Baptist Health Medical Center-Stuttgart

“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: 48468 Based on observation and interview it was determined that the facility was not maintained in a clean and sanitary environment in that: A During tour of the Medical-Surgical Unit on 07/30/2025 between 1:00-2:00 Pm it was observed that 1.The call light outside the doors had black substances on the walls in Room 219 2. Room 219 had black substance on air unit and ceiling tiles 3 In room 225 there was residue on the bathroom door, a brown-red stain on the wall, the paint on the walls was bubbling and peeling away and there was a black/grey residue on the vents of the air-conditioning unit. 4 In room 209 there was rust in the tub, black stains on six ceiling tiles, black substance under the light switch, water pooled in the light fixture in the ceiling, and a black/grey residue on the vents of the air-conditioning unit. 5 In room 212 there was water pooling in the overhead light fixture above a patient in bed. 6 Throughout the unit the air-conditioning units had a black/grey buildup on all the vents. 7 There was an odor of wetness throughout the unit 8 The findings in A were confirmed in interview with the Director of Maintenance The failed practice promoted the spread of infection and had the likelihood to affect all patients in the facility. See A-701.”

“INFECTION PREVENTION CONTROL ABX STEWARDSHIP CFR(s): 482.42 The hospital must have active hospital-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 collaboration with the hospital-wide quality assessment and performance improvement (QAPI) program. This Condition is not met as evidenced by: 47891 Based on observation and interview it was determined that the facility was not maintained in a clean and sanitary environment in that: A During tour of the Medical-Surgical Unit on 07/30/2025 between 1:00-2:00 Pm it was observed that 1 The crash cart had rust on the top and along the edges 2 In the anteroom to rooms 225 and 226 there were dead bugs on the countertop and under the sink. 3 In room 225 there was residue on the bathroom door, a brown-red stain on the wall, the paint on the walls was bubbling and peeling away and there was a black/grey residue on the vents of the air-conditioning unit. 4 In room 209 there was rust in the tub, black stains on six ceiling tiles, black substance under the light switch, water pooled in the light fixture in the ceiling, and a black/grey residue on the vents of the air-conditioning unit. 5 In room 208 a dirty washcloth left in the shower, paint bubbling and peeling by the window and door, water pooling in the overhead light fixture, and a black/grey residue on the vents of the air-conditioning unit. 6 In room 210 there was water flowing from the overhead light fixture on to a chair and the floor and there was a black/grey residue on the vents of the air-conditioning unit. 7 In room 212 there was water pooling in the overhead light fixture above a patient in bed. 8 Throughout the unit the air-conditioning units had a black/grey buildup on all the vents. 9 There was an odor of wetness throughout the unit 6 The findings in A were confirmed in interview with the Pharmacist in Charge and Infection Control Senior Preventionist. The failed practice promoted the spread of infection and had the likelihood to affect all patients in the facility. See A-750.”

“PHARMACY: REPORTING ADVERSE EVENTS CFR(s): 482.25(b)(6) Drug administration errors, adverse drug reactions, and incompatibilities must be immediately reported to the attending physician and, if appropriate, to the hospital’ s quality assessment and performance improvement program. This Standard is not met as evidenced by: 31039 Based on review of policy, review of Medication Occurrences, review of Clinical Records and interview, it was determined the Facility failed to assure evidence of medication errors, notification to the practitioner and any interventions the practitioner ordered were recorded, in four (#21, #22, #24 and #25) of six (#20-#26) patient’s clinical records reviewed where a medication error occurred. The failed practice did not ensure the clinical record would reflect: 1. exactly what happened in the course of the patient’s treatment, 2. medication errors were recorded, 3. notification to the practitioner and 4. any interventions the practitioner ordered after the error. Also, had these patients needed to be transferred to a higher level of care, their records would not have given the next care providers a clear and accurate picture of these patients’ medical history. The failed practice had the likelihood to affect any patients who received a medication error. The findings follow: A. Record review of the facility’s policy titled, “Safety Event Reporting System,” approved November 2024, showed when a medication error occurred, documentation in the clinical record should include a description of the event to include what happened, the patient’s condition, physician notification, and any interventions ordered. B. Review of Medication Occurrences for the previous 3 quarters (October 2024- June 2025) showed the following six patient’s had medication errors and were reviewed: patient #20 on 10/24/24, patient #21 on 11/17/24, patient #22 on 11/19/24, patient #23 on 12/11/24, #24 on 3/1/25 and patient #25 on 4/4/25. C. Review of the clinical records showed patients #21, #22, #24 and #25’s clinical records did not contain evidence of the medication errors, notification to the practitioner or any interventions the practitioner ordered. D. During an interview on 07/30/25 at 3:03 PM, the Director of Pharmacy verified the findings at A, B, and C.”

