Crenshaw Community Hospital

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 50417 Based on a review of the hospital medical record (MR), hospital policies and procedure, Hospital B (Receiving Hospital 1), Hospital C (Receiving Hospital 2), and interviews with staff it was determined the hospital failed to provide an appropriate medical screening exam (MSE) within the capability of the facility’s emergency department (ED) to determine whether an emergency medical condition existed for all patients who presented to the ED seeking care. This did affect two of twenty MRs including Patient Identifier (PI) # 7 and PI # 15, who presented to the ED for a MSE. Findings include: Cross Refer to C2406 for findings.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) and 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 50417 Based on a review of the hospital medical record (MR), policies and procedure, Hospital B MR (Receiving Hospital 1), Hospital C MR (Receiving Hospital 2), and interviews with staff it was determined the hospital failed to provide an appropriate medical screening exam (MSE) within the capability of the facilities emergency department (ED) to determine whether an emergency medical condition existed for all patients who presented to the ED. This did affect two of twenty ED MRs reviewed to include Patient Identifier (PI) # 7 and PI # 15 and had the potential to affect all ED patients served by the facility. Findings include: Title: EMTALA Guidelines Policy Number: #AHW.400.0070 Revision Date: 9/24/25 Policy: ...All patients shall receive a medical screening exam that includes providing all necessary testing and on-call services within the capability of the Hospital to reach a diagnosis... Title: Suicide Precautions Policy Number: AHW.600.0020 Revision Date: 9/24/24 Procedure: Emergency Department and Medical Surgical Unit: ...When a patient is assessed by the clinical staff and it is determined that the patient is suicidal, the nurse should complete a Suicidal Leveling System Form and assess the patient’s risk level. 1. PI # 7 presented to the hospital ED on 2/8/26 at 11:56 PM with a chief complaint of abdominal pain, nausea, and vomiting. Review of the triage noted dated 2/8/26 at 11:56 PM revealed the patient presented with a chief complaint of abdominal pain with constipation. Review of the ED Provider note dated 2/9/26 at 12:29 AM revealed the patient presented with right upper quadrant abdominal pain and cramping with physical exam findings of abdominal distention. Review of the MR revealed the patient was administered Dilaudid and Phenergan for pain and nausea then discharged home on 2/9/26 at 12:59 AM. Further review of the MR revealed no laboratory or diagnostic testing was performed. Review of the MR dated 2/9/26 at 12:09 PM revealed PI # 7 presented to the hospital ED with continued abdominal pain and left without being seen. Review of Hospital B MR revealed the patient presented to the hospital ED on 2/9/26 at 2:07 PM with abdominal pain. The patient was diagnosed with Mechanical Small Bowel Obstruction Secondary to a 2.5 centimeter Gallstone in the Distal Ileum and Gallbladder Ileus found on an abdominal and pelvic computed tomography (CT) scan. The patient was then transferred to Hospital C and underwent a surgery for a Cholecystoduodenal Fistula. An interview was conducted on 2/19/26 at 9:55 AM with Employee Identifier (EI) # 1, Chief Nursing Officer (CNO) who confirmed an appropriate MSE includes providing all necessary testing and on-call services with the capability of the Hospital to reach a diagnosis was not performed. 53356 2. PI # 15 presented to the hospital ED on 10/1/25 with a chief complaint of suicidal ideations with a plan. Review of the triage noted dated 10/01/25 at 9:30 AM revealed the patient presented to the ED via Emergency Medical Systems with a chief complaint of suicidal ideations with a plan to walk into traffic. Review of the ED Provider note dated 10/01/25 at 9:40 AM revealed the patient was suicidal with a plan to walk out into traffic and had previously walked into traffic. Review of the MR revealed no documentation a suicidal screening was performed nor PI #15 was placed on 1:1 monitoring, searched for instruments of self-harm or placed on a psychiatric hold to complete the MSE. An interview was conducted on 2/19/26 at 10:23 AM with EI # 1, CNO, who confirmed an appropriate MSE, including a Suicidal Leveling System Form and assessing the patient’s risk level, was not completed per the hospital policy.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 50417 Based on a review of the Bylaws, Rules and Regulations, medical record (MR) review, facility policy and procedure, and interviews with staff, it was determined the hospital failed to: provide an appropriate medical screening examination (MSE) within the capability of the hospital’s emergency department (ED) to determine whether an emergency medical condition existed for all patients who presented to the ED seeking care. These deficient practices affected one of twenty sampled patients that presented to the ED for a MSE. Findings included: Cross Refer to findings at A 2406.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) and 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 50417 Based on review of medical records (MR), facility Bylaws, Rules, and Regulations, facility policy, and interviews with staff it was determined the hospital failed to: 1. Document who is qualified to perform a MSE. 2. Provide an appropriate medical screening examination (MSE) within the capability of the facility’s emergency department (ED) to determine whether an emergency medical condition existed for all patients who presented to the ED. This did affect one of twenty sampled ED patients reviewed, to include Patient Identifier (PI) # 9, and had the potential to affect all ED patients served by the facility. Findings include: A review of the facility Bylaws, Rules and Regulations revealed no documentation of who is qualified to perform the MSE. A review of the facility’s policy, EMTALA Guidelines, revealed no documentation of who is qualified to perform the MSE and the facility had no policy pertaining to the MSE. PI # 9 presented to the facility ED on 3/31/25 at 12:06 PM with a chief complaint of threat to kill himself. A review of the MR revealed no MSE was performed. An interview was conducted on 7/24/25 at 11:26 AM with EI # 1, Chief Nursing Officer, and EI # 2, Associate Chief Nursing Officer, who confirmed there was no documentation the MSE was performed.”

