Eureka Springs Hospital Commission

“COMPLIANCE WITH 489.24 CFR(s): [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: 51070 Based on review of emergency log, clinical record, and interview, it was determine the facility failed to comply with to comply with the responsibilities of Medicare hospitals in emergency cases §489.24. The failed practice did not ensure patients who presented to the Emergency Department (ED) received appropriate treatment and/or transfer to stabilize their Emergency Medical Condition (EMC) See tag # 2405 and 2407”

“EMERGENCY ROOM LOG CFR(s): [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 51070 Based on review of policy, training materials, emergency log, and interview, it was determined the facility failed to document in the emergency log, one (#1) of twenty five (#1-#25) patients who presented to the Emergency Department (ED) with an emergency medical condition. The failed practice did not allow for the hospital to keep track of individuals seeking care. The failed practice had the likelihood of affecting all patients presenting to the ED. Findings follow: A. Review of policy “Emergency Services”, last revised 03/18/2011, showed “A record shall be kept on every patient who presents to the ED weather treated or not, and shall be entered into the ED log.” B. Review of policy “Emergency Medical Treatment and Active Labor Act (EMTALA) Compliance in the ED” approved 11/14/2013, showed “The ED physician shall assess the individual and determine disposition, emergent or non-emergent. Nursing staff shall not make this determination, either verbally or by charting.” C. Review of training materials “EMTALA with updated COVID-19 Implications” no date, showed that “The hospital must maintain a central log of individuals who come to the dedicated ED seeking treatment and indicate whether these individuals: refused treatment, were denied treatment...or were discharged.” During an interview with the Chief Executive Officer (CEO) on 08/19/25 at 12:58 PM, she confirmed that all new hires are required to take this training. D. Evidence was requested on 08/19/25 at 12:10 PM and again on 08/20/25 at 8:45 AM, which showed all patients who presented to the ED seeking care had been entered into the log and could be tracked. During an interview with Director of Nursing on 08/20/25 at 8:00 AM, she stated a patient had presented to the ED on 07/04/25 with an apparent emergency medical condition but refused to register when the patient and friends were informed the Hospital did not have the treatment requested. She confirmed the staff failed to enter the patients information in the ED log or notify the Physician. E. During an interview with the Chief Executive Officer on 08/20/25 at 9:00 AM, she confirmed the findings in A-D.”

“STABILIZING TREATMENT CFR(s): (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 51070 Based on review of clinical records, the facility failed to provide stabilizing treatment for one (#1) of twenty-five (#1-#25) patients reviewed, who presented with an emergency medical condition (EMC), in that the facility did not ensure the patient’s condition was stabilized prior to discharge or that the patient was transferred to an outside facility with the capability to stabilize the EMC. The failed practice had the likelihood of affecting all patients presenting with an EMC. Findings follow: A. Review of Patient #1’s clinical record showed the following: a) Patient #1, a nursing home resident, was brought in by ambulance for percutaneous endoscopic gastrostomy (PEG) tube dislodgement on 07/03/25 at 4:11 AM. b) A Physician note dated 07/03/25 4:06 AM, showed PEG tubes were not available at Eureka Springs Hospital and that Patient #1’s PEG tube had been out for 2-3 hours. The Physician documented he had attempted several times to place a Foley catheter to keep PEG tube hole open without success. Further, the note showed the Physician contacted Mercy Hospital in Berryville to request transfer but was told they did not have PEG tubes and transfer was denied. The note showed the plan was to “return to nursing home.” No evidence was provided which showed additional stabilizing treatment was given, or that an attempt was made to transfer patient to a different facility with PEG tube placement capabilities. c) Review of orders dated 07/03/25 at 5:51 AM, showed the Physician placed orders for Patient #1 to “follow-up with local MD and transfer to appropriate facility.” d) Review of (Named) Ambulance company’s, computer aided dispatch (CAD) log, dated 07/03/25 at 4:47 AM, showed “Patient is going for PEG tube placement, drop off location showed as Berryville Hospital. A second entry on 07/03/25 at 6:21 AM, showed Eureka Springs Hospital called and advised the new destination for Patient #1 was the Blossoms Nursing Home. After the ambulance began transportation back to nursing home, they received a call that “The Director of Nursing from the Blossoms Nursing Home advised that Patient #1 needed to go to Mercy Hospital in Berryville and that the Nursing Home would fax required forms for transport.” e) During an interview with the Director of Nursing at the Nursing Home where Patient #1 lives, on 08/28/25 at 7:55 AM, she stated “I told the ED doctor in Berryville that I called the ambulance company and told them to take Patient #1 to Berryville since Eureka Springs Hospital doesn’t have a surgeon who could place a new PEG tube.” The Director of Nursing confirmed that a surgeon at Berryville Hospital replaced the PEG tube and discharged the patient back to the Nursing home the following day. B. During an interview with the Chief Executive Officer on 08/21/25 at 9:30 AM, she confirmed Patient #1 had been discharged back to nursing home and that the facility lacked the capability to place a PEG tubes.”

“Discharge planning process. CFR(s): (a)The REH’s discharge planning process must identify, at an early stage of the provision of services, those patients who are likely to suffer adverse health consequences upon discharge in the absence of adequate discharge planning and must provide a discharge planning evaluation for those patients so identified as well as for other patients upon the request of the patient, patient’s representative, or patient’s physician. This Standard is not met as evidenced by: 46733 Based on policy and procedure review, review of the (Electronic Medical Record) EMR template, and interview, the facility failed to have a process in place to document comprehensive discharge planning assessments by a qualified health professional in a timely manner in the medical record. The failed practice did not ensure continuity of care and appropriate follow-up for patients upon their departure from the facility and had the likelihood of affecting all patients in the facility triaged and/or placed on observation in the facility. Findings follow: A. Review of Discharge Planning Policy dated 12/6/24 showed, “Policy Statement-Eureka Springs Hospital is committed to providing safe and effective discharge planning for all patients seeking care, treatment and services. This policy outlines the procedures and responsibilities involved in the discharge planning process to ensure continuity of care and appropriate follow-up for patients upon their departure from the Eureka Springs Hospital to post-discharge care and reduce factors leading to preventable additional healthcare encounters including admissions or readmissions to other facilities. Procedure-1. Discharge Planning Process A) All patients seeking services in the ED (Emergency Department) or placed in observation will undergo an initial assessment to determine their medical condition and treatment requirements. B) Patients identified for discharge needs will receive a comprehensive discharge planning assessment by a qualified professional. Plans of care and discharge plans may be modified as patient care needs change. C) Discharge planning will be patient-centered and individualized based on the patient’s medical condition, social determinants of health and available resources. D) Discharge planning will be completed in a timely manner to ensure that the organization can arrange for the patient’s care needs and avoid unnecessary delays. 3. Documentation-A) All aspects of the discharge planning process will be documented in the patient’s medical record, including assessments, interventions, referrals, and patient education provided.” B. During a review of the EMR template, and interview with the CNO (Chief Nursing Officer) on 2/5/25 at 1:45 PM, the CNO could not provide evidence of a place for documentation in the EMR template for initial and ongoing discharge planning assessments and could not verbalize where in the EMR the assessments should be documented. C. The findings in A and B were confirmed and verified with the CNO, CEO (Chief Executive Officer), and CFO (Chief Financial Officer) at the time of the findings.”

“Provision of services. CFR(s): (a) The REH’s health care services must be furnished in accordance with appropriate written policies that are consistent with applicable state law. This Condition is not met as evidenced by: 50014 Based on policy and procedure review and interview, it was determined that the facility failed to have an eligible and/or board-certified pathologist to oversee the laboratory and a laboratory director per Arkansas State Regulations. The failed practice did not ensure that the laboratory services were being performed under a board-certified pathologist. The failed practice had the likelihood to affect all patients presenting to the hospital. Findings follow: A. Review of Rules for Hospitals and Related Institutions in Arkansas, Section 19 B 2, showed that “The laboratory shall be under the oversight of a pathologist who is board certified or eligible. A pathologist who is not based at the hospital shall make at least a monthly visit and submit a monthly written report to the Hospital Administrator.” B. In an interview with Chief Executive Officer on 11/22/2024 at 8:21 AM, she stated that “on 11/21/2024, the previous Pathology group had terminated their contract with the hospital. We are in the process of making an offer to another pathology group. As of today, we do not have a pathology group or a laboratory director for the laboratory.””