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 48468 Based on observation of the kitchen, emergency department, laundry room., med surgery and interview, it was determined the facility failed to maintain the building physical structure, safety, environment, and equipment in a state of good repair. The failed practice promoted the spread of infection and/or placed the patients at risk of fire. The failed practice had the likelihood to affect all patients, staff and visitors, Finding follow: A. Observation of the kitchen on 07/28/2025 at 1:25 PM showed rusted and dirty vents in sitting area. B. Observation of the trauma one in emergency department on 7/28/2025 @ 1:31 PM showed vents needed cleaning. C. Observation of the Med Surgery on 07/28/2025 @ 1:55 PM a wheelchair was blocking an electrical panel D. Observation of the Operating Room halls on 07/28/2025 @ 2:24 PM no exhaust fan was functioning correctly E. Observation of the conference room 2 on 7/28/2025 @ 2:30 PM has water stains on ceiling tiles F. Observation of the laundry room on 07/29/2025 @ 9:25 AM water stain ceiling tiles all over G. Observation of hospital on 7/29/2025 @10:00 AM throughout the hospital the peeling of the wall was coming apart H. The findings A-F were verified by the Director of Maintenance on 07/29/2025 at the time of observation.”

“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: 47891 Based on observation and interview it was determined that the facility failed to maintain the Labor and Delivery nutrition and supply room in a sanitary manner. This promoted the spreading of infectious material to patient care supplies. The failed practice had the likelihood to affect all patients receiving care in the labor and delivery unit. The failed practice had the likelihood to affect all patients on the Labor and Delivery Unit. Findings follow: A During tour of the Labor and Delivery Unit on 01/29/2025 at 10:30 AM it was observed that there was a room with both patient nutrition and clean supplies. The clean supplies were in close proximity the coffee maker and trash can. It was observed that there were dark stains on the supplies wall. B The findings in A were confirmed with the Pharmacist in Charge. Based on observation and interview it was determined that the facility was not maintained in a clean and sanitary environment. The failed practice did not ensure that the patients in the Medical-Surgical unit were not exposed to potential infectious material. The failed practice had the likelihood to affect all patients receiving care on the Medical-Surgical Unit. Findings follow: A During tour of the Medical-Surgical Unit on 07/30/2025 between 1:00-2:00 Pm it was observed that 1 The crash cart had rust on the top and along the edges 2 In the anteroom to rooms 225 and 226 there were dead bugs on the countertop and under the sink. 3 In room 225 there was residue on the bathroom door, a brown-red stain on the wall, the paint on the walls was bubbling and peeling away and there was a black/grey residue on the vents of the air-conditioning unit. 4 In room 209 there was rust in the tub, black stains on six ceiling tiles, black substance under the light switch, water pooled in the light fixture in the ceiling, and a black/grey residue on the vents of the air-conditioning unit. 5 In room 208 a dirty washcloth left in the shower, paint bubbling and peeling by the window and door, water pooling in the overhead light fixture, and a black/grey residue on the vents of the air-conditioning unit. 6 In room 210 there was water flowing from the overhead light fixture on to a chair and the floor and there was a black/grey residue on the vents of the air-conditioning unit. 7 In room 212 there was water pooling in the overhead light fixture above a patient in bed. 8 Throughout the unit the air-conditioning units had a black/grey buildup on all the vents. 9 There was an odor of wetness throughout the unit 10 The findings in 1-7 were confirmed in interview with the Pharmacist in Charge and Infection Control Nurse. 11 In Sterile Supply there were corrugated boxes storing items. 12 In Operating Room (OR) #1 there was a used face mask on the anesthesia cart. 13 The doors to OR #1 were worn and bare wood exposed meaning they cannot be disinfected. 14 After the terminal clean none of the equipment was moved to clean supply. 15 During a terminal clean of OR #1 the technician dipped a used cloth into the cleaning solution bucket and reused the same cloth after cleaning the wheels of a gurney and after dusting high surfaces the technician shook the duster in hte room disbursing the dust and debris throughout the OR. Throughout this cleaning mobile surfaces were not relocated to allow sanitzation of the floor under same objects. 16 A stainless steel cart had a plank of rotted wood under it. 17 The findings in 11-16 were confirmed with the Senior Infection Preventionist.”