“INFECTION PREVENT & CONTROL & ABT STEWAR PROG CFR(s): The CAH must have active facility-wide programs, for the surveillance, prevention, and control of HAIs and other infectious diseases and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic-resistant organisms. Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in coordination with the facility-wide quality assessment and performance improvement (QAPI) program. This Condition is not met as evidenced by: 40119 Based on observations, Manufactures Guidelines for Cleaning, Disinfection, and Sterilization of Transducers, hospital policy and procedure, Centers for Disease Control and Prevention Guidelines for the Prevention of Intravascular Catheter-Related Infections, Chloraprep (Chlorhexidine Gluconate and Isopropyl Alcohol) Manufactures Directions for Use and interviews with the staff, it was determined the facility failed to ensure the staff followed infection control requirements per regulations and hospital policy and procedure. Refer to C 1206.”

“DRUGS AND BIOLOGICALS ARE APPROPRIATELY STORE CFR(s): (3) Drugs and biologicals are appropriately stored; This Standard is not met as evidenced by: 40119 Based on observations and interviews with the staff it was determined the hospital staff failed to ensure used laboratory (lab) tubes were not stored with clean lab tubes available for patient use. This deficient practice had the potential to negatively affect all patients served by the hospital. Findings include: 1. A tour of the lab services department was conducted on 1/8/25 at 1:19 PM. During the tour the surveyor observed a used blue topped lab tube with coagulated blood inside the lab collection tray which stored clean lab tubes available for patient use. An interview was conducted, during the tour, with Employee Identifier # 8, Phlebotomist, who confirmed the blue topped lab tube was filled with coagulated blood and was stored with the clean lab tubes available for patient use.”