“Laboratory services. CFR(s): The REH must provide basic laboratory services essential to the immediate diagnosis and treatment of the patient consistent with nationally recognized standards of care for emergency services, patient population, and services offered. The REH must ensure that - (a) Laboratory services are available, either directly or through a contractual agreement with a certified laboratory that meets requirements of part 493 of this chapter. (b) Emergency laboratory services are available 24 hours a day. This Condition is not met as evidenced by: 50014 Based on review of personnel files and interviews, it was determined that the facility failed to provide basic laboratory services 24-hours a day based on nationally recognized standards of care. The failed practice did not ensure a timely diagnosis of patients being seen in the hospital. Without a diagnosis for treatment, the patient receiving emergent services had the likelihood for a delayed care. Findings follow: A.Review of Medical Technologist/Medical Laboratory Technician Competency Assessment on 11/22/2024 at 8:25 AM, showed the only employee in the laboratory was a Medical Laboratory Technician who was not competent in the following: 1) Selecting correct tube order. 2) Processing/storing specimens correctly (including spencimens sent to reference laboratory. 3) Performing waived tests according to package insert instructions. 4) Performs non waived kit testing. 5) Understands when to to hold sample for culture. 6) Understands when to hold sample for culture. B. Review of Clinical Laboratory Medical Technician job description dated 05/06/2021, stated the Job summary as “Under the supervision of the Eureka Springs Hospital Laboratory Director and the Laboratory Supervisor, the technician is responsible for the performance of testing and operation of the clinical laboratory services for Eureka Springs Hospital. The Medical Technician is capable of working without direct supervision and he/she adheres to all established policies of the hospital. The technician sees that all results are performed and reported accurately and in a timely manner.” The duties of a Medical Technician as the following: 1) Participates in and directs daily specimien collection and performs requested analyses. 2) Confers regularly withthe Laboratory Supervisor and heeps he/she informed of any problems with equipment, abnormal tests , and/or quality control problems. C. In an interview with the Interim Chief Executive Officer on 11/22/2024 at 8:26 AM, she stated, “as of 11/21/2024 at 7:30 AM, the laboratory medical technician and the Registered Nurses in house are doing laboratory blood draws and a courier service is driving them to Berryville Hospital.” The surveyor asked what would happen if a patient who needed emergent care, that could only be diagnosed through laboratory results, walked in and needed services. She stated, “the laboratory blood work results would not be done in a timely manner.” D. In an interview with Registered Nurse #1 on 11/22/2024 at 8:10 am, he stated, “We are drawing laboratory draws on patients and then couriering them to Berryville Hospital because we do not have anyone in the laboratory qualified to run laboratory tests. We have been on trauma diversion since 11/21/2024 at 7:45 am.” The surveyor asked the nurse what they would do if someone walked in having a possible heart attack, he said, “we would draw a troponin laboratory blood test, however, by the time the results returned from Berryville Hospital, the patient could die.””

“Nursing services. CFR(s): The REH must have an organized nursing service that is available to provide 24-hour nursing services for the provision of patient care. The nursing services must be furnished and supervised by a registered nurse. Nursing services must meet the needs of patients. This Condition is not met as evidenced by: 50014 Based on an interview, it was determined the facility failed to ensure a Registered Nurse, who is responsible for the operation of the services to include determining the types and numbers of nursing personnel to provide nursing care, was directing the nursing services. The failed practice did not ensure a Registered Nurse supervised the care provided in the facility. The failed practice had the likelihood of affecting all patients receiving care in the facilty. See O-604 for details.”

“Nursing leadership. CFR(s): (b)The director of the nursing service must be a licensed registered nurse. The individual is responsible for the operation of the service, including determining the types and numbers of nursing personnel and staff necessary to provide nursing care for all areas of the REH. This Standard is not met as evidenced by: 50014 Based on an interview, it was determined the facility failed to ensure a Registered Nurse, who is responsible for the operation of the services to include determining the types and numbers of nursing personnel to provide nursing care, was directing the nursing services. The failed practice did not ensure a Registered Nurse supervised the care provided in the facility. The failed practice had the likelihood of affecting all patients receiving care in the facilty. Findings follow: In an interview with the Interim Chief Executive Officer on 11/22/2024 at 9:30 AM, she confirmed that there was not a Registered Nurse directing nursing services. She stated, “I am making out the schedules for the staff.” The Interim Chief Executive Officer confirmed she was not a Registered Nurse.”

“Compliance with Federal, state, and local law CFR(s): (a)The REH must be in compliance with applicable Federal laws related to the health and safety of patients. (b) The REH must be located in a state that provides for the licensing of such hospitals under state or applicable local law; and is (1) Licensed in the state as an REH; or (2) Approved as meeting standards for licensing established by the agency of the state or locality responsible for licensing hospitals. (c) The REH must assure that personnel are licensed or meet other applicable standards that are required by state or local laws to provide services within the applicable scope of practice. This Condition is not met as evidenced by: 46733 Based on facility memo review, menu review, policy and procedure review, Quality Assurance Performance Improvement (QAPI) meeting minutes, observation, and interview, the facility failed to maintain food and nutrition services according to the Arkansas State Board of Health Rules for Hospitals in Arkansas section 17, revised on 06/17/24, to meet the individual dietary needs of patients, prepared and stored under the direction of Nutrition Services in accordance with the Rules Pertaining to Retail Food Service Establishments in that meals were being ordered from a local restaurant, not prepared in the facility by qualified staff. This failed practice did not ensure food was served by qualified individuals with knowledge of infection prevention and control measures, safety practices, cleaning of equipment and applicable areas, the patient’s individual caloric and protein needs, pertinent allergies, and food/drug interaction. This failed practice had the likelihood of affecting all patients in the facility who were served meals from the restaurant. Findings follow: A. Review of Memo titled, “Change in Patient Meal Provision” (not dated) showed, “Effective immediately, all patient meals will be provided by (Named) restaurant. Please note the following procedures: Meal Ordering and Observation: Nursing staff will be responsible for ordering meals as needed for patients in an observation status. Meal Pick-up: A designated hospital staff member will be responsible for picking up meals from the restaurant. Temperature Check: Upon arrival, all meals must be temperature-checked to ensure they are safe for consumption. Recording: Temperature checks for all hot meals must be recorded in the nourishment log. Thank you for your cooperation and attention to these new procedures to ensure the safety and comfort of our patients.” B. Review of Menu from (Named) restaurant showed, “Reviewed & approved 09/06/24 by (Named) Registered Dietitian.” C. Review of the Menu from (Named) restaurant showed the following options: Breakfast Choices -1. All American Breakfast, 2. The Breakfast Basics, 3. Veggie Hashbrowns. Lunch and Dinner Choices-1. Turkey Club, 2. Grilled Chicken Sandwich, 3. Grilled Cheese, 4. Hamburger/Cheeseburger, 5. Chicken Strip Dinner. D. Review of Policy and Procedure titled “Patient’s Right for Foodservice” with a review date of 09/06/23 showed, “The Dietary department will respect the patient’s right regarding confidentiality, conflict resolution, cultural/religious beliefs and nutritional care. 1. The Patient has the right to adequate nutritional care during his/her hospital stay. 3. The patient has a right to voice complaints about his/her care including nutritional care. When Dietary receives a complaint, it will be investigated and when possible, resolved. 4. The patient has the right to be served food according to his/her ethnic, cultural, or religious beliefs and diet preferences. An effort will be made to serve Kosher food and other ethnic food when requested by the patient.” E. Review of QAPI Meeting Minutes for the 4th Quarter 2023 dated 01/19/24, showed “Dietary-Everything good except missed one test tray temps, new employee but was trained on procedure. Regulations state that test tray temps need to be done 3 x a week, but since we do not have that many patients, doctor trays will be used unless we have patients. There was also 2 diet to patient tray set up that wasn’t served correctly by CNA (Certified Nursing Assistant) in December, so that made it 95% instead of 100.” The facility could not provide any QAPI Meeting minutes for the first, second and third quarters of 2024. F. Review of Policy and Procedure for Registered Dietitian Monthly Sanitation and Safety Inspections for food service areas showed, “Purpose: To establish guidelines for registered dietitians (RDs) to conduct monthly sanitation and safety inspections in hospital kitchens and/or food service areas ensuring compliance with food safety regulations and maintaining a clean and safe food preparation environment. Scope: This policy applies to all registered dietitians working in the hospital and responsible for conducting inspections in areas that food is assembled for patient meal service.” G. Review of Policy and Procedure for “Hospital Patients Receiving Meals from a Restaurant” showed, “Purpose: To establish guidelines for the introduction of restaurant meals into the hospital environment to maintain, food safety, prevent the spread of infections, and ensure patient well-being. Scope: This policy applies to all patients receiving meals from external restaurants while hospitalized.” H. During an observation in the Emergency Room (ER) Nourishment Room showed expired food and nourishments in a cabinet and the freezer of the refrigerator. For example: xxxxxxxxx I. During an interview with the ER Director on 11/05/24 at 10:20 AM, she stated the facility stopped feeding meals from the kitchen about two months ago but there are still some items available in the kitchen and ER Nourishment Room if needed. She said the facility is ordering food for the patients from “a restaurant across the street.” She said all the Dietary staff resigned. J. During an interview with the Interim CEO (Chief Executive Officer) on 11/06/24 at 2:30 PM, she stated the facility had a “Dietitian available for consult if needed.” She confirmed the facility was ordering food from a restaurant to feed patients as needed and did not provide a contract for the Dietitian. She confirmed the hospital does not have a Nutrition Services Department. K. During an interview with RN #1 on 11/06/24 at 2:15 PM in the Nourishment Room of the ER, he stated and confirmed that when a patient needs food it is ordered from a local restaurant. He also confirmed the presence of snacks for the patients in the ER Nourishment Room. L. During an interview with RN #2 on 11/06/24 at 2:20 PM at the ER nurses’ station he stated and confirmed that when a patient needs food it was ordered from a local restaurant. He also confirmed the presence of snacks for the patients in the ER Nourishment Room.”