“EMERGENCY SERVICES CFR(s): 482.55 The hospital must meet the emergency needs of patients in accordance with acceptable standards of practice. This Condition is not met as evidenced by: 47891 Based on clinical record review, policy review and interview, it was determined the facility failed to have a policy in place to determine the stability of patients presenting to the Emergency Department when commonly required emergency services were not available for one of one (#1) patients. The failed practice placed the patients at risk of complications of pregnancy and had the likelihood to affect all obstetrical patients seen in the Emergency Department. Findings follow: See A-1104 for details.”

“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: 47891 Based on clinical record review, policy review and interview, it was determined the facility failed to have a policy in place to determine the stability of patients presenting to the Emergency Department when commonly required emergency services were not available for one of one (#1) patients. The failed practice placed the patients at risk of complications of pregnancy and had the likelihood to affect all obstetrical patients seen in the Emergency Department. Findings follow: A. Review of the facility’s policy titled, ‘Protocol for Triage of the Obstetric Woman” with an approval date of 12/2024 showed, “Women who are at less than 20 weeks gestation or with a non-obstetric emergency will be triaged in the main emergency department unless the Obstetric (OB) Provider requests triage in the labor and delivery department for assessment and observation. Regardless of the presenting complaint, care of the pregnant woman includes assessment of the fetus.” B. Review of Patient #1’s 05/25/2025 (Saturday) clinical record showed the following: 1) At 8:24 AM, Arrival complaint was “5 weeks, spotting, cramping.” 2) At 8:48 AM, Physician #1 Medical Screening Exam showed, “I provided an appropriate medical screening exam to the patient: An emergency medical condition exists. This visit is: Emergent.” 3) At 9:48 AM, Chief complaint updated showed, “Abdominal cramping, pregnancy.” 4) At 9:49 AM, ED Triage Note showed, “Pt (patient) states that she has had some ongoing cramping and spotting, was told by fertility doctor that if cramping became too severe to be evaluated; pt states she would like her HCG levels checked, reports 5 weeks gestation.” 5) At 9:50 AM, pain was documented as a “4-moderate pain.” 6) At 10:04 AM, “Lab - hCG, quantitative, pregnancy” was ordered. 7) Physician #1 note at 10:04 AM showed, “Chief complaint: pregnancy, abdominal cramping. Vaginal bleeding during pregnancy. Quality: spotting. Severity: moderate. Onset quality: sudden. Duration: 1 day. Timing: constant. Progression: unchanged. Chronicity: new. Prior pregnancy: no. Pregnancy confirmed by ultrasound: no. Gestational age: 5.5 weeks. Prenatal care: no prenatal care. Number of pads used: 1. Number of tampons used: 0. Context: at rest and spontaneously. Not after bowel movement, not after intercourse, not after urination, not during bowel movement, not during intercourse not during urination and not genital trauma. Relieved by: nothing. Worsened by: nothing. Ineffective treatments: none tried. Associated symptoms: abdominal pain, no back pain, no dizziness, no dyspareunia, no dysuria, no fatigue, no fever, no nausea and no vaginal discharge. Abdominal pain: Location: L (left) flank and R (right) flank; Quality: cramping; Severity: mild; Onset quality: sudden; Duration: 1 day; Timing: constant; Progression: unchanged; Chronicity: new. Risk factors: no bleeding disorder, no gynecological surgery, no hx (history) of ectopic pregnancy, no hx of endometriosis, does not have multiple partners, no new sexual partner, no ovarian cysts, no ovarian torsion, no PID (pelvic inflammatory disease), no prior miscarriage, no STD (sexually transmitted disease), no STD exposure, no terminated pregnancy and no unprotected sex. Mr. (Ms.) (Patient #1) is an otherwise healthy 36-year-old female who arrives to the emergency room from home via POV (privately owned vehicle). Pt states that she has had some ongoing cramping and spotting, was told by fertility doctor that if cramping became too sever to be evaluated; pt states she would like her HCG levels checked, reports 5 weeks gestation. Past surgical history: cesarean section , classic 3; tubal ligation; wrist surgery. Gastrointestinal: abdominal cramping. Genitourinary: spotting on pads noted. Physical exam: Vitals: Patient is afebrile vitals signs are stable and within normal limits. General: She is not in acute distress. Appearance: Normal appearance. She is obese. She is not ill-appearing, toxic-appearing or diaphoretic. Procedures: none. ED Course: HCG quant: 989.5. HCG ranges 2 to 4 weeks gestational age. This is consistent with the patient’s dates. Clinical Impression: Threatened abortion. Medical Decision Making: Patient presents with early term cramping and spotting at 5 weeks gestational age pregnancy. She was told by the nursing staff of her fertility doctor to come to the emergency room to get checked out. UA (urinalysis) and urine pregnancy test both were normal showing that the patient is still pregnant. A beta hCG test was performed on the serum and the value was 989 which indicates that the patient is between 2 and 4 weeks gestational age. The cutoff for 5 weeks being 1000. Patient is informed of the news and is told to follow-up with her fertility specialist and to establish care with an OB/GYN to follow the pregnancy. She is medically stable and is discharged home. Problems addressed: Threatened abortion: undiagnosed new problem with uncertain prognosis. Risk Details: Patient to follow-up with her fertility specialist or establish care with an OB/GYN, she is to return to the emergency room if her symptom persist or worsen. Assessment/Plan: Patient with a threatened abortion based upon history and presentation. UA and urine pregnancy test were both normal and the patient still showing as pregnant on the urine pregnancy test. A serum beta hCG was performed for comparison purposes with her fertility specialist. It was 989 which is consistent with a 2 to 4-week gestational age pregnancy. Patient is instructed to follow-up with her fertility specialist and establish care with an OB/GYN to follow the pregnancy. She is to return to the emergency room for symptoms persist or worsen. She is medically stable and is discharged home. (Physician #1) 05/25/24 1051 (10:51 AM). Discharge Instructions: Body in the early term of pregnancy is usually indicative of what we as physicians called a threatened abortion. This does not mean that you have miscarried the child in fact your urine test still shows that you are pregnant and a quantitative hCG shows that you are between 2 and 4 weeks gestational age. The value is 989. Typical pregnancy at 5 weeks should be 1000. Your urinalysis was negative for any infection. I recommended you follow-up with your fertility doctor for continued care. In addition you will need to get an OB/GYN who will be the doctor that will deliver the baby. If her condition worsens please feel free to return to the emergency room for further evaluation.” 8) At 10:41 AM, hCG lab resulted of 989.5 mIU/mL (milli-international units per milliliter). 9) At 10:50 AM, Patient Discharged. 10) At 10:50 AM, “Departure Condition” showed, “Departure Condition: Good; Mobility at Departure: Ambulatory; Patient Teaching: Discharge instructions reviewed, follow-up care reviewed, patient verbalized understanding; Patient discharged to: Home.” 11) There was no evidence of any ultrasound or imaging completed on Patient #1 for further assessment. There was no evidence that the medical decision making considered an ectopic pregnancy. C. Review of Patient #1’s 05/30/2025 (Thursday) clinical record showed the following: 1) At 5:52 PM, Arrival complaint: 5-6 weeks pregnant - bleeding 2) At 6:37 PM, Physician #3 Medical Screening Exam, “I provided an appropriate medical screening exam to the patient. An emergency medical condition exists. This visit is: Emergent.” 3) At 6:37 PM, Chief Complaints Updated: Vaginal bleeding. 4) At 6:39 PM, pain was documented as “1-mild pain.” 5) At 6:37 PM, ED Triage Note showed, “Patient states she is pregnant, started having vaginal bleeding-spotting since 05/24.” 6) At 6:41 PM, Pregnancy last 6 weeks showed, “Are you having headaches unresolved by Over-the-Counter medications?: No Are you experiencing double vision, floaters, spots, decreased vision, or tunnel vision?: No Are you experiencing RUQ (right upper quadrant)/epigastric pain?: No. Postpartum Hemorrhage: Are you using one or more pads per hour?: No. Have you been pregnant in the last 6 weeks?: Yes.” 7) Physician #2 note at 6:49 PM (electronically signed at 7:53 PM) showed, “Chief Complaint, Patient presents with: Vaginal bleeding. 36 - year-old female currently 5 to 6 weeks pregnant presents with complaint of vaginal bleeding. Moderate discomfort at the pelvic region. Bright red bleeding. Utilizes 1 pad today. 3 previous pregnancies. Throat (?) with a different partner. History of tubal reversal. Vaginal Bleeding: Quality: Bright red; Severity: Moderate; Onset quality: Gradual; Duration: 24 hours; Timing: Intermittent; Progression: Unchanged; Chronicity: New; Menstrual history: Regular; Number of pads used: 1; Possible pregnancy: yes; Context: spontaneously; Relieved by: Nothing; Worsened by: Nothing; Ineffective treatments: Rest; Associated symptoms: no dysuria, no fever, no nausea and no vaginal discharge; Risk factors: gynecological surgery (Tubal reversal) and new sexual partner; Risk factors: no bleeding disorder and no prior miscarriage. Past surgical history: Procedure: Cesarean section, classic 3; Tubal ligation; wrist surgery. Genitourinary: Positive for vaginal bleeding. Negative