“PATIENT CARE POLICIES CFR(s): [The policies include the following:] (vi) Procedures that ensure that the nutritional needs of inpatients are met in accordance with recognized dietary practices. All patient diets, including therapeutic diets, must be ordered by the practitioner responsible for the care of the patients or by a qualified dietitian or qualified nutrition professional as authorized by the medical staff in accordance with State law governing dietitians and nutrition professionals and that the requirement of § 483.25(i) of this chapter is met with respect to inpatients receiving post CAH SNF care. This Standard is not met as evidenced by: 30952 Based on dietary policies and procedures, observations, temperature, and sanitizer log documentation, it was determined the facility failed to ensure: 1. Non-Perishable Foods had received, and expiration dates documented on the packaging. 2. Staff notified the Dietary Manager, and Maintenance staff the 3-Compartment Sink was not working. 3. Dishes washed in the dish machine washer reached acceptable temperatures during the wash, rinse, and final rinse cycles. This affected all patients, staff, and visitors who were served meals prepared at the facility. Dietary Policy Number DIE.600.0020 Title: Storage of Non-Perishable Foods Policy: All non-perishable foods shall be stored in a manner which maximizes nutrient retention and food quality. ...Procedure: ...6. All open or new containers/bags/boxes are clearly labeled with product name, open date, and d/c (discontinue) date (expiration date or manufacturer’s storage/shelf-life recommendations). 7. When food items are received dates are written on each item so that accurate rotation of food is achieved ... Dietary Policy Number DIE.1000.0010 Title: General Safety Rules Review/Revision Date: 7/9/21 Policy: Optimal safety will be practiced ...at all times. ...Report to Supervisor ...3. Any unsafe conditions, such as broken ...defective equipment Dietary Policy Number: DIE.800.0060 Title: Temperature Log, Dish Machine Review/Revision Date: 7/9/21. Policy: The employee placing the dirty dishes into the dish washer shall document the temperature of the dish washer in order to ensure the machine’s proper function and to ensure the washing of all utensils in a sanitary manner. Procedure: 1. The temperature of the dish machine’s wash and final rinse cycles shall be documented at least once during each meal. 2. Documentation shall be made on the dish machine temperature log. form which includes the date, the meal, and the machine. ...4. If wash temperature is not 145, rinse above 150 sanitizing above 180 or above the Dietary Manager is to be notified. 5. The Dietary Manager shall check and monitor the temperature ... 6 ...If temperature (is) not in correct range ...suspend dish machine washing and notify maintenance ... 1. A tour and observations were conducted on 1/8/25 at 10:25 AM in the hospital dietary department with Employee Identifier (EI) #, 12, Dietary Manager. Observations conducted in the Dry Storage area revealed the following: One 7 pound (lb.) 8 ounce (oz) can strawberry glaze with no received and no expiration date. Three 6 lb. cans Sliced apples with no expiration date. Two 6 lb. 12 oz cans Bella Vista Pinta Beans in Brine with no expiration date. One 7 lb. 11 oz can Chocolate waffle cone and enrober coating (Enrobing coating is a process that coats food items with a layer of chocolate or other coating) with no received and no expiration date. Six 5 lb. packs of yellow cake mix with no received and no expiration date. An interview was conducted on 1/8/25 at 10:50 AM with EI # 12, who confirmed staff had not documented the received date on dry food products. There was no use by or expiration date on the above food products. 2. The dietary tour revealed a 3-Compartment Sink not in use. There was no hot water for use in the sink. EI # 12 reported all dishes including pots and pans were washed in the dish machine. Review of the Pot and Pan Dishwashing Temperature/Sanitizer Record documentation, which was the 3-Compartment Sink log, revealed on 12/28/24 dinner wash and rinse temperatures were 000, on 12/29/24 breakfast, lunch, and dinner wash and rinse temperatures were 000, on 12/30/24 lunch and dinner wash and rinse temperatures were 000. Further review of the Pot and Pan Dishwashing Temperature/Sanitizer Record revealed on 12/31/24 staff documented “not working” for breakfast, lunch, and dinner. There was no documentation the Dietary Manager, or maintenance was notified the 3-Compartment Sink needed repair. An interview was conducted on 1/8/25 at 11:30 AM with EI # 12, who reported repair parts were ordered, but she/he did not know when the sink would be repaired. An interview was conducted on 1/9/25 at 8:25 AM with EI # 14, Safety Manager/Maintenance. The surveyor requested documentation when maintenance was notified of the 3-Compartment Sink malfunction. EI # 14 provided a Maintenance Work Request dated 1/6/25 at 8:30 AM. EI # 14 reported the dietary staff notified maintenance of the equipment failure on 1/6/25, which was 10 days after the 3-Compartment Sink temperatures were not acceptable, and the sink was in need of repair. An interview was conducted on 1/9/25 at 9:40 AM with EI # 12 who confirmed dietary staff failed to notify the Dietary Manager and maintenance for 10 days the 3-Compartment Sink was not functioning. 3. Observations of staff using the dish machine to wash lunch dishes was conducted on 1/8/25 at 1:20 PM. EI # 17, Cook, performed dish pre- wash, and EI # 15, Cook, performed clean dish removal from the dish machine, placement of clean dishes on cart, and clean dish removal from the dish machine washroom. A wash cycle was in progress upon entry, and the Champion dish machine temperature dials read, wash 140 degrees (Fahrenheit), rinse 136 degrees, final rinse (sanitizing) 120. Lunch trays being removed from the machine by EI # 15. EI # 15 placed the lunch trays on the clean rack and loaded the rack onto the clean cart. EI # 17 completed pre-wash then placed plates, plate tops, and trays into the dish machine. The temperature dials read, wash 130 degrees, rinse 138 degrees, and final rinse 126 degrees. The two dish machine loads failed to reach the required temperature wash, and rinse temperature for the two loads of dishes. EI # 15 loaded the plates/tops/trays onto a cart and exited the dish machine room. The surveyor interviewed EI # 17 after the dish loads failed to reach acceptable temperatures. EI # 17 reported the wash should be 160-165, and final rinse should be 180. EI # 17 stated, “the temperatures were right when the first loads ran.” The dishes were not properly sanitized and were removed from the dish washer room and taken into the kitchen. Review of the January 2025 Dish Machine Temperature Log dated 1/8/25 revealed no lunch wash and rinse temperature documentation. Staff had failed to document the 1/8/25 dish machine temperatures were not acceptable to sanitize the dishes. An interview was conducted on 1/8/25 at 2:15 PM with EI # 12, who confirmed the dish machine temperatures were not at acceptable levels. The surveyor asked EI # 12 should the two trays of dishes be re-washed. EI # 12 instructed EI # 15 to retrieve the two carts of dishes, then instructed dietary staff to wait 30 minutes or so to allow the hot water to reach the acceptable temperatures before re-wash began.”