“Infect prevent & control & antibiotic steward CFR(s): The REH must have active facility-wide programs for the surveillance, prevention, and control of healthcare-associated infections (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 facility-wide quality assessment and performance improvement (QAPI) program. This Condition is not met as evidenced by: 50014 Based on policy and procedure review, committee meeting minutes review and interview, it was determined that the facility failed to have a facility wide infection prevention and control and antibiotic stewardship program in that the facility failed to ensure: 1. The Infection Control Preventionist had training or certification in infection prevention or control. 2. Daily humidity logs were obtained from the Operating Room. 3. Water temperatures were set at 160 degrees Fahrenheit (F) and water to chlorine bleach ratio was maintained at 150 parts per million (ppm) for contaminated linens 4. Hand hygiene was being monitored in the facility. 5. A sanitary environment was maintained to avoid sources and transmission of infection by ensuring expired supplies were not available for patient use in 1 (#1) of 2 (#1 and #2) Endoscopy Suites. 6. The facility had a facility-wide antibiotic stewardship program. 7. Which nationally recognized guidelines were utilized by the facility for antibiotic usage. 8. Determine as to whether the antibiotic stewardship program met the scope and complexity of the services provided. 9. A system was in place for tracking infections and antibiotic usage or a system was in place for reporting the information to the Quality Assessment and Performance Improvement (QAPI) committee. 10. Policies and procedures were developed and implemented based on nationally recognized guidelines. 11. Communication and collaboration with the Quality Assessment and Performance Improvement (QAPI) program. 12. Infection prevention and control education and training was provided to facility staff. 13. Communication and collaboration with the antibiotic stewardship program. The failed practices promoted the spread of infection and did not ensure the facility had an effective infection prevention and control program or antibiotic stewardship program in place. The failed practices had the likelihood to affect all patient receiving care in the facility. See O-0462, O-0464, O-466, O-0472, O-0474, O-0476, O-0478, and O-0480 for details.”

“Discharge planning. CFR(s): An REH must have an effective discharge planning process that focuses on the patient’s goals and treatment preferences and includes the patient and their caregivers/support person(s) as active partners in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient’s goals for care and their treatment preferences, ensure an effective transition of the patient from the REH to post-discharge care, and reduce the factors leading to preventable hospital admissions or readmissions. This Condition is not met as evidenced by: 51070 Based on review of policies and procedures, record review and interview it was determined the facility failed to provide a process for discharge planning that was individualized to meet the patients’ needs and goals of care, or that included the patient, family and/or support person as an active participant in their plan. Further the facility failed to evaluate, review, or update their discharge planning process to reflect the Rural Emergency Hospital healthcare model following their conversion on 12/31/2023. The failed practice had the likelihood to affect all patients receiving care in the facility. See O-0646 and O-0648 for details.”

“Quality assessment & performance improvement CFR(s): The REH must develop, implement, and maintain an effective, ongoing, REH-wide, data-driven quality assessment and performance improvement (QAPI) program. The REH’s governing body must ensure that the program reflects the complexity of the REH’s organization and services; involves all REH departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The REH must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 51070 Based on policy and procedure review, committee minutes review and interview, it was determined the facility failed to implement and maintain and ongoing Rural Emergency Hospital (REH) wide data driven quality assessment and performance improvement (QAPI) program in that the facility failed to: 1. Collect data or track outcomes to improve performance improvement activities in an ongoing effort to improve health outcomes. 2. Collect, measure and analyze adverse events to ensure the facility was meeting the clinical and safety needs of the patients and staff. 3. Set priorities for current or future performance improvement activities. 4. Provide a mechanism for reporting or tracking and trending adverse events in that no adverse event data had been collected, analyzed and used to improve outcomes during the 2024 calendar year. 5. Ensure the Governing Body provided guidance and oversight for an ongoing Quality Assurance Performance Improvement (QAPI) Program aimed at improving outcomes and mitigating risk to patients and staff. The failed process did not ensure that qualified staff members and mechanisms were in place for collecting and tracking key indicators to improve performance improvement activities. The failed practice had the likelihood of affecting all patients receiving services in the facility. See O-0762, O-0764, O-0768 and O-0774 for details.”

“Development of EP Policies and Procedures CFR(s): §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility’s geographic area. This Standard is not met as evidenced by: 47688 Based on interview and review of the facility’s emergency preparedness and disaster drills it was determined that the facility to create and maintain policy and procedures for conducting disaster drills and failed to conduct disaster drills for 2023 and 2024. The failed practice did not ensure the facility staff was prepared to act in the event of a disaster and placed the patients at risk of injury in the event of a disaster. Findings follow: A. Review of the facility’s policy and procedures on 11/05/2024 showed that the facility failed to create and maintain a policy and procedure for conducting and recording disaster drills. B. A request was made for the evidence of disaster drills conducted in 2023 and 2024. There was no evidence provided. C. The finding of A and B were verified with the Facilities Director on 11/06/2024 at 12:15 PM.”

“Infect prevent & control program org & policy CFR(s): (a) The REH must demonstrate that: (1) An individual (or individuals), who is qualified through education, training, experience, or certification in infection prevention and control, is appointed by the governing body, or responsible individual, as the infection preventionist(s)/infection control professional(s) responsible for the infection prevention and control program and that the appointment is based on the recommendations of medical staff leadership and nursing leadership; This Standard is not met as evidenced by: 50014 Based on employee file review and interview it was determined the Infection Control Preventionist had no training or certification in infection prevention or control. The failed practice did not allow the facility to have a trained or certified individual overseeing the infection control program and had the likelihood to affect all patients in the facility and employees. Findings follow: A. In an interview with the Laboratory Director on 11/05/24 at 9:30 AM, she stated that she “let her boss know that she was not trained in infection control, she assisted the previous nurse who was the infection control preventionist.” The facility made her the Infection Control Preventionist with the intent to obtain education and qualifications. The facility enrolled her in a preparatory class for Certification in Infection Control. “She stated that she has been in two classes, the class is teaching her how to pass the test; not the actual content of the class.” B. A request was made to the Laboratory Director on 11/05/2024 at 9:30 AM for a ob description for the Infection Control Preventionist. There was no evidence provided for a job description. C. Review of the Laboratory Director’s personnel file showed no evidence of infection prevention or control education.”

