J Paul Jones Hospital

“Infect prevent & control program org & policy CFR(s): (a)(3) The infection prevention and control program include surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and that the program also addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 53356 Based on hospital policy and procedure, Centers for Disease Control (CDC) guidelines, observations, and interviews with staff, it was determined the hospital failed to ensure staff followed hospital policy and accepted standards of practice to prevent hospital acquired infections. This deficient practice affected three of eight observations of care including Patient Identifier (PI) # 24, PI # 29, and had the potential to affect all patients treated at this hospital. Findings include: Hospital Policy: Emergency-Infection Control Policy Number: Not Listed Revised: 6/2005 Handwashing Technique ...B. Glove Practices The appropriate use of gloves is essential to proper infection control. Gloves should always be worn when there is the reasonable anticipation of contact with blood, other potentially infections materials...You should change gloves when moving from a contaminated body site to a clean site on the same patient, always change gloves after patient contact. Do not wear the same pair of gloves when caring for more than one patient...Hand antisepsis with alcohol-based rubs or handwashing should always be performed after changing or removing your gloves... CDC, Clinical Safety: Hand Hygiene for Healthcare Workers Article Date: 2/27/24 ...When to wear gloves When needed for Standard Precautions (when you anticipate that you will come in contact with blood or other infections materials, mucous membranes, non-intact skin, potentially contaminated skin, or contaminated equipment)... 1. An observation of Intavenous (IV) insertion and medication administration to PI # 24 was conducted on 3/4/26 at 8:44 AM. Employee Identifier (EI) # 3, Registered Nurse (RN), applied gloves, swabbed the patient’s antecubital site with alcohol. and then palpated for a vein. EI # 3 failed to maintain aseptic technique prior to IV insertion. EI # 3 performed hand hygiene, swabbed the needleless injection hub with alcohol, then connected a bag of Lactated Ringers to PI # 24’s IV line. EI # 3 failed to wear gloves during the procedure. An interview was conducted on 3/5/26 at 2:05 PM with EI # 2, Director of Nurses, who confirmed the staff failed to maintain aseptic technique during IV insertion and failed to wear gloves during the IV medication administration procedure per policy. 2. An observation of IV medication administration for PI # 24 was conducted on 3/4/26 at 11:25 AM. EI # 3 performed hand hygiene, swabbed the needleless injection hub with alcohol, then connected a pre-mixed bag of Amiodarone to PI # 24’s IV line. EI # 3 failed to wear gloves during the procedure. An interview was conducted on 3/5/26 at 2:05 PM with EI # 2, who confirmed the staff failed to wear gloves during the IV procedure per policy. 3. An observation of a Computed Tomography (CT) Scan of PI # 29 was conducted on 3/4/26 at 2:40 PM. EI # 4, Radiology Technician, was observed with gloves on, opened two doors, transported patient to CT room, proceeded to clean patient bed, assisted patient to table after raising footrests on wheelchair, proceeded to type on keyboard, assisted patient back to hospital area, and did not remove gloves. No hand hygiene was observed. An interview was conducted on 3/5/26 at 2:09 PM with EI # 2, who confirmed the staff failed to perform proper hand hygiene. 41623 50417”

“Excercise of rights. CFR(s): (b)The patient has the right to -- (1) Participate in the development and implementation of their plan of care. This Standard is not met as evidenced by: 41623 Based on Medical Record (MR) review, hospital policy, and interviews with staff, it was determined the hospital failed to ensure the patient’s rights to participate in the development of their plan of care was followed. This deficient practice affected four of 28 patient MRs reviewed including Patient Identifier (PI) # 6, PI # 15, PI # 19, PI # 17, and had the potential to affect all patients admitted to this hospital. Findings include: Hospital Policy: Patient Bill of Rights Policy Number: Not Listed Revised Date: 3/1/1996 Each patient shall be afforded the following rights... Participate in the development and implementation of your plan of care... 1. PI # 6 was admitted to observation on 1/4/26 with diagnoses including Hypoxia and Upper Respiratory Infection. Review of the MR revealed no documentation a plan of care was developed with PI # 6. PI # 6 was discharged on 1/6/26 with diagnoses including Productive Cough and Upper Respiratory Infection. An interview was conducted on 3/5/26 at 2:05 PM with Employee Identifier (EI) # 2, Director of Nurses, who confirmed the hospital failed to develop a plan of care for PI # 6. 2. PI # 15 was admitted to observation on 10/20/25 with diagnoses including Shortness of Breath and Elevated Temperature. Review of the MR revealed no documentation a plan of care was developed with PI # 15. PI # 15 was discharged on 10/22/25 with diagnoses including Multi Vessel Coronary Artery Disease and Dyspnea. An interview was conducted on 3/5/26 at 2:05 PM with EI # 2 who confirmed the hospital failed to develop a plan of care for PI # 15. 53356 3. PI # 19 was admitted to observation on 9/22/25 with diagnoses including Urinary Tract Infection and Possible Pyelonephritis. Review of the MR revealed no documentation a plan of care was developed with PI # 19. PI # 19 was discharged on 9/23/25 with diagnoses including Acute Urinary Tract Infection and Leukocytosis. An interview was conducted on 3/5/26 at 1:26 PM with EI # 2 who confirmed the hospital failed to develop a plan of care for PI # 19. 50417 4. PI # 17 was admitted to observation on 10/9/25 with diagnoses including Altered Mental Status and Dehydration. Review of the MR revealed no documentation a plan of care was developed with PI # 17. PI # 17 was discharged on 10/10/25 with diagnoses including Leukocytosis and Dehydration. An interview was conducted on 3/5/26 at 2:18 PM with EI # 2, who confirmed the hospital failed to develop a plan of care.”

“. K3 Building: 0101 K6 Plan Approval: 1956/1965/1972/2001(renovations)/2024 CT Modular Building K7 Survey Under: 2012 Existing K8 REH Generator: One Natural Gas/Propane Onan 35kW (installed in 1995) FACP: Fire Lite MS 10 UD (installed in 2014) Locking Devices: Access Control at ER Exit Only Smoke Detection: Complete Type of Structure: 1956, 1965, 1972 one story protected non-combustible Type II(111). The facility has a partial automatic sprinkler system (only the front lobby and business offices, during the 2001 renovations). A CT Modular Building was added in 2024. During a routine recertification survey conducted on this date, the requirements of 42 CFR 485.44 - REH was 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. .”

“Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This Standard is not met as evidenced by: 42853 . Based on review of documentation, the facility failed to maintain the smoke detectors per the requirements of: 2012 NFPA 101, 19.3.4.1, and 9.6.1.3 2010 NFPA 72, 14.4.5.3.2 This deficiency affects all of the smoke detectors. Findings include: During a tour of the facility, the facility failed to provide a smoke detector sensitivity test conducted within the past two years. The last documented sensitivity test was dated 06/29/2023. 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: 42853 . Based on review of documentation, the facility failed to maintain the spark ignited natural gas generator per the requirements of: 2012 NFPA 99, 6.5.4.1.3, 6.4.4.1.3, 6.5.4.1.1.2, 6.4.4.1.1.3, and 6.5.4.2 2010 NFPA 110, 8.4.9, 8.4.9.1 This deficiency affects 1 of 1 generators. Findings include: During a tour of the facility, the facility failed to provide documentation of the Level 1 EPSS generator’s four hour load test conducted within the past 36 months. A member of the maintenance staff was present when this deficiency was identified.”