“NURSING SERVICES CFR(s): Nursing services must meet the needs of patients. (1) A registered nurse must provide (or assign to other personnel) the nursing care of each patient, including patients at a SNF level of care in a swing-bed CAH. The care must be provided in accordance with the patient’s needs and the specialized qualifications and competence of the staff available. This Standard is not met as evidenced by: 40119 Based on review of medical records (MR), hospital policy and procedure, and staff interviews it was determined the hospital staff failed to ensure a Heparin (anticoagulant medication) drip was administered per the hospital policy and procedure. This deficient practice did affect one of one MR reviewed with a Heparin drip, including Patient Identifier (PI) # 20, and had the potential to negatively affect all patients being served by the hospital. Findings include: Hospital Policy: Critical Care Administration of a Heparin Drip Policy Number: PHARM- 47.06 Revision Date: 12/6/24 Policy: To provide safe and effective anticoagulation with Heparin therapy upon the written order of a physician. Procedure: To follow a specific protocol when administering Heparin...to a critical patient requiring anticoagulation therapy. Indications for Heparin use: Deep Vein Thrombosis (DVT), Pulmonary Embolism (PE)...When Lovenox (Enoxaparin) anticoagulation is inappropriate (example severe renal impairment.) ...Maintenance Dose...Maintenance dose will be based on patient weight. Therapy will be initiated with standard concentration of 25,000 units in 500 ml (milliliter) 0.45 % Normal Saline (NS)... Dosing for confirmed PE or DVT...Initial dose: 18 units/kg/hr (units per kilogram per hour). Dosing for CVA (stroke), post stent, to rule out MI (heart attack) or if major bleeding risk... Initial dose: 12 - 15 units/kg/hr... See chart below Maintenance Dosing: DVT/PE Maintenance Dosing Chart (based on 18 units/kg/hr) Patient weight...100 kg (highest weight on the chart)...Heparin required 1800 units/hr...rate 38 ml/hr ACS (Acute Coronary Syndrome) Maintenance Dosing Chart (based on 15 units/kg/hr) Patient weight...120 kg (highest weight on the chart)...Heparin required...1800 units/hr...rate 36 ml/hr ACS Maintenance Dosing Chart (based on 12 units/kg/hr) Patient weight...120 kg (highest weight on the chart)...Heparin required 1350 units/hr...rate 27 ml/hr Monitoring during Heparin Infusion: ...Laboratory monitoring and dosing adjustments...repeat PTT (partial thromboplastin time - blood test that measures how long it takes for blood to clot) 4 hours after start of Heparin infusion and 4 hours after each dosage adjustment. Adjust bolus and infusion according to chart below... PTT... below 35 seconds...infusion rate change...80 unit/kg bolus plus increase rate by 200 units/hr (4 ml/hr)... 1. PI # 20 was admitted to the hospital on 12/15/24 with diagnoses including Altered Mental Status, Right Lower Lobe Pneumonia, and Acute Kidney Injury. Review of the Patient Progress Notes dated 12/15/24 at 8:09 PM revealed a patient weight of 136.08 kg. Review of the physician order dated 12/15/24 revealed an order for Heparin 25,000 Units/500 ml of NS with a rate of “titrate.” There was no documentation the physician specified which maintenance dosing chart should be used for the patient’s heparin drip administration. Review of the MR revealed a copy of the Critical Care Administration of a Heparin Drip policy with PI # 20’s information. Review of the policy revealed a star symbol was documented surrounding the ACS Maintenance Dosing Chart (based on 15 units/kg/hr) and a check mark was placed by the patient weight of 120 kg dosing, which required 1800 units/hr of Heparin. Review of the Heparin administration form revealed the patient’s weight of 136 kg and the Heparin drip was initiated on 12/15/24 at 10:50 PM with a rate of 1350 units/hr, which was 450 units/hr less than the dosing required per the ACS Maintenance Dosing Chart for the patient’s weight. Further review revealed the Heparin dosage was not increased to the required dosing, 1800 units/hr of Heparin, per the ACS Maintenance Dosing Chart until 12/16/24 at 8:00 PM. Review of the History and Physical note dated 12/16/24 at 8:31 AM revealed documentation of Chronic Kidney Disease and “D-dimer (blood test used to help diagnose blood clotting problems such as DVT, PE) was high will place on a Heparin drip with protocol...” Review of the laboratory testing dated 12/16/24 at 7:49 PM revealed a PTT of 29.0 seconds. Further review of the Heparin administration form revealed on 12/16/24 at 8:00 PM Heparin was increased to 1800 units/hr from the current 1750 units/hr, which was an increase of 10 units per hour. There was no documentation a Heparin bolus of 80 units/kg was administered, and the Heparin was increased by 200 units/hr per the hospital policy and procedure. An interview was conducted on 1/9/25 at 5:08 PM with Employee Identifier (EI) # 1, Chief Nursing Officer, who confirmed the Heparin drip was not administered per the hospital policy and procedure.”

“REHABILITATION THERAPY SERVICES CFR(s): Physical therapy, occupational therapy, and speech-language therapy pathology services furnished at the CAH, if provided, are provided by staff qualified under State law, and consistent with the requirements for therapy services in §409.17 of this subpart. This Standard is not met as evidenced by: 30952 Based on medical record (MR) review, and interview, it was determined the facility failed to ensure: 1. A physician order was obtained and documented for a Physical Therapy evaluation. 2. The Physical Therapy (PT) Plan included the frequency, and duration for physical therapy services. This affected Patient Identifier (PI) # 36, in one of one rehabilitation services record reviews, and had the potential to affect all patients who required rehabilitation services. Findings include: 1. PI # 36 was admitted to the facility inpatient unit on 11/5/24 with diagnoses including Weakness and Falls. Review of the MR revealed a PT Evaluation dated 11/7/24. Further review of the MR revealed no physician order for the 11/7/24 PT Evaluation. Review of the 11/7/24 PT Evaluation revealed the frequency, and duration of physical therapy services was “as available.” The PT plan failed to include the frequency, and duration for PT services. An interview was conducted on 1/9/25 at 2:18 PM with Employee Identifier # 2, Chief Executive Officer, who confirmed there was no physician order for the PT evaluation, and the PT Plan did not include the frequency, and duration of the PT services.”