“Infect prevent & control program org & policy CFR(s): (a)(2) 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 REH and between the REH and other health care settings; This Standard is not met as evidenced by: 50014 Based on policy and procedure review, and in interview, it was determined that the infection control prevention and control program did not ensure: 1. Daily humidity logs were obtained from the Operating Room. 2. Water temperatures were set at 160 degrees Fahrenheit (F) and water to chlorine bleach ratio was maintained at 150 parts per million (ppm) for contaminated linens 3. Hand hygiene was being monitored in the facility. The failed practice had the likelihood to transmit infections throughout the hospital and had the likelihood to affect all patients receiving care. Finding follow: A. Review of the Eureka Springs Hospital Infection Control Meeting minutes dated January 1, 2024, through September 30, 2024, showed the following: 1. No humidity log presented to infection control preventionist. 2. Laundry water temperatures were less than or equal to 120 F. B. Review of policy titled, “Humidity and Temperature in the Operating Room (OR) and Endoscopy Suites” dated 06-07-23, showed the “relative humidity of not less than 20% and no greater than 60% and a temperature range of 68 to 73 degrees F shall be maintained in the surgical and endoscopy suites. Humidity and temperature in the surgical endoscopy suites shall be checked and recorded daily during a normal work week by Facility/Safety personnel. The OR personnel will check it daily during their normal work week. OR personnel will be responsible for checking and recording the Central Sterile supply temperature and humidity during their normal work week. Facility/Safety personnel will be notified of all recordings out of specific parameter range.” C. Review of the ESH Infection Control Meeting minutes dated “Bimonthly 3, 2024”, the Infection Control Preventionist asked for the daily humidity logs from the facility department. In the “Bimonthly 4”, 2024 meeting minutes it stated that the humidity logs had not been given to the infection control preventionist. The surveyor requested humidity logs from Facility Director. There were no logs provided. D. Review of the policy titled, “In-Hospital Laundering of Potentially Infectious Body Substance Contaminated Clothing and Uniforms,” dated 03-08-2011, showed “Clothing items are to be washed in the hottest temperatures permitted by the clothing items and with bleach if the cloth will tolerate this. Dry items on the highest heat the cloth will tolerate.” E. “Review of Rules for Hospitals and Related Institutions in Arkansas Table 9 showed that laundry water should be nothing less than 120 F for noninfectious substances on linens. If there are infectious substances, then it should be 160 F. Review of Rules for Hospitals and Related Institutions in Arkansas Table 9 showed the water to chlorine bleach ratio should be 150 parts per million (ppm). F. Review of documents provided by the facility failed to show the ratio of water to chlorine bleach ppm. Interview with the Facilities Director on 11-06-24 at 2:40 PM, she stated that “They need to purchase a heater to increase the water temperature when they have infectious disease on fabrics.” G. Review of policy titled, “Direct Observation and Hand Hygiene,” dated 2016, showed the procedure for observing hand hygiene. In an interview with the Emergency Room Director on 11-05-24 at 9:04 AM, she stated “hand hygiene observation has never been done.” She was unable to provide documentation of the hand hygiene procedure form. H. Review of Infection Prevention Report Card 2024 showed hand hygiene compliance was 100% for January through June, however, no documentation was provided to the surveyor.”

“Infect prevent & control program org & policy CFR(s): (a)(3) The infection prevention and control program include surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and that the program also addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 46733 Based on policy and procedure review, observation, and interview, the facility failed to maintain a sanitary environment to avoid sources and transmission of infection by ensuring expired supplies were not available for patient use in 1 (#1) of 2 (#1 and #2) Endoscopy Suites. The failed practice did not ensure that expired supplies would not be used during procedures performed in the Endoscopy Suites and had the likelihood of affecting all patients having endoscopy procedures. Findings follow: A. Review of policy and procedure titled “Monitoring of Expired Supplies,” with a review date of 06/07/2021 showed, “All supplies will be checked on a monthly basis for expiration and contamination.” B. During a tour of the Endoscopy Suites on 11/04/24 from 2:20 PM to 3:30 PM the following expired supplies were observed in Endoscopy Suite #1: 1-bottle containing 800 mls (milliliters) of sterile water opened but not dated when opened 178-polyp traps expired on 08/25/24 37-biopsy valves expired 08/18/24 1-Esophageal/colonic wire guided balloon dilatation catheter Expired Airway Box Supplies: 1-7.5 mm Oral/Nasal tracheal tube cuffed expired 10/28/24 1-8.5 mm Oral/Nasal tracheal tube cuffed expired 07/01/24 2-9.0 mm Oral/Nasal tracheal tube cuffed expired 10/08/24 C. During an interview with the ER (Emergency Room) Director at the time of the observations, she confirmed the findings above. Based on review of SGNA (Society for Gastroenterology Nurses and Associates, Inc.) Guidelines and Standards, Facility Protocol, observation, and interview, the facility failed to maintain a sanitary environment by not ensuring flexible endoscopes were reprocessed every seven days when not used for 4 (2 Esophagogastroduodenoscopes (EGD) Scopes and 2 Colonoscopes) of 4 flexible endoscopes. The failed practice did not ensure that the endoscopes were not contaminated and free of bioburden prior to use and had the likelihood of affecting all patients having endoscopy procedures. Findings follow: A. Review of SGNA Standards of Infection and Prevention of Flexible Gastrointestinal Endoscopes, 2018 showed, 9. Storage- “The authors of a systematic review concluded that endoscopes can be stored for 7 days if they have been effectively reprocessed and are stored in a way that keeps them completely dry and free from environmental and human contamination (Schmelzer, Danies, & Hough, 2015).” The Standard goes on to say, “e. SGNA supports a 7-day storage interval for reprocessed endoscopes but only if they were reprocessed and stored according to professional guidelines and manufacturer instructions.” B. Review of Facility Protocol to Identify Scopes Ready for Patient Use, not dated, showed, “If a scope has not been used in seven (7) days, it shall be reprocessed.” C. During a tour of the Endoscopy Suites on 11/4/24 from 2:15 PM to 3:30 PM, showed there were 4 Flexible Endoscopes (2 EGD scopes and 2 Colonoscopes) hanging in a closed cabinet in Endoscopy Suite #1 with no identifying information as to when they had been last cleaned. D. During an interview with the ER Director at the time of the observation, she stated that she was responsible for processing the endoscopes on the monthly procedure days between cases and she confirmed the scopes were only cleaned on procedure days and once during the 7 days prior to procedure day. She stated and confirmed they were not cleaned every 7 days. She was unable to state to the surveyor which professional standards or guidelines were followed by the facility. She confirmed there was no visual indicator on the scopes that showed when they were last cleaned. Based on observation, and interview the facility failed to maintain a sanitary environment to avoid sources of transmission of infection by not ensuring expired nourishments and food were available for patient consumption in 1 of 1 Kitchen and 1 of 1 Nourishment Room located in the Emergency Room (ER). The failed practice did not ensure patients would not consume expired food or nourishments and had the likelihood of affecting all patients who received food from the kitchen or nourishments from the ER Nourishment Room. Findings follow: A. During a tour of the kitchen on 11/05/24 from 9:00 AM to 11:30 AM and 1:00 PM to 2:45 PM the following expired items were found in the kitchen cabinets, on the countertops, in the refrigerators, freezers, and dry good storage room: Entry area to kitchen next to coffee pot- 1-box containing 13 packets of hot cocoa mix with date of 12/28/22 written on it 1-box full hot cocoa mix packets with date of 11/01/23 written on it 1-box containing 25 no sugar added hot cocoa packets with 09/20/23 written on it 1-box containing 50 packets of chicken bouillon with no expiration date 1-box containing 25 packets of beef bouillon with no expiration date 1-box containing 50 packets of beef bouillon with no expiration date 2-80-count boxes full of coffee packets with no expiration date 1-box of 15 coffee packets with no expiration date Kitchen Cabinets- 1-1-pound bag of brown sugar expired 12/06/23 2-boxes of yellow cake mix expired 09/18/24 1-box white cake mix expired 09/14/24 1-5-pound bag containing approximately 1 pound of all-purpose flour expired 10/09/24 1-5-pound bag containing approximately 1 pound of sugar expired 08/29/24 1-opened bag of country style gravy mix with opened date of 05/02/24 and no expiration date 1-opened bag of chicken gravy mix with open date of 09/29 no year and no expiration date 1-opened bag of brown gravy mix with no opened date or expiration date 1-opened bag of dried refried beans opened 11/18/23 and no expiration date 1-opened bag of dried cheddar cheese sauce with an open date of 08/13 no year and no expiration date Counter top- 1-opened loaf of bread with no opened or expiration date 1-1 gallon canola oil about ½ full with date of 01/28/22 written on it 1-can frying oil with date 09/25 written on it 1-plastic container of parsley flakes with 10/06/22 written on it 1-4x8-plastic container full of sweetener packets with no expiration date 1-4x4-plastic container that contained about 35-40 sugar packets with no expiration date 1-plastic bag of soy sauce packets about 250-300 with no expiration date White Refrigerator (Freezer)- 3-large plastic bags filled with yellow shells filled with cheese no expiration date 1-large plastic bag ¾ full of yellow shells filled with cheese no expiration date 1-large plastic bag that contained 12 hush puppies opened 10/30/23 with no expiration date 1-large plastic bag that contained approximately 50 hush puppies opened 04/12 no year noted and with no expiration date 1-large plastic bag that contained 3 hash brown patties opened 06/07 no year noted and with no expiration date 1-2-pound bag about ¾ full of green beans with no opened or expiration date 1-large plastic bag about 2-3 pounds of French fries opened 05/29 no year noted and with no expiration date 1-2.5-pound bag about 1/3 full of roasted peppers/onions with a date of 09/13/23 on the bag unsure if the opened or expired date Silver Refrigerator- 1-family size spaghetti sauce with expiration date of 06/19/25 had mold growing inside of lid of jar 2-one-gallon containers almost full of pickles with no expiration date 1-gallon of soy sauce full with “best by” date of 10/21/24 1-4.63-pound container of Maraschino cherries one quarter full with no expiration date 2-6 count muffin pans (one of which had a muffin missing) filled with either chocolate muffins or brownies in a large plastic bag with no expiration date Shelving Unit 1- 3-48 count 8-ounce water bottles no expiration date 1-96 count approximately ½ empty 4-ounce orange juice with a “best by” date of 10/04/24 Dry Good Storage Room- 3-36-ounce boxes dried rice pilaf with date of 11/12/23 written on box not sure if received date or expiration date 2-36-ounce boxes of Spanish rice with a date of 09/25 no year written on the box 4-108-ounce cans cut sweet potatoes with date of 10/23/23 written on box unsure if received date or expiration date 2-16-ounce cans pan coating frying oil with a date of 09/25 no year written on the can 2-22 count boxes containing cup of soup with a date of 09/09 written on the box 2-5-pound boxes of cornbread mix with date of 05/01/23 written on the box 1-5-pound box ½ full of cornbread mix with date of 05/01/23 written on the box 3-16-ounce containers of vegetable base no expiration date 11-20-ounce bottles of ketchup no expiration date 18-6-ounce cans of tuna with expiration date of 05/06/24 2-6-pound cans of pizza sauce with 11/28 written on the can 1-gallon canola oil with 11/28/22 written on the bottle 1-gallon dill pickles with “rec’d 05/15” no year and no expiration date on container 1-gallon olive oil with 11/12/23 written on the bottle 2-6.38-pound cans of diced tomatoes with 02/20 written on the cans 2-26-ounce dried mashed potatoes with 10/23/23 written on the package 3-14-ounce packages of chicken gravy mix with 09/25 written on the package 1-14-ounce package of country gravy mix with 12/11 written on the package 4-15-ounce packages of brown gravy mix with 12/11 written on the package 3-29-ounce packages of cheddar cheese sauce mix with 07/24 written on the package B. During a tour of the ER Nourishment Room on 11/06/24 from 2:00 PM to 2:45 PM the following expired nourishments were found in the refrigerator freezer and in a cabinet: Freezer- 8-hot pockets with no “use by” or expiration date 9-instant food thickener expired 09/07/24 4-orange sherbet expired 07/30/24 2-vanilla ice cream expired 07/30/24 1-Uncrustable with no “use by” or expiration date 3-sausage biscuit with cheese with no “use by” or expiration date Four-Drawer Brown Cabinet- 9-breakfast syrup with no “use by” or expiration date 4-grape jelly with no “use by” or expiration date 5-strawberry jam with no “use by” or expiration date 4-reduced sugar fruit spread grape with no “use by” or expiration date 4-reduced sugar fruit spread strawberry with no “use by” or expiration date 7-peanut butter with no “use by” or expiration date C. During an interview with the ER Director on 11/05/24 at 10:30 AM she stated the hospital had stopped using the kitchen a couple of months ago and there were no full-time dietary staff. She stated the facility did/could/had used some of the food from the kitchen at times for patients but that most of the time food was ordered from a local restaurant. She stated the dietary staff used to monitor the expiration dates on all the food and nourishments, but they had all quit. She verified the expired food and nourishments in the kitchen and stated that a local food bank was coming to get the food and nourishments. D. During the tour of the ER Nourishment Room the findings of expired nourishments were verified with Registered Nurse #1 and Registered Nurse #2. 50014 Based on policy and procedures, observation and an interview, it was determined that the facility failed to maintain a clean and sanitary environment in the Operating Room (OR) and the Emergency Room (ER). By not assuring the cleanliness and sanitary environments, the facility could not prevent transmission of infections. The failed practice had the likelihood to affect all patients who were seen in the hospital. Findings follow: A. Review of “Departmental Responsibilities,” dated 02-13-23, showed “ESH Housekeeping Departments primary function is to develop and maintain a safe, functional, and pleasant environment that will enable the hospital to achieve it central goal: care of the patient. The hospital environment is a critical aspect of patient care, directly affecting every patient and employee. The responsibilities include maintenance of interior areas such as ...utility, service and supply rooms.” B. Review of “Infection Prevention Report Card 2024” for January through June 2024, showed Environmental Services met 100% of their benchmarks. C. Interview with the Facilities Director on 11-06-24 at 2:40 PM, she stated that the schedule for cleaning the hospital was daily except for Sundays because she did not have staff to work. She described the process that she teaches her new employees in orientation. The surveyor asked for a copy of the orientation that she provided to employees. No orientation documentation was received. D. Observation of the cabinet below the sink in the ER nourishment room on 11-06-24 at 1:30 PM, showed the cabinet was cracked under the pipes with black substance in a circle about 6 inches wide. The findings were verified with the Registered Nurse (RN) on duty. E. Observation of ER #1, showed expired supplies: 20 sterile q-tips expired 09-20-21, 12 laboratory tubes expired 05-02-24, 10-24 gauge 0.75 needles expired 07-31-24. The findings were verified with RN on duty. F. Observation of ER #1, showed 20 sterile instrument packages compromised by being torn and/or brown-colored stained. The findings were verified with RN on duty. G. Observation of ER #1, showed six laryngoscope blades hanging on the wall in a plastic container on 11-04-24 at 12:30 PM, that were not individually packaged which could not ensure the blades had been disinfected. The findings were verified with RN on duty.”