for dysuria and vaginal discharge. Clinical Impression: Threatened abortion. Medical Decision Making: Suspected IUP at 5 to 6 weeks; Abnormal uterine bleeding; History of tubal ligation reversal; New partner; Afebrile; No vaginal discharge; No dysuria. Assessment/ Plan: (Patient #1) is a 36 y.o. (year-old) female diagnosed today with: Final diagnoses: Threatened abortion; Patient relatively asymptomatic, just wanted to recheck her quantitative hCG, last 1 done on 5/25, was 989. Last menstrual cycle was 4/20, which puts her at about 3 and half to 4 weeks prior. Patient was advised to follow up with (Named Physician). Schedule an appointment as soon as possible for a visit in 3 days as needed, if symptoms worsen, Post Hospitalization. Stuttgart ER, 1703 North Buerkle, Stuttgart Arkansas 72160 (Phone number provided) As needed, If symptoms worsen. (Physician #2) 05/30/24 1953.” 8) At 7:49 PM, HCG result was 1,077.3 mIU/mL. 9) At 7:53 PM, Discharge Condition showed, “Departure Condition: Good; Mobility at Departure: Ambulatory; Patient Teaching: Discharge instructions reviewed; Patient verbalized understanding; Patient discharged to: Home; Form of transportation: Patient driving; Accompanied by: Alone.” 10) At 7:54 PM, Patient #1 was discharged. 11) There was no evidenceof any ultrasound or imaging completed on Patient #1 for further assessment. There was no evidence that the medical decision making considered an ectopic pregnancy. D. During an interview with Physician #2 on 04/15/2025 at 12:00 PM showed the following when asked: 1) What is the process for treating a woman of child-bearing age presenting with abdominal pain and bleeding or spotting? He stated he would obtain vital signs including pulse, blood pressure, oxygen saturation. He would determine if they were stable or unstable. He would find out how long it’s been since their last ultrasound. He would determine the severity of bleeding along with their past medical history. 2) After reviewing Patient #1’s clinical record, would you have treated Patient #1 any differently? He stated the only thing different would have been to do an ultrasound, but the ultrasound tech isn’t there 24 hours a day. The ultrasound tech isn’t available on weekends or after normal business hours. E. During an interview with Physician #1 on 04/15/2025 at 3:00 PM and on 04/16/2025 at 8:05 AM, showed the following when asked: 1) Do you utilize or follow any protocols or guidelines in the ED? Do you utilize any standing order sets in the ED for OB patients? He stated he used ACOG (The American College of Obstetricians and Gynecologists) 2018 guidelines and stated he had access to them on his phone. 2) Do you utilize any standing order sets in the ED for OB patients? He stated yes, but not in this (Patient #1) specific situation. Specific orders were placed in EPIC. 3) What is the process for treating a woman of child-bearing age presenting with abdominal pain and bleeding or spotting? He stated he would establish the term of pregnancy, whether it’s the first child or not, gather the patient’s background and past OB history, and establish a rough estimate of gestational age then decide the next steps to take. He stated he did not have ultrasound available on the weekend or after normal working hours. He stated he can perform an HCG test. He stated he would have to establish whether there is a threatened abortion or ectopic pregnancy. If there might have been a threatened abortion, then let it take it’s course. If the HCG was positive, then have the patient follow up with fertility doctor or OB/GYN. He would draw a baseline HCG. He stated per ACOG guidelines, if the HCG doubles in two days, then it’s probably a normal intrauterine pregnancy. If it doesn’t double, then it’s a possible ectopic pregnancy. 4) After reviewing Patient #1’s clinical record, would you have treated Patient #1 any differently? He stated with Patient #1, her vital signs were normal and there was nothing on her exam that she was in any danger. He stated he told her she could always come back to the ER for further assessment. He stated ultrasound isn’t available on weekends or after normal working hours. He stated he wasn’t trained in performing ultrasounds on pregnant women due to the fact it required specialized training. F. In an interview with the ER (Emergency Room) Manager on 04/15/2025 at 4:10 PM, when asked if ultrasound was available to the ER physicians she stated there was an ultrasound machine available in the ED. If the physician is comfortable to do the ultrasound then they can. Some physicians aren’t comfortable doing ultrasounds. When asked if transvaginal ultrasound was available in the ER, she stated it wasn’t available. She stated that if the patient was emergent, they could be transferred out, and if they weren’t emergent, the patient could wait to receive an ultrasound the next morning. She stated it was determined by the physician.”