“RECORDS SYSTEM CFR(s): Dated signatures of the doctor of medicine or osteopathy or other health care professional. This Standard is not met as evidenced by: 30952 Based on facility policy and procedure, medical record (MR) review, and interviews, it was determined the facility failed to ensure verbal orders were signed by the physician within 48 hours per facility policy. This affected seven of twenty inpatient MR’s reviewed, and included Patient Identifier (PI) # 3, PI # 9, PI # 4, PI # 12, PI # 6, PI # 2, PI # 5, and had the potential to affect all patients admitted to this facility. Findings include: Facility Policy Number: HIM-38.01 Title: Medical Record Documentation and Content ...Policy: ...Documentation will comply with the documentation standards and requirements... Procedure: ...Content ...Entries and orders must be authenticated by authorized individuals, dated, and timed. ...VO (verbal order) signatures must be signed by the physician within 48 hours... 1. PI # 3 was admitted to the facility on 1/3/25 with diagnoses including Status Post Femur Fracture. Review of the MR revealed five verbal orders dated 1/3/25 and five verbal orders dated 1/4/25, “pending”, not signed/authenticated by the physician within 48 hours per policy. An interview was conducted on 1/9/25 at 4:35 PM with Employee Identifier (EI) 1, Chief Nursing Officer, who confirmed verbal orders were not authenticated per facility policy. 2. PI # 9 was admitted to the facility on 12/25/24 with diagnoses including Severe Chronic Obstructive Pulmonary Disease. Review of the MR revealed three verbal orders dated 12/26/24 “pending”, not signed/authenticated by the physician within 48 hours per policy. An interview was conducted on 1/9/25 at 4:19 PM with EI 1 who confirmed verbal orders were not authenticated per facility policy. 3. PI # 4 was admitted to the facility on 12/25/24 with diagnoses including Urinary Tract Infection with Sepsis. Review of the MR revealed four verbal orders dated 1/4/25 “pending”, not signed/authenticated by the physician within 48 hours per policy. An interview was conducted on 1/9/25 at 4:25 PM with EI 1 who confirmed verbal orders were not authenticated per facility policy. 4. PI # 12 was admitted to the facility on 1/2/25 with diagnoses including Anemia. Review of the MR revealed twenty-one verbal orders dated 1/2/25 and eight verbal orders dated 1/3/25, “pending”, not signed/authenticated by the physician within 48 hours per policy. An interview was conducted on 1/9/25 at 4:20 PM with EI 1 who confirmed verbal orders were not authenticated per facility policy. 5. PI # 6 was admitted to the facility on 1/3/25 with diagnoses including Encephalopathy. Review of the MR revealed fourteen verbal orders dated 1/4/25 and two verbal orders dated 1/5/25, “pending”, not signed/authenticated by the physician within 48 hours per policy. An interview was conducted on 1/9/25 at 4:29 PM with EI 1 who confirmed verbal orders were not authenticated per facility policy. 6. PI # 2 was admitted to the hospital on 12/30/24 with a diagnosis of Pulmonary Edema. Review of the MR revealed verbal orders entered into the electronic health record by the Registered Nurse (RN) on 12/30/24 and 1/7/25 were not signed by the physician within 24 hours per hospital policy. An interview was conducted on 1/9/25 at 4:30 PM with EI # 1, who confirmed verbal orders entered by the RN were not signed by the physician within 24 hours per facility policy. 7. PI # 5 was admitted to the facility on 1/2/25 with a diagnosis of Urinary Tract Infection. Review of the MR revealed verbal orders entered into the electronic health record by the RN on 1/3/25, 1/4/25, and 1/6/25 were not signed by the physician within 24 hours per hospital policy. An interview was conducted on 1/9/25 at 4:30 PM with EI # 1, who confirmed verbal orders entered by the RN were not signed by the physician within 24 hours per facility policy.”

“PROTECTION OF RECORD INFORMATION CFR(s): The CAH maintains the confidentially of record information and provides safeguards against loss, destruction, or unauthorized use. This Standard is not met as evidenced by: 30952 Based on observation, hospital policy and procedure, and interview, it was determined the facility failed to ensure all records were secured and protected from potential water damage. This had the potential to affect all patient medical records. Findings include: Crenshaw Community Hospital Policy and Procedure Title: Medical Record Storage Review/Revision Date 1/12/24 Policy: It is the policy ...that all records ...shall be secured in such a manner as to provide protection from damage and unauthorized access ... A tour of the Medical Record department was conducted on 1/7/25 at 2:55 PM. There were numerous paper files on open shelves throughout the MR department. There were sprinklers located in the ceiling above the open file shelves. An interview was conducted on 1/7/25 at 3:00 PM with Employee Identifier (EI) # 19, Health Information Management Manager, who reported the paper files were patient medical records not yet scanned into the electronic health record. EI # 19 verified the MR department had sprinklers located in the ceiling above the paper records. EI # 19 confirmed file shelves holding paper medical records were not able to close and cover the medical record paper files. EI # 19 confirmed the facility MRs were not protected from potential water damage.”