“Antibiotic Stewardship program organization CFR(s): (b)(2) The facility-wide antibiotic stewardship program: (i) Demonstrates coordination among all components of the REH responsible for antibiotic use and resistance, including, but not limited to, the infection prevention and control program, the QAPI program, the medical staff, nursing services, and pharmacy services; (ii) Documents the evidence-based use of antibiotics in all departments and services of the REH; and (iii) Documents any improvements, including sustained improvements, in proper antibiotic use; This Standard is not met as evidenced by: 50014 Based on interview, it was determined that the facility did not have a facility wide antibiotic stewardship program. By not assuring the facility had an antibiotic stewardship program, the facility could not assure antibiotic usage and resistance, evidence-based use of antibiotics in all departments, and documentation of antibiotic improvements within the facility. The failed practice had the likelihood to promote antibiotic resistance to all patients receiving antibiotics at the facility. Findings follow: In an interview with the Laboratory Director (Infection Control Preventionist) on 11-06-24 at 2:30 PM, a request was made for evidence of antibiotic use and resistance and evidence-based use of antibiotics in all departments of the hospital. The Infection Control Preventionist stated “She does not have any documentation for antibiotic stewardship.””

“Antibiotic Stewardship program organization CFR(s): (b)(3) The antibiotic stewardship program adheres to nationally recognized guidelines, as well as best practices, for improving antibiotic use; and This Standard is not met as evidenced by: 50014 Based on policy and procedure review and an interview, it was determined that there was no evidence as to which nationally recognized guidelines were utilized by the facility for antibiotic usage. The failed practice did not ensure the infection control program was directed by established guidelines. The failed practice promoted the spread of infection and antibiotic resistance. Finding follow: A. A request was made for policies and procedures stating as to which nationally recognized guidelines were used for Infection Prevention and Control. There was no evidence provided. B. In an interview with the Laboratory Director (Infection Control Preventionist) on 11-06-24 at 2:30 PM, she stated “I do not know which guidelines are used.””

“Antibiotic Stewardship program organization CFR(s): (b)(4) The antibiotic stewardship program reflects the scope and complexity of the services furnished by an REH. This Standard is not met as evidenced by: 50014 Based on interview, it was determined that the facility had not determined as to whether the antibiotic stewardship program met the scope and complexity of the services provided. The failed practice had the likelihood to promote antibiotic resistance and had the likelihood to affect all patients receiving antibiotics at the facility. Findings follow: A. A request was made for evidence as to whether the antibiotic stewardship program met the scope and complexity of the services provided. There was no evidence provided. B. The findings in A were verified in an interview with the Infection Control Preventionist on 11-06-24 at 2:30 PM.”