“QAPI EXECUTIVE RESPONSIBILITIES CFR(s): 482.21(e)(1), (e)(2), (e)(5) The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: 1) That an ongoing program for quality improvement and patient safety, including the reduction of medical errors, is defined, implemented, and maintained . (2) That the hospital-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety and that all improvement actions are evaluated. (5) That the determination of the number of distinct improvement projects is conducted annually. This Standard is not met as evidenced by: 31039 Based on review of Medical Staff Bylaws, review of Quality Review Committee Meeting Minutes and interview, it was determined the Governing Body failed to ensure the bylaws of the facility were implemented in that the Quality Review Committee failed to meet five (October and December 2023 and February, March and May 2024) out of twelve (June 2023 through May 2024) months reviewed. By not meeting monthly, it delayed all the recommendations to the Governing Body pertaining to the quality assurance tasks of the Staff and review and evaluation of the quality of the medical and hospital care. The failed practice had the likelihood to affect all patients that receive treatment and care in the facility. Findings follow: A. Record review of the Medical Staff Bylaws, dated 2023, showed the committee was to meet monthly or more often as necessary. B. Record review of the Quality Review Committee Meeting Minutes for the previous twelve months (June 2023 through May 2024) showed the October and December 2023 and February, March and May 2024 meetings were missed. C. During an interview on 06/25/2024 at 10:37 AM, the Associate Director of Nursing verified the findings at B and stated they switched to quarterly meetings after the August 2023 meeting. The Medical Staff Bylaws had not been updated and approved, prior to the Quality Review Committee deciding to decrease the frequency of their meetings.”

“PHARMACY ADMINISTRATION CFR(s): 482.25(a) [§482.25 Condition of Participation: Pharmaceutical Services .....The medical staff is responsible for developing policies and procedures that minimize drug errors. This function may be delegated to the hospital’s organized pharmaceutical service.] §482.25(a) Standard: Pharmacy Management and Administration The pharmacy or drug storage area must be administered in accordance with accepted professional principles. This Standard is not met as evidenced by: 31039 Based on review of policy, review of Pyxis Medstation Controlled Drug Activities Verification Log, and interview, it was determined the facility failed to adhere to policy in that two (Medical/Surgical and Emergency Room) of three (Medical/Surgical, Emergency Room and Obstetrics) Pyxis Medstations had missing Charge Nurse signatures. By not signing the Pyxis Medstation Controlled Drug Activities Verification Log at the end of each shift, the facility could not assure nurses were not leaving the building while there were pending discrepancies that should have been resolved, to prevent theft, loss and diversion. The failed practice had the likelihood to affect all patients in the hospital. Findings follow: A. Record review of the facility’s policy “Automated Dispensing Cabinet” approved January 24, 2024, showed the Charge Nurse was to review the Controlled Substance Activity reports for all users at the end of the shift. The Charge nurse was to sign and indicate on the Verification Log that the reports had been reviewed and was to report any irregularities to the Shift Supervisor or Unit Supervisor for further investigation. B. Review of the Pyxis Medstation Controlled Drug Activities Verification Logs for Medical/Surgical and Emergency Room for the month of June 2024 (June 1st through June 23) showed the following missing Charge Nurse shift signatures: 1. Emergency Room 7 AM to 7 PM: 6/3, 6/4, 6/7, 6/8, 6/9, 6/12, 6/13, 6/17, 6/18, 6/21 and 6/22; 2. Emergency Room 7 PM to 7 AM: 6/3, 6/15, 6/16 and 6/23; 3. Medical/Surgical 7 AM to 7 PM: 6/3; and 4. Medical/Surgical 7 PM to 7 AM: 6/9 and 6/13. C. During an interview on 06/24/24 at 10:20 AM, the Director of Pharmacy verified the findings at B.”