“INFECTION PREVENT & CONTROL POLICIES CFR(s): The infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the CAH and between the CAH and other healthcare settings; This Standard is not met as evidenced by: 40119 Based on observations, Manufactures Guidelines for Cleaning, Disinfection, and Sterilization of Transducers, hospital policy and procedure, Centers for Disease Control and Prevention (CDC) Guidelines for the Prevention of Intravascular (IV) Catheter-Related Infections, ChloraPrep (Chlorhexidine Gluconate and Isopropyl Alcohol) Manufactures Directions for Use (MDU) and interviews with the staff it was determined the hospital staff failed to ensure: a. Hand hygiene was performed per the hospital policy. b. An Endo cavity transducer probe was cleaned and disinfected according to the manufacturer’s guidelines. c. IV access was initiated per CDC guidelines and ChloraPrep MDU. This did affect one of five medication preparation observations, including Patient Identifier (PI) # 4, all patients who had a transvaginal ultrasound, one of one wound care observation, including Patient Identifier (PI ) # 5, one of one observation for initiation of an IV access, including unsampled patient 1, one of one observation of scope cleaning, and had the potential to negatively affect all patients served by the hospital. Findings include: Hospital Policy: Handwashing Policy Number: AHW.100.0032 Revision Date: 5/27/16 Policy: Crenshaw Community Hospital is committed to providing quality healthcare within an environment that is clean and safe for it’s patients ... Handwashing is the single most important factor in reducing the risk of transmission of infectious agents ... Hands are to be washed in the following instances: ...4. After contact with...inanimate objects that are likely to be contaminated). ...5. After removing gloves. ...Procedure: ...9. Turn off water with paper towel ... Canon Guidelines for Cleaning, Disinfection, and Sterilization of Transducers 2B702-067EN* P 1. Safety Precautions ...1.2 Safety Precautions 1. Precautions concerning cleaning, disinfection, and sterilization. ...Clean the transducer before and after examination. Disinfect or sterilize as required... 2. After cleaning, rinse the transducer thoroughly with purified water to remove all chemical residues. After disinfection, rinse the transducer thoroughly with sterile or deionized water to remove all chemical residues....may be harmful to the human body. 3. After chemical cleaning or chemical disinfection, thoroughly dry the transducer surface. ...6. To ensure the prevention of infection, confirm the effectiveness of each chemical for cleaning, disinfection, or sterilization. ...7. Do not clean, disinfect, or sterilize the transducer using chemicals or methods other than those specified in this guide ...the transducer may not be properly cleaned, disinfected, or sterilized or may be damaged. 2. Cleaning, Disinfection, Sterilization 2.1 Cleaning ...(3) Wash off all organic materials...from the transducer under purified water... ...(4) In accordance with tables and figures in section 3, immerse the transducer in a cleaning solution or wipe the transducer using wipes to dissolve all remained organic material ... (5) Remove all residual organic materials and cleaning solution from the transducer by rinsing it under purified water. Confirm that all organic material and cleaning solution have been removed. Do not reuse the purified water. (6) Dry the surface of the transducer ... 2.2. Disinfection Before disinfection, the transducer must be cleaned. ...Items to be used: Sterile protective gloves, disinfectant, sterile water or deionized water, sterile soft cloth, or gauze>> ... (2) Disinfect the transducer using chemicals listed in section 3 ... Model name ...Chemical name/type 3. List of Chemicals Cleaning Chemical name/type ---Enzyme ...Cidezyme, 3 Rapid Multi-Enzyme cleaner, Aniosyme DD1, Neodisher ... Low/Middle-Level Disinfection-2 (High-level disinfection is also required in the USA.) ... ...High-Level Disinfection-2 Chemical name/type Glutaraldehyde ... Trade name Cidex ...Cidex Plus 28-day solution ... Hydrogen peroxide ...Trophon ...Sporox II, 7.5.% Revital-Ox Resert High Level Disinfectant 2%... CDC Guidelines for the Prevention of Intravascular (IV) Catheter-Related Infections Date: 2011 ...Hand Hygiene and Aseptic Technique 1 ... Palpation of the insertion site should not be performed after the application of antiseptic ... ChloraPrep MDU Date: Not documented. Instructions for use: Pinch ...do not touch sponge ... 1. An observation for insulin preparation was conducted on 1/7/25 at 12:19 PM with Employee Identifier (EI) # 6, Registered Nurse in the medication preparation room on the medical unit. EI # 6 cleaned the medication preparation counter with a disinfecting cloth, wiped an insulin vial septum with an alcohol pad, and withdrew 2 units of insulin from the vial into the syringe. EI # 6 failed to perform hand hygiene before insulin preparation. On 1/7/25 at 12:23 PM, EI # 6 administered 2 units of Humulin insulin to PI # 4. An interview was conducted on 1/9/25 at 5:00 PM with EI # 1, Chief Nursing Officer, who confirmed staff should perform hand hygiene before medication preparation. 2. A tour of the radiology department and interview with EI # 10, Radiology Manager, was conducted on 1/7/25 at 1:30 PM. The surveyor observed an ultrasound (US) machine. The surveyor asked what types of US were performed? EI # 10 reported transvaginal US were performed among other procedures. The surveyor observed an endocavity transducer probe, and one box McKesson Ultrasound latex nonsterile disposable probe covers. The surveyor asked how the transvaginal transducer probe was cleaned after use? EI # 10 removed a canister of Chlorox Healthcare Hydrogen Peroxide wipes from the cabinet. The surveyor asked if the facility had a policy for disinfection of the endocavity transducer probe between patients. EI # 10 reported the department did not have a policy. The surveyor requested the manufacturer’s directions for disinfection of the facility endocavity transducer. On 1/7/25 at 2:01 PM, the surveyor interviewed EI # 11, Ultrasound Technician. EI # 11 reported after each use, the latex transducer cover is disposed of, and the transducer probe is cleaned with soap and water to remove the US gel. EI # 11 reported the probe was then wiped with Chlorox Healthcare Hydrogen Peroxide Cleaner Disinfectant Wipes (active ingredient hydrogen peroxide 1.4). Review of the Canon Guidelines for cleaning, disinfection, and sterilization of transducer provided by EI # 10 revealed the facility endocavity transducer probe required an enzymatic cleaner, rinse with purified water, followed by high-level disinfection. An interview was conducted on 1/7/25 at 4:18 PM with EI # 1 who confirmed the facility had failed to follow the manufacturer’s directions for cleaning and disinfection of the endocavity transducer probe. 3. An observation was conducted on 1/8/25 at 9:11 AM with EI # 6, and EI # 18, Patient Care Technician (PCT), to observe wound care provided to PI # 5. During the observation, EI # 6 performed hand hygiene using soap and water then turned the water off with bare hand. EI # 6 failed to use paper towel to turn the water off. EI # 18 removed gloves after cleaning the patient after a bowel movement then donned clean gloves without performing hand hygiene. EI # 18 failed to perform hand hygiene after removing gloves and prior to donning clean gloves. An interview was conducted on 1/9/25 at 4:58 PM with EI # 1 who confirmed the hospital staff failed follow the hospital hand hygiene policy. 4. An observation was conducted on 1/8/25 at 11:41 AM with EI # 5, RN, for the initiation of an IV access on unsampled patient 1. EI # 5 opened the sterile ChloraPrep sponge package, pinched the wings of the ChloraPrep sponge to release the ChloraPrep solutions into the sponge, then with gloved finger rubbed the sponge of the ChloraPrep. EI # 5 failed to not touch the sponge of the ChloraPrep prior to use. EI # 5 then disinfected the left arm IV access site with the ChloraPrep sponge, obtained the IV needle and touched the disinfected IV access site three times with gloved hand prior to the insertion of the IV needle. EI # 5 failed to disinfect the IV access site again after touching the site and prior to needle insertion. An interview was conducted on 1/9/25 at 4:55 PM with EI # 1 who confirmed the staff failed to initiate the IV access per CDC guidelines and ChloraPrep MDU. 5. An observation was conducted on 1/9/25 at 8:40 AM with EI # 9, Operating Room Technician, cleaning a scope after completion of a colonoscopy. After scrubbing the scope in the sink, EI # 9 placed the scope in the DSD Edge machine (used for disinfection and sterilization). EI # 9 then removed his/her gloves, and without performing hand hygiene, touched the handle on the lid of the machine and programmed the DSD machine. EI # 9 then exited the area without performing hand hygiene. An interview was conducted on 1/9/25 at 4:52 PM with EI # 1 who confirmed staff failed to perform hand hygiene per hospital policy.”