“Leadership responsibilities. CFR(s): (c)(1) The governing body, or responsible individual, must ensure all of the following: (i) Systems are in place and operational for the tracking of all infection surveillance, prevention and control, and antibiotic use activities, in order to demonstrate the implementation, success, and sustainability of such activities. (ii) All HAIs and other infectious diseases identified by the infection prevention and control program as well as antibiotic use issues identified by the antibiotic stewardship program are addressed in collaboration with the REH’s QAPI leadership. This Standard is not met as evidenced by: 50014 Based on interview, it was determined that the facility leadership failed to have a system in place for tracking infections and antibiotic usage or a system in place for reporting the information to the Quality Assessment and Performance Improvement (QAPI) committee. The failed practice did not allow the facility to implement processes for reducing infection and improvement of antibiotic usage. The failed practice had the likelihood to affect all patients receiving care in the facility. Findings follow: A. A request was made for evidence of the Infection Control Program reporting tracking of infections and antibiotic usage to the QAPI committee. There was no evidence provided. B. The findings in A was confirmed in an interivew with the Laboratory Director (Infection Control Preventionist) on 11-06-24 at 2:30 PM.””

“Leadership responsibilities. CFR(s): (c)(2) The infection prevention and control professional(s) are responsible for: (i) The development and implementation of facility-wide infection surveillance, prevention, and control policies and procedures that adhere to nationally recognized guidelines. (ii) All documentation, written or electronic, of the infection prevention and control program and its surveillance, prevention, and control activities. (iii) Communication and collaboration with the REH’s QAPI program on infection prevention and control issues. (iv) Competency-based training and education of REH personnel and staff, including medical staff, and, as applicable, personnel providing contracted services in the REH, on the practical applications of infection prevention and control guidelines, policies and procedures. (v) The prevention and control of HAIs, including auditing of adherence to infection prevention and control policies and procedures by REH personnel. (vi) Communication and collaboration with the antibiotic stewardship program. This Standard is not met as evidenced by: 50014 Based on interview, the facility failed to: 1. Develop and implement policies and procedures based on nationally recognized guidelines. 2. Communicate and collaborate with the Quality Assessment and Performance Improvement (QAPI) program. 3. Provide education and training to facility staff. 4. Communicate and collaborate with the antibiotic stewardship program. The failed practice did not allow for the facility to have an active infection control program to reduce the rate of infections and healthcare acquired infections in the facility. The failed practice had the likelihood to affect all patients receiving care in the facility. Findings follow: A. A request was made for evidence of the following: 1. Development and implementation of policies and procedures based on nationally recognized guidelines. 2. Communication and collaboration with the QAPI program. 3. Education and training provided to facility staff. 4. Communication and collaboration with the antibiotic stewardship program. 5. There was no evidence provided. B. The findings in A were confirmed in an interview with the Laboratory Director (Infection Control Preventionist) on 11-06-24 at 2:30 PM.”

“Organization and staffing. CFR(s): (a)Patient care responsibilities must be delineated for all nursing service personnel. Nursing services must be provided in accordance with recognized standards of practice. This Standard is not met as evidenced by: 31039 Based on review of facility policy, review of Crash Cart check sheets and interview, it was determined the facility failed to assure nursing staff was checking crash carts (per policy) for two of two (Operating Room and Emergency Department) crash carts reviewed. The failed practice did not ensure medications and supplies were 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 the facility policy titled, “Audits: Emergency Medication Supply (Crash Cart),” effective date April 1, 2005, showed the crash cart should have been checked by the nursing staff every shift. B. Review of the Crash Cart check sheets on 11/5/2024 showed the following: 1. Emergency Department for the month of November 2024, showed missing crash cart checks on the following shifts: AM on 11/01/24, AM on 11/02/24, PM on 11/04/24. 2. Procedure dates for the Operating Room were as follows: 05/29/2024, 06/20/2024, 07/17/2024,08/21/2024, 09/18/2024 and 10/30/2024. The crash cart was not checked on the following procedure days: 05/29/2024, 06/20/2024, 07/17/2024, 09/18/2024 and 10/30/2024. C. During an interview on 11/05/2024 at 8:56 AM, the Interim Chief Executive Officer verified the crash carts had not been checked on the shifts/dates listed in findings B. Based on review of policy, observation and interview, it was determined the facility failed to secure the contents of one of one (Emergency Department) crash cart, per policy. By not securing the crash cart, the medications were accessible to non-licensed persons and the facility could not assure they would be there and available when an emergency occurred. The failed practice had the likelihood to affect all patients requiring emergency medications. Finding follow: A. Record review of the facility policy titled, “Audits: Emergency Medication Supply (Crash Cart),” effective date April 1, 2005, showed the crash cart should have been sealed at all times while not in use to assure the contents remain undisturbed. Nursing Services are responsible to notify Pharmacy Services when the cart has been entered, and when Pharmacy Services are not available, it falls to the Nursing Supervisor. B. During a tour of the Emergency Department on 11/05/2024 at 10:15 AM, observation showed the Crash Cart was in the Trauma Room, not sealed and the following medications available to non-licensed persons: 1. #3 Adenosine 6 mg (milligrams)/2 ml (milliliters); 2. #4 Amiodarone 150 mg/3ml; 3. #3 Atropine 1mg/10ml; 4. #3 Calcium Chloride 1 g(gram)/10ml; 5. #2 Digoxin 0.5mg/2ml; 6. #2 Dobutamine 250mg/20ml; 7. #5 Epinephrine 1mg/10ml; 8. #2 Epinephrine 1mg/1ml; 9. #2 Flumazenil 1mg/ 10ml; 10. #4 Furosemide 40mg/ml; 11. #3 Labetalol 5mg/ml; 12. #2 Lidocaine 100mg/5ml; 13. #4 Magnesium Sulfate 1g/2ml; 14. #4 Naloxone 0.4mg/ml; 15. #3 Norepinephrine 4mg/4ml; 16. #2 Tranexamic Acid 1000mg/10ml; 17. #2 Dextrose 50% 50ml; 18. #2 Dopamine 800mg/ Dextrose 5% Water 500ml; 19. #1 Heparin 25,000 units/ in 50% Normal Saline 500ml; 20. #1 Lidocaine 2g/ Dextrose 5% Water 500ml; 21. #1 Nitroglycerine 25 mg/ Dextrose 5% Water 250ml; 22. #3 Norepinephrine 4mg/4ml; 23. #3 Potassium Chloride 10mEq(milliequivalents); 24. #2 Sodium Bicarbonate 50 mEq/ 50ml; 25. #1 TNKase 50mg; and 26. #2 Propofol 1000mg/100ml; and 26. #3 Propofol 200mg/ 20ml. C. During an interview on 11/05/2024 at 10:15, The Director of Pharmacy verified the unsecured crash cart and the contents inside.”

“Discharge planning process. CFR(s): (a)(7) The REH must assess its discharge planning process on a regular basis. The assessment must include ongoing periodic review of a representative sample of discharge plans. This Standard is not met as evidenced by: 51070 Based on review of policy and procedure and interview it was determined the facility failed to assess its discharge planning process to meet the needs of the Rural Emergency Hospital (REH) patient population in that the facility did not review or update its discharge policies or procedures following its conversion to an REH on December 1, 2023 or periodically review a sample of discharge plans. The failed practice did not ensure the needs of patients were being met to achieve continuity of care or reduce the likelihood of readmission. The failed practice had the likelihood to affect all patients discharged from the facility. Findings follow: A. A request was made for a Discharge Policy or Procedure that reflected the needs of the REH patient population on 11/4/2024. There was no evidence provided. During an interview with the Chief Nursing Officer on 11/4/2024 at 10:35 AM, it was confirmed that the facility was utilizing the Critical Access Hospital Policy and Procedures, dated 02-07-2023, prior to their conversion to an REH on 12-1-2023. B. Review of Policy titled, “Discharge Planning or Transfer for OBS (observation), Acute Care, or Swingbed,” last reviewed 02/07/2023, showed that discharge planning will be “initiated upon admission and updated as is pertinent to the patient’s status and progress.” C. Review of Policy titled “Patient’s Rights” last reviewed 05/18/2016, showed the patient has “the right to be informed by the responsible practitioner or his delegate of any continuing health care requirement following discharge from the hospital.” D. In an interview with the Emergency Department (ED) Director on 11/4/2024 at 1:30 PM, the ED Director stated that the Registered Nurse (RN) caring for the patient was responsible for any discharge planning needs or scheduling. The ED Director stated this is “not being done,” patients are told to follow-up with their provider. The ED Director stated that charts are audited for completeness, however there is no periodic review of discharge planning or the discharge process to ensure its adequacy in meeting patient needs.”