“DELIVERY OF DRUGS CFR(s): 482.25(b) §482.25(b) Standard: Delivery of Services In order to provide patient safety, drugs and biologicals must be controlled and distributed in accordance with applicable standards of practice, consistent with Federal and State law. This Standard is not met as evidenced by: 31039 Based on review of Rules for Hospitals and Related institutions in Arkansas, review of Postpartum Hemorrhage Cart Checklist and interview, it was determined the facility failed to check the integrity of the seal at the beginning of each shift (per Rules) for one of one (Postpartum Hemorrhage Cart) kit observed on tour. The potential existed for the emergency medication kit not to have medications present for patient emergencies. The failed practice had the likelihood to affect all patients who needed medications in an emergency. Findings follow: A. Record review of Rules for Hospitals and Related institutions in Arkansas, effective June 20, 2022, showed applicable personnel shall check the cart for the integrity of the seal each shift. Documentation shall reflect that the seal is intact. B. Record review of the Postpartum Hemorrhage Cart Checklist showed the checklist was to be completed weekly on Tuesdays. The checklist started in December of 2023 and the last check was June 18, 2024. The signatures were weekly. C. During an interview on 03/25/24 at 2:30 PM, the Director of Quality/ Stroke Co-Ordinator verified the integrity of the seal to the Stroke emergency medication kit was not being checked each shift.”

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 47688 Based on observation of the Emergency Department, Inpatient Facilities, Obstetrics Unit, and Operating Rooms and interview, it was determined the facility failed to maintain the building physical structure, safety, environment, and equipment in a state of good repair. The failed practice promoted the spread of infection and/or placed the patients at risk of fire. The failed practice had the likelihood to affect all patients, staff and visitors. Findings follow: A. Observation of the Emergency Department on 06/24/24 showed the following: 1) at 10:51 AM, peeling paint in Emergency Room (ER) room 3 2) at 10:51 AM, dirty exhaust vents in ER room 3 3) at 10:54 AM, peeling paint in ER room 4 5) at 10:57 AM, door frame damage in ER room 2 6) at 10:58 AM, missing air conditioning vent and exhaust vent in Biohazard Room 7) at 11:00 AM, exposed wood under supply room sink 8) at 11:05 AM, peeling material around nurses station. B. The findings in A were verified by the Head of Maintenance on 06/24/24 at the time of observation. C. Observation of the Inpatient Department on 06/24/24 showed the following: 1) at 9:52 AM, door frame damage in room 217 2) at 9:52 AM, uncovered linen in the linen closet located in front of the nurses station 3) at 9:53 AM, food tray located in the soiled utility room 4) at 9:54 AM, exposed cooling pipes in linen closet 5) at 10:00 AM, broken electrical socket in bathroom of room 213 6) at 10:01 AM, calcium buildup around sink in room 212 7) at 10:02 AM, wall damage next to air conditioner in room 212 8) at 10:13 AM, electrical socket damaged in hallway leading into East Hall 9) at 10:15 AM, damaged fire doors in the East Hall 10) at 10:16 AM, mold located on the inside wall of the EV room in the east hall 11) at 10:16 AM, large hole in the inside wall of the EV room in the east hall 12) at 10:16 AM, wallpaper peeling and wall damage on the outside wall of the EV room in the east hall 13) at 10:18 AM, broken base board at the the bottom of fire doors leading into labor and delivery D. The findings in C were verified by the Head of Maintenance on 06/24/24 at the time of observations. E. Observation of the Obstetrics Unit on 06/24/24 showed the following: 1) at 10:39 AM, Peeling material around the nurses station F. The finding in E was verified by the Head of maintenance on 06/24/24 at the time of observation. G. Observations of the Operating Rooms (OR) on 06/24/24 showed the following: 1) at 2:12 PM, paint damage in OR 2 2) at 2:30 PM, emergency doors leading to operating rooms did not latch 3) at 2:32 PM, peeling baseboard outside of OR 3 H. The findings in G were verified by the Head of maintenance on 06/24/24 at the time of observation.”

“LIFE SAFETY FROM FIRE CFR(s): 482.41(b) Life Safety from Fire This Standard is not met as evidenced by: 47688 Based on observation, review of National Fire Protection Association (NFPA) 101 standards and interview, it was determined the facility failed to ensure that the generator was maintained in that an emergency stop switch was not installed on the generator and there was no battery powered emergency light installed on the generator. The failed practice did not ensure the facility had the means of stopping the generator in the event of an emergency, the generator would be able to run in the event of an emergency and did not ensure the facility staff had the ability to view the generator in the event of an emergency. The failed practice had the likelihood to affect all patients, visitors and staff in the facility. Findings follow: A. Review of NFPA 101 standards showed the facility was to provide battery-powered emergency lighting as required by NFPA 101, 2012 edition. B. On 06/25/2024 at 10:15 PM observation of the emergency generator showed there was no covered emergency stop switch installed 10 to 15 feet away from the generator. C. On 06/25/2024 at 10:12 PM, observation of the emergency generator showed there was no battery powered emergency light installed on the generator. D. The findings in A through C were verified by the Head of Maintenance on 06/25/2024 at the time of the observations.”

