: 2012 Existing K8 HOSP Generator: One Diesel, Willings Detroit Allison 500 kW (installed 2012) FACP: Simplex 4100ES (installed 2018) Smoke Detection: Corridors and hazardous rooms Locking Devices: None Beds: 51 Census: 16 Type of Structure: This 1976 addition is a two story unprotected noncombustible structure, Type II(000). This building 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 Surveyor while accompanied by the facility maintenance personnel. .”

“Multiple Occupancies - Construction Type CFR(s): NFPA 101 Multiple Occupancies - Construction Type Where separated occupancies are in accordance with 18/19.1.3.2 or 18/19.1.3.4, the most stringent construction type is provided throughout the building, unless a 2-hour separation is provided in accordance with 8.2.1.3, in which case the construction type is determined as follows: * The construction type and supporting construction of the health care occupancy is based on the story in which it is located in the building in accordance with 18/19.1.6 and Tables 18/19.1.6.1 * The construction type of the areas of the building enclosing the other occupancies shall be based on the applicable occupancy chapters. 18.1.3.5, 19.1.3.5, 8.2.1.3 This Standard is not met as evidenced by: 45258 . Based on observation, the facility failed to maintain the separation between construction types per the requirements of: 2012 NFPA 101, 19.1.3.5, and 8.2.1.3 (1) 2012 NFPA 221, 4.8.4.1 This deficiency affects 1 of 2 separations of different construction types. Findings include: During a tour of the facility, the surveyor observed the folowing: 1. A non-fire rated caulk used above the ceiling over the fire barrier cross corridor doors in the 4-hour fire barrier separating Building 0104 and Building 0204 on the second floor; to seal the following penetrations: a. A 1/2” EMT conduit b. A 1” metal conduit c. Four wires 2. The corridor fire doors seperating Building 0104 from Building 0204 on the second floor, failed to release from the magnetic hold open device under activation of the fire alarm system A member of the maintenance staff was present when this deficiency was identified. .”

“Means of Egress - General CFR(s): NFPA 101 Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11. 18.2.1, 19.2.1, 7.1.10.1 This Standard is not met as evidenced by: 45258 . Based on observation, the facility failed to maintain the means of egress per the requirements of: 2012 NFPA 101, 19.2.1, and 7.1.10.1 This deficiency affects 1 of 2 stairwell exits. Findings include: During a tour of the facility, the surveyor observed five Freon cylinders, one cinder block, two strands of chord, two pieces of metal track, one gallon jug and one can of wasp/hornet spray on the landing between the roof and the second floor obstructing the exit discharge of this stairwell located by the second floor Nurses’ Station. A member of the maintenance staff was present when this deficiency was identified. .”

“Horizontal Exits CFR(s): NFPA 101 Horizontal Exits Horizontal exits, if used, are in accordance with 7.2.4 and the provisions of 18.2.2.5.1 through 18.2.2.5.7, or 19.2.2.5.1 through 19.2.2.5.4. 18.2.2.5, 19.2.2.5 This Standard is not met as evidenced by: 45258 . Based on observation, the facility failed to maintain a horizontal exit per the requirements of: 2012 NFPA 101, 19.2.2.5, 7.2.4.3.1, and 8.3.5.1 This deficiency affects 1 of 6 2-hour fire/smoke walls. Findings include: During a tour of the facility, the surveyor observed non-fire rated caulk was used to seal the following penetrations in the 2-hour fire/smoke wall above the ceiling over the fire barrier cross corridor doors located on the second floor between the Nurses’ Station and the East Hall: 1. Multiple wires 2. Around a 1” conduit A member of the maintenance staff was present when this deficiency was identified. .”

“Cooking Facilities CFR(s): NFPA 101 Cooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: * residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2 This Standard is not met as evidenced by: 45258 . Based on observation, the facility failed to provide an approved method to ensure appliances that are protected under the hood, if they are moved, they are returned to the approved design location per the requirements of: 2012 NFPA 101, 19.3.2.5.1, and 9.2.3 2011 NFPA 96, 12.1.2.2, 12.1.2.3, and 12.1.2.3.1 This deficiency affects 1 kitchen hood. Findings include: During a tour of the facility, the surveyor observed that the facility failed to provide an approved method to ensure appliances that are protected under the hood, if they are moved, they are returned to the approved design location. A member of 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, 19.3.5.1, and 9.7.5 2011 NFPA 25, 5.3.1.1.1.3 This deficiency affects 2 of 2 smoke compartments. Findings include: During the review of the documentation, the facility failed to provide documentation that the following quick-response (QR) sprinklers had been replaced or a representative sample tested within 20 years of installation: 1. The 1999 QR sprinklers located in the Physical Therapy (PT) area 2. The 2001 QR sprinklers located in the PT Corridor, PT Bathroom/Storage area and the Morgue A member of the maintenance staff was present when this deficiency was identified. .”