“Discharge planning process. CFR(s): (a)(8) The REH 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, home health agency (HHA), skilled nursing facility (SNF), inpatient rehabilitation facility (IRF), or long term care hospital (LTCH) data on quality measures and data on resource use measures. The REH 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: 51070 Based on record review and interview, it was determined the facility failed to assist patients and their families in selecting a post-acute provider in four (#14, #18, #20, #21) of eleven (#11-#21) records reviewed in that patients were directed to schedule their own follow-up appointments after discharge. The failed practice did not ensure continuity of care or reduce the risk of readmissions. The failed practice had the likelihood of affecting all patients discharging from the facility. Findings follow: A. Review of patient records on 11-6-2024, showed Patient #14, #18, #20 and #21 were directed to schedule their own follow-up appointments after discharge. B. Review of Patient #14’s record showed six visits during the 2024 calendar year, five for mental health reasons. Patient #14 was directed to make their own follow-up appointments with no evidence of referral to medical or mental health providers. C. During an interview with Registered Nurse #3 on 11-5-2024 at 9:30 AM, it was confirmed that patients are directed to make their own appointments following discharge as there is no Social Work or Case Management to help identify or assist with making discharge arrangements if needed.”

“Notice of rights. CFR(s): (a)(2) The REH must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. The REH’s governing body or responsible individual must approve and be responsible for the effective operation of the grievance process and must review and resolve grievances, unless it delegates the responsibility in writing to a grievance committee. The grievance process must include a mechanism for timely referral of patient concerns regarding quality of care or premature discharge to the appropriate Utilization and Quality Control Quality Improvement Organization. At a minimum: (i) The REH must establish a clearly explained procedure for the submission of a patient’s written or verbal grievance to the REH. (ii) The grievance process must specify time frames for review of the grievance and the provision of a response. (iii) In its resolution of the grievance, the REH must provide the patient with written notice of its decision that contains the name of the REH contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. This Standard is not met as evidenced by: 31039 Based on review of policy, review of Record of Complaint Investigations, and interview, it was determined the facility failed to provide evidence the complainant received a written notice of its decision that contained the name of the Rural Emergency Hospital (REH) contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and the date of completion for six of six (#1-#6) grievances received since 12/01/2023. By not responding to the patient’s grievances, the facility was not honoring the patients’ rights to prompt resolution of their grievances. This failed practice had the likelihood to affect the rights of all patients who file a grievance with the facility. Findings follow: A. Record review of facility policy titled “Patient Complaint Grievance Procedure,” revised 10/02/2023, showed the facility was to do a thorough investigation and document the results on the complaint record. It also showed the patient was to receive a response from the Grievance Committee or the investigating Department Director. B. Review of the Record of Complaint Investigation forms for Grievances #1 through #6 showed no evidence documented that a thorough investigation was done, and the complainant received a written notice of its decision that contained the name of the Rural Emergency Hospital (REH) contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and the date of completion. C. During an interview on 11/5/2024 at 1:32 PM, the Interim Chief Executive Officer verified the six grievances did not have evidence the complainant received a written notice of its decision that contained the name of the Rural Emergency Hospital (REH) contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and the date of completion.”

“Privacy and safety. CFR(s): (c)(2) Receive care in a safe setting. This Standard is not met as evidenced by: 46733 Based on policy and procedure review, observation and interview, it was determined the Hospital Housekeeping Department failed to maintain a safe, hygienic environment in one of one Housekeeping Closet in the Endoscopy Department by not ensuring the door to the closet was secured, not available for patient/visitor entry, and the closet was clean and maintained. The failed practice did not ensure patients received care in a safe setting that was free of hazards and contamination and had the likelihood of affecting any patient having endoscopy procedures. Findings follow: A. Review of Policy and Procedure titled, Department Responsibilities reviewed 02/13/2023 and approved by the Director of Facilities showed, “Eureka Springs Hospital Housekeeping Department’s primary function is to develop and maintain a safe, functional, and pleasant environment that will enable the hospital to achieve its central goal: care of the patient. The hospital environment is a critical aspect of patient care, directly affecting every patient and employee. Besides furthering patient care, the environment affects the morale and performance of the entire staff of the hospital. A safe hospital environment is more than an accident-free environment. It is also sanitary and hygienic. In addition to maintaining a safe and clean environment, the Housekeeping Department must maintain an atmosphere that is both functional and pleasant.” “PROCEDURE: DEPARTMENTAL RESPONSIBILITIES- Maintenance of Interior Areas: Public areas such as lobbies, reception rooms, circulating spaces such as halls, Patient rooms, Operating and emergency departments, Treatment rooms, utility rooms, lavatories, Dressing rooms, rest rooms, lavatories, Service and supply rooms. Maintenance Procedures: Window washing, wall cleaning, floor care, furniture dusting, light fixture cleaning, trash removal from patient and employee areas.” B. During a tour of the Preop/PACU (Post Anesthesia Care Unit) and Endoscopy Suites on 11/4/24 from 2:15 PM to 3:30 PM, there was a key observed in the doorknob of the Housekeeping Closet that was between Endoscopy Suite #1 and Endoscopy Suite #2. Observation of the inside of the closet showed a white plastic shelving unit with cleaning products on the shelves. Next to this shelving unit there was a large white sink with dried, soiled towels on the left rim of the sink, used disposable endoscope cleaning wire brushes were hanging on the faucet of the right side of the sink and one used cleaning brush was laying under the faucet. The interior of the sink was filled with dirt and debris and what appeared to be grass and three grape sized balls of a lent type of debris and a rusty screw on the right rim of the sink. C. In an interview with the Emergency Room Director at the time of the findings, she confirmed the key in the lock and stated it was “always there” and that she had never been in that closet and had no idea the last time it had been cleaned by Housekeeping. She confirmed potential access to cleaning products by unauthorized patients and visitors and confirmed the sink findings. D. In an interview with the Director of Facilities on 11/06/24 at 2:40 PM she stated that she could not remember the last time that she or her staff had been in that closet, if ever.”

“Restraint or seclusion: Staff training req CFR(s): (f)(1) The REH must provide patient-centered competency-based training and education of REH personnel and staff, including medical staff, and, as applicable, personnel providing contracted services in the REH, on the use of restraint and seclusion. This Standard is not met as evidenced by: 31039 Based on interview, it was determined the facility failed to provide patient centered competency-based training and education on the use of restraint and seclusion. By not proving this training and education to staff, the staff does not have the knowledge or education in the event a patient would need to be placed in a restraint or placed in seclusion. The failed practice had the likelihood to affect patients that were brought to this facility, who needed to be restrained or put in seclusion. Findings follow: A. During an entrance conference on 10/04/2024 at 1:30 PM, a request list was given to the Chief Nursing Officer. Competency-based training in the use of restraints and seclusion for personnel and staff was requested. B. During an interview on 10/06/2024 at 8:59 AM, the Interim Chief Executive Officer verified the facility has not trained their staff and personnel in the use of restraints and seclusion.”

“Restraint or seclusion: Staff training req CFR(s): (f)(2) The training must include alternatives to the use of restraint/seclusion. This Standard is not met as evidenced by: 31039 Based on interview, it was determined the facility failed to provide patient centered competency-based training and education on the use of restraint and seclusion that included alternatives to the use of restraints/ seclusion. By not proving this training and education to staff, the staff does not have the knowledge or education in the event a patient would need to be placed in a restraint or placed in seclusion, nor the alternatives to use of restraints/ seclusion. The failed practice had the likelihood to affect patients that were brought to this facility, who needed to be restrained or put in seclusion. Findings follow: A. During an entrance conference on 10/04/2024 at 1:30 PM, a request list was given to the Chief Nursing Officer. Competency-based training in the use of restraints and seclusion including alternatives, for personnel and staff, was requested. B. During an interview on 10/06/2024 at 8:59 AM, the Interim Chief Executive Officer verified the facility has not trained their staff and personnel in the use of restraints and seclusion, nor any alternatives.”