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 47891 Based on observation and interview, it was determined that the facility failed to maintain a sanitary environment in that 15 doors to patient rooms on the Medical Surgical Unit were worn to bare wood, had holes, and/or had unfinished wooden plugs. The failed practice did not ensure the doors could be disinfected due to the porous nature of the wood. The failed practice had the likelihood of affecting all patients cared for in these rooms. Findings follow: A. Observation of the Medical Surgical Unit on 6/24/2024 showed all patient room doors were worn to bear wood and had either holes left open in the door or the holes had been plugged with unfinished wooden plugs. B. The findings in A were confirmed during an interview with Assistant Director of Nursing at 9:50 AM on 6/24/2024. Based on observation and interview, it was determined that the facility failed to ensure tape residue was not present on the walls and doors of Room 216, 217 and 222. The failed practice did not ensure the walls and doors could be disinfected due to the sticky nature of the tape residue. The failed practice had the likelihood to affect all patients admitted to these rooms. Findings follow: A. Observation of Room 216 and 217 on 6/24/2024 at 10:10 AM showed peeling tape holding up signs on the wall inside the patient rooms. B. Observation of Room 222 showed there was a sign on the bathroom door held by peeling tape. C. The findings in A and B were confirmed in an interview with the Assistant Director of Nursing at 10:10 AM on 6/24/2024. Based on observation and interview, it was determined the facility failed to ensure the linen in the linen closet on the Medical Surgical Unit was covered. Failure to keep the linens covered did not prevent transmission of dust debris and infectious material. The failed practice had the likelihood to affect all patients who were receiving linen from the linen closet. Findings follow: A. Observation of the linen closet on the Medical Surgical Unit at 9:53 AM on 6/24/2024 showed the linen were stored on shelves with no covering over the sides. B. The findings in A were confirmed during an interview with the Assistant Director of Nursing at 9:53 AM on 6/24/2024. Based on observation and interview, it was determined the facility failed to ensure a sanitary environment in that behind the Newborn Nursery door there was red colored discoloration and a large spider web with a live spider. The failed practice promoted the spread of infection and had the likelihood to affect all patients receiving care in the newborn nursery. Findings follow: A. Observation of the Newborn Nursery at 11:30 AM on 6/24/2024 showed the floor behind the door was discolored and stained with dirt and a red discoloration and a large spider web with a live spider. B. The findings in A were confirmed during an interview with the Assistant Director of Nursing at 11:30 AM on 6/24/2024. Based on observation and interview, it was determined the facility failed to maintain a sanitary environment in that there were three environmental services carts stored in an unmarked room with a leak and a large puddle of water with a dustmop. The pipe in the room contained a black substance. The failed practice promoted the spread of infection and had the likelihood to affect all patients’ rooms in which the carts were used. Findings follow: A. Observation of an unmarked room at 11:45 AM on 6/24/2024 showed three environmental services carts were stored in the room. The room had a leak and a large puddle of water in the corner of the room with a dustmop standing in the puddle. The pipe from which the leak was coming had a buildup of a black substance covering the pipe and insulation. B. The findings in A were confirmed during an interview with the Assistant Director of Nursing at 11:45 AM on 6/24/2024. Based on observation and interview, it was determined that the facility failed to maintain a sanitary environment in that in the laundry area there was a gap between the door jamb and the nearby washer, and the concrete floor was not sealed. Failure to maintain this area promoted the transmission of infectious material to the freshly laundered linens. The failed practice had the likelihood to affect all patients admitted to the facility. Findings follow: A. Observation of the laundry area at 11:40 AM on 6/24/2024 showed there was a gap between a door jamb and the washing machine that allowed dust and debris to flow in from the unfinished area behind the door. B. Observation of the laundry area at 11:40 AM on 6/24/2024 showed the concrete floor was not sealed with did not allow for disinfection due to the porous nature of the concrete. C. The findings in A and B were confirmed during an interview with the Assistant Director of Nursing at 11:40 AM on 6/24/2024.”