“Portable Fire Extinguishers CFR(s): NFPA 101 Portable Fire Extinguishers Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 18.3.5.12, 19.3.5.12, NFPA 10 This Standard is not met as evidenced by: 41792 . Based on observation, the facility failed to maintain portable fire extinguishers per the requirements of: 2012 NFPA 101, 19.3.5.12, and 9.7.4.1 2010 NFPA 10, 6.1.3.4, and 6.1.3.8.3 This deficiency affects 26 stored portable fire extinguishers located in the North Mechanical Room/Extinguisher Storage Room. Findings include: During a tour of the facility, the surveyor observed 15 portable fire extinguishers laying on their sides, on the floor; with another 11 extinguishers laying on top of these in the North Mechanical Room/Extinguisher Storage Room. A member of the maintenance staff was present when this deficiency was identified. .”

“Corridor - Doors CFR(s): NFPA 101 Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc. This Standard is not met as evidenced by: 41792 . Based on observation, the facility failed to maintain a corridor door per the requirements of: 2012 NFPA 101, 19.3.6.3.2 S&C-07-18 This deficiency affects 1 corridor door. Findings include: During a tour of the facility, the surveyor observed the corridor door for Patient Room 207 had a 5/8 inch gap between the door and door frame when the door was closed and latched. 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 limit the movement of gas fueled appliances with casters located under the kitchen hood, by a restraining device per the requirements of: 2012 NFPA 101, 19.5.1.1, and 9.1.1 2009 NFPA 54, 9.6.1.1, 9.6.1.2, and 10.12.6 This deficiency affects 2 of 2 Deep Fryers. Findings include: During a tour of the facility, the surveyor observed that the facility failed to provide restraining devices for the two gas fueled deep fryers with casters. A member of maintenance staff was present when this deficiency was identified. .”

“Portable Space Heaters CFR(s): NFPA 101 Portable Space Heaters Portable space heating devices shall be prohibited in all health care occupancies, except, unless used in nonsleeping staff and employee areas where the heating elements do not exceed 212 degrees Fahrenheit (100 degrees Celsius). 18.7.8, 19.7.8 This Standard is not met as evidenced by: 41792 . Based on observation, the facility failed to prohibit a portable space heating device per the requirements of: 2012 NFPA 101, 19.7.8 This deficiency affects 1 of 8 smoke compartments. Findings include: During a tour of the facility, the surveyor observed a portable space heating device that was on and sitting on the carpeted floor of the 2nd Floor Doctors Sleeping Room. This was located in a patient/doctor sleeping smoke compartment and the facility was unable to provide documentation that the heating element did not exceeding 212 degrees. A member of the maintenance staff was present when this deficiency was identified. .”

“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 diesel generator’s fuel per the requirements of: 2012 NFPA 99, 6.5.1, 6.4.4.1.1.3, and 6.5.4.2 2010 NFPA 110, 1.3, and 8.3.8 This deficiency affects 1 of 1 generator. Findings include: During the review of the documentation, the facility failed to provide documentation that a fuel quality test was performed within the past twelve months using tests approved by ASTM standards. The last fuel quality test the facility provided was from 05/2022. 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 patient treatment area. Findings include: During a tour of the facility, the surveyor observed an un-approved power strip with a diagnostic computer, printer and desk phone plugged in to it. The power strip was located within 4’ of a patient treatment bed in the Echocardiogram Room, on the 2nd floor. A member of the maintenance staff was present when this deficiency was identified.”

“Gas Equipment - Precautions for Handling Oxyg CFR(s): NFPA 101 Gas Equipment - Precautions for Handling Oxygen Cylinders and Manifolds Handling of oxygen cylinders and manifolds is based on CGA G-4, Oxygen. Oxygen cylinders, containers, and associated equipment are protected from contact with oil and grease, from contamination, protected from damage, and handled with care in accordance with precautions provided under 11.6.2.1 through 11.6.2.4 (NFPA 99) 11.6.2 (NFPA 99) This Standard is not met as evidenced by: 41792 . Based on observation, the facility failed to maintain the oxygen cylinders per the requirements of: 2012 NFPA 99, 11.6.2.3 (11) This deficiency affects 1 of 1 Medical Gas Storage areas. Findings include: During a tour of the facility, the surveyor observed ten type H oxygen cylinders (150 cu.ft. each) all secured by one chain in the Medstar Air Care Services medical gas storage area next to Building 0204. A member of the maintenance staff was present when this deficiency was identified.”