“DISCHARGE PLANNING CFR(s): (8) The CAH must assist patients, their families, or the patient’s representative in selecting a post-acute care provider by using and sharing data that includes, but is not limited to, HHA, SNF, IRF, or LTCH data on quality measures and data on resource use measures. The CAH must ensure that the post-acute care data on quality measures and data on resource use measures is relevant and applicable to the patient’s goals of care and treatment preferences. This Standard is not met as evidenced by: 30952 Based on review of the hospital discharge planning program, and interviews, it was determined the facility failed to include quality measure data during discharge planning when discharged to post-acute care. This did affect four of four patients discharged to post-acute care, one patient to home health care, and three patients to skilled nursing facilities for rehabilitation services. This affected Patient Identifier (PI) # 3, PI # 9, PI # 6, PI # 36, and had the potential to affect all patients discharged in need of post-acute care. Findings include: 1. MR review revealed PI # 3 was discharged on 1/7/25 to a Skilled Nursing Facility (SNF) for rehabilitation services, PI # 9 was discharged on 12/27/24 with home health care services, PI # 6 was discharged on 1/7/25 to a SNF for rehabilitation services, and PI # 36 was discharged on 11/7/24 to a SNF for rehabilitation services. There was no MR documentation the facility shared/provided the patient/family or patient representative with the post-acute provide quality measurement data. A review of the discharge planning service was performed on 1/9/25 at 11:08 AM with Employee Identifier (EI) # 13, Discharge Planning/Utilization Review Nurse. In an interview conducted 1/9/25 at 11:08 AM, the surveyor asked EI # 13 was information was provided to patients/families whose discharge plan included home care, skilled nursing facilities, and long-term care? EI # 13 reported the hospital facility Patient Freedom of Choice form and sometimes facility pamphlets with the services offered was provided. The surveyor asked EI # 13 if the hospital shared the provider quality measures data. EI # 13 stated the provider quality measure data was not provided. The facility failed to assist the patient/families in selection of a post-acute provider by sharing provider quality measures data. An interview was conducted on 1/9/25 at 5:15 PM with EI # 2, Chief Executive Officer, who confirmed the hospital failed to share/provide patients/families quality measures data during selection of post-acute care providers for PI # 3, PI # 9, PI # 6, and PI # 36.”

“RESTRAINT AND SECLUSION CFR(s): All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. This Standard is not met as evidenced by: 40119 Based on review of medical records (MR), hospital policy and procedure, and staff interviews it was determined the hospital staff failed to ensure: 1. Physician order(s) were obtained every four hours for a behavioral restraint. 2. A one hour face to face assessment was conducted for a patient in seclusion. This deficient practice did affect one of two MRs reviewed with a restraint, including Patient Identifier (PI) # 20, and one of one MRs reviewed with seclusion, including PI # 14, and had the potential to affect all patients requiring seclusion and restraints. Findings include: Hospital Policy: Restraints and Seclusion Policy Number: AHW.400.0052 Revision Date: 9/15/23 Purpose: Crenshaw Community Hospital strives to protect the rights and dignity of all patients by seeking a restraint-free environment while emphasizing both the physical and emotional wellbeing of our patients... Policy and Procedure: A. Definitions. ...5. Licensed Independent Practitioner (LIP): Any individual who is permitted by law and the hospital to provide care and services...within the scope of the individual’s license and...granted clinical privileges... C. Ordering and Face to Face Evaluation. ...4. In emergency application situations, a RN (Registered Nurse) may initiate application when less restrictive interventions have either been exhausted or have been determined to be effective (ineffective) to protect the patient and/or others... 5. No order for restraints or seclusion may exceed four (4) hours. 6. An authorized LIP must provide a new order for each 4-hour episode of restraint... 10. The following guidelines regarding ordering and evaluation are specific to Violent/Self Destructive Restraints...when a restraint or seclusion is used for the management of violent and/or self-destructive behavior that jeopardizes safety, the RN immediately notifies the LIP... The LIP performs a face-to-face evaluation within 1 (one) hour of initiation of restraint or seclusion... 1. PI # 20 was admitted to the hospital on 12/15/24 with diagnoses including Altered Mental Status, Right Lower Lobe Pneumonia, and Acute Kidney Injury. Review of the Restraint/Seclusion Monitoring Log dated 12/16/24 revealed the patient was in a restraint from 9:45 AM until 2:00 PM, which was 4 hours and 15 minutes. Review of the Restraint Physician Order Form dated 12/16/24 at 9:48 AM revealed an order for a behavioral/violent restraint. There was no documentation of a second Physician Order to continue the restraint past the initial four-hour timeframe. An interview was conducted with Employee Identifier (EI) # 1, Chief Nursing Officer, who confirmed there was no documentation of a physician order every four hours per the hospital policy. 2. PI # 14 was admitted to the hospital on 1/31/24 with a diagnosis of Schizoaffective, Bipolar Type. Review of the Physician Order Form and Restraint/Seclusion Monitoring Log dated 2/18/24 revealed the patient was placed in seclusion from 10:25 AM until 2:30 PM. Review of the Seclusion/Restraint Face to Face Assessment dated 2/18/24 revealed the face-to-face assessment was completed at 2:30 PM, four hours and five minutes after the initiation of seclusion. An interview was conducted on 1/9/25 at 5:02 PM with EI # 3, Director of Behavioral Health, who confirmed the face-to-face assessment was not completed within one hour of the initiation of seclusion.”

“K3 Building: 0102 K6 Plan Approval: 1960, 04/28/2004 K7 Survey Under: 2012 Existing K8 HOSP Generators: Both Diesel, #1 Generac 177 kW (installed 2000), #2 Catapillar 500 kW (installed 2007) FACP: Simplex 4100 (installed 2006) Locking Devices: Magnetic full time only in the Psych. Unit Smoke Detection: Corridor Beds: 35 Census: 15 Type of Structure: 1960, 04/28/2004 single story unprotected noncombustible, Type II (000). The building has a complete automatic sprinkler system. During an initial conversion survey conducted on this date, the requirements of 42 CFR, Subpart 482.41 were not met as evidenced by the following deficiencies of the 2012 NFPA 101 Life Safety Code (LSC), the 2012 NFPA 99 Health Care Facilities Code and the standards referenced by these codes, as observed by the LS Surveyors while accompanied by the facility maintenance personnel.”

“Doors with Self-Closing Devices CFR(s): NFPA 101 Doors with Self-Closing Devices Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of: * Required manual fire alarm system; and * Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and * Automatic sprinkler system, if installed; and * Loss of power. 18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8 This Standard is not met as evidenced by: 42853 Based on observation, the facility failed to maintain the magnetic hold open devices for multiple sets of smoke doors and fire doors per the requirements of: 2012 NFPA 101, 19.2.2.2.7, and 7.2.1.8.2(4) This deficiency affects 6 of 8 cross-corridor smoke/fire doors. Findings include: During a tour of the facility, the surveyor observed the magnetic hold open devices for 6 of the cross-corridor smoke/fire doors failed to release during loss of power to the fire alarm system. The two set of smoke cross-corridor smoke doors for the Psych.Unit did performed as designed. A member of the maintenance staff was present when this deficiency was identified.”

“Gas and Vacuum Piped Systems - Other CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Other List in the REMARKS section any NFPA 99 Chapter 5 Gas and Vacuum Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. Chapter 5 (NFPA 99) This Standard is not met as evidenced by: 41792 Based on observation, the facility failed to maintain the Operating Room smoke evacuation/WAGD system per the requirements of: 2012 NFPA 99, 5.1.3.7.7, and 5.1.3.8 This deficiency affects 2 of 2 Operating Rooms (OR). Findings include: During a tour of the facility, the surveyor could not verify that the smoke evacuation system or WAGD system continued to operate in OR’s 1 and 2 after the activation of the fire alarm system using smoke aerosol on the smoke detector in OR 1. A member of the maintenance staff was present when this deficiency was identified.”

“Gas Equipment - Cylinder and Container Storag CFR(s): NFPA 101 Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum “CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING.” Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99) This Standard is not met as evidenced by: 41792 Based on observation, the facility failed to maintain the oxygen cylinders per the requirements of: 2012 NFPA 99, 11.6.5.4 This deficiency affects 1 of 1 outside oxygen cylinder storage area. Findings include: During a tour of the facility, the surveyor observed the oxygen cylinders in the outside oxygen cylinder storage area were not protected from continuous exposure to direct rays of the sun where extreme temperatures prevail. A member of the maintenance staff was present when this deficiency was identified.”