“Program scope. CFR(s): (a)(1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes and identify and reduce medical errors. This Standard is not met as evidenced by: 51070 Based on committee meeting minutes review and interview, it was determined the facility failed collect data or track outcomes to improve performance improvement activities in an ongoing effort to improve health outcomes. The failed practice had the likelihood to affect all patients receiving services in the facility. Findings follows: A. Review of the “QAPI (Quality Assessment and Performance Improvement) Plan” dated 04/06/2022, showed that the “Performance Improvement plan will identify and address opportunities to continuously improve the safety and quality of care provided for the benefit of patients, the community, and other customers.” B. Review of QAPI Committee Minutes on 11/7/2024, showed the QAPI Committee had not met since January 19, 2024. C. Review of QAPI Committee Minutes on 11/7/2024, showed the April 2024 meeting was cancelled due to new REH requirements and a “new plan will be presented to the board for review and once accepted will be presented to the staff”. A new and/or updated QAPI plan was requested but none was provided. D. In an Interview with the Chief Nursing Officer (CNO) on 11/4/2024 at 10:35, the CNO stated “the facility did not have an updated QAPI plan to reflect the needs of their Rural Emergency Hospital (REH) healthcare model” and “currently there was no performance improvement activities being done”.”

“Program scope. CFR(s): (a)(2) The REH must measure, analyze, and track quality indicators, including adverse patient events, staffing, and other aspects of performance that assess processes of care including REH service and operations. This Standard is not met as evidenced by: 51070 Based on committee minutes review and interview it was determined the facility failed to collect, measure and analyze adverse events to ensure the facility was meeting the clinical and safety needs of the patients and staff. The failed practice had the likelihood of affecting all patients receiving care in the facility. Findings follow: A. Review of the “Quality Assurance and Performance Improvement (QAPI) Plan” dated 04/06/2022, showed that the facility will “measure, analyze and track quality indicators including patient adverse events to assess hospital processes and performance.” B. A request was made on 11/04/2024 and again on 11/06/2024 for a log or evidence of adverse events and/or incident reporting. None was provided. C. The Pharmacy Director provided a copy of “Monthly Med Pending Incidents/Clarification (for Pharmacy &Therapeutics resolution log development)” on 11/05/2024 which showed three medication errors in the month of July and three in August. No evidence was provided which showed corrective action or performance improvement had been undertaken to prevent medication errors. D. In an interview with the Emergency Department (ED) Director on 11/04/2024 at 10:00 AM, the ED Director stated that the facility used to report quality measures into several national databases but since losing their compliance officer and converting to a Rural Emergency Hospital in December of 2023 no one had been entering data. The ED Director followed up through email by citing that the former Compliance Officer was over QAPI and had been let go by the facility. Since her departure no one had been doing QAPI. E. Review of the 2024 ER (Emergency Room) Department Quality Reporting Dashboard on 11/05/2024, showed no data reported under the following headings: a. Quality Indicators - for January through November b. MI (Myocardial Infarction)/Stroke - no data for January through June or September through November c. Throughput - no data January through November d. Performance - no data August through November E. A review of the 2024 Pharmacy Quality Reporting Dashboard on 11-5-2024, showed no quality indicators had been reported for April through November. F. A request was made for Quality Indicators/Dashboards from Radiology, Respiratory and Surgical Services on 11/04/2024 to the Chief Nursing Officer, and again on 11/05/2024 and 11/07/2024 to the Interim Chief Executive Officer. No evidence was provided.”

“Program activities. CFR(s): (c)(1) The REH must set priorities for its performance improvement activities that -- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. This Standard is not met as evidenced by: 51070 Based on review of Quality Assessment and Performance Improvement (QAPI) meeting minutes and interview, it was determined the facility failed to set priorities for current or future performance improvement activities. The failed practice did not ensure quality outcomes or that patients were receiving care in a safe environment. The failed practice had the likelihood to affect all patients receiving care in the facility. Findings follow: A. Review of the “Quality Assurance and Performance Improvement Plan” dated 04/06/2022, showed that the “Governing Body assumes responsibility for the hospitals QAPI program” and “Quality Council/Steering Committee” will “prioritize process improvement projects” and “integrate quality management and process improvement activities”. B. A request was made for evidence of performance improvement activities current and/or future planned on 11/4/2024. There was no evidence provided. C. In an interview with the Chief Nursing Officer on 11/4/2024 at 10:35 AM, she confirmed the facility did not have any current performance improvement activities ongoing or future activities planned.”

“Program activities. CFR(s): (c)(2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the REH. An adverse patient event means an untoward, undesirable, and usually unanticipated event that causes death or serious injury or the risk thereof. Medical error means an error that occurs in the delivery of health care services. This Standard is not met as evidenced by: 51070 Based on review of Policy and Procedure, record review and interview it was determined the facility failed to provide a mechanism for reporting or tracking and trending adverse events in that no adverse event data had been collected, analyzed and used to improve outcomes during the 2024 calendar year. The failed practice did not ensure that patients receive safe high quality of care and that outcomes meet the needs and goals of the patients and the facility. The failed practice had the likelihood to affect all patients receiving care in the facility. Findings follow: A. A review of Policy titled “Risk Management Plan” effective date 1/15/2014, showed the Risk Manger was responsible for collecting adverse event information and working with the Performance Improvement Committee to “facilitate identification, follow-up, and corrective action on prevention of problems/needs in patient care and safety.” B. A request was made on 11/4/2024 and again on 11/06/2024 for a log or evidence of adverse events and/or incident reporting. None was provided. C. During an interview with the Interim Chief Executive Officer on 11/06/2024 at 1:30 PM, she stated the facility had not had a Risk Manager since April of 2024. When asked what mechanism was in place for reporting, she stated the employees can send an email and the concern will be followed up on. D. During an interview with Marketing Associate on 11/07/2024 at 8:20 AM, she confirmed that she conducts patient satisfaction surveys via phone, however the information was not aggregated to inform performance improvement activities.”

“Executive responsibilities. CFR(s): (d)The REH’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the REH), 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 REH-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety; and that all improvement actions are evaluated. (3) That clear expectations for safety are established. (4) That adequate resources are allocated for measuring, assessing, improving, and sustaining the REH’s performance and reducing risk to patients. This Standard is not met as evidenced by: 51070 Based on review of committee meeting minutes and interview, it was determined the Governing Body (GB) failed to ensure guidance and oversight for an ongoing Quality Assurance Performance Improvement (QAPI) Program aimed at improving outcomes and mitigating risk to patients and staff. The failed process did not ensure that qualified staff members and mechanisms were in place for collecting and tracking key indicators to improve performance improvement activities. The failed practice had the likelihood of affecting all patients receiving services in the facility and staff. Findings follow: A. A review of the “QAPI Plan” last reviewed 04/06/2022, showed that “the GB assumes responsibility for the hospitals QAPI program” and that the GB is responsible for “ensuring the QAPI program reflects all provided services including contract staff and prevention/reduction of medical errors”. B. A review of “Medical Staff Minutes” for December 2023, March 2024, May 2024, July 2024, showed no evidence of ongoing quality review. Minutes dated May 2, 2024, showed a “QA (Quality Assurance) plan is being reviewed and evaluated to mirror the needs of our REH designation” and will be presented later for approval. Minutes for meetings occurring after July 2024 were requested, none was provided. C. In an Interview with the Chief Nursing Officer (CNO) on 11/4/2024 at 10:35 AM, the CNO stated “the facility did not have an updated QAPI plan to reflect the needs of their Rural Emergency Hospital (REH) healthcare model” and “currently there was no performance improvement activities being done”.”

“Records system. CFR(s): (a)(2) The records must be legible, complete, accurately documented, readily accessible, and systematically organized. This Standard is not met as evidenced by: 46733 Based on medical record review and review of the Arkansas State Board of Health Rules for Hospitals and Related Institutions in Arkansas, revised 06/17/24, and interview, the facility failed to maintain complete and accurate medical records by not ensuring Pre Anesthesia Assessments were documented on the medical record for eight (Patients #2-#6 and #8-#10) of nine Endoscopy Patients and failed to ensure History and Physicals had been performed, documented and updated on the date of the endoscopy procedure for six (Patients #3-#6 and #8, #10) of nine Endoscopy Patients. This failed practice did not assure accuracy of the information in the medical record and did not assure the medical record contained all required, signed documentation. This failed practice had to likelihood of affecting all patients having endoscopy procedures in the facility. Findings follow: A. During a medical record review on 11/06/24, Patients #2-#6 and #8-#10 did not have a documented Pre-Anesthesia Assessment. B. During a medical record review on 11/06/24, Patients #3-#6 and #8, #10 did not have a History and Physical in the record that had been completed within thirty days of the procedure date. C. Review of the Arkansas State Board of Health Rules for Hospitals and Related Institutions in Arkansas revised 06/17/24, showed, “Section 14, Health Information Services, A. General Requirements 1. A medical record shall be maintained for each patient admitted for care in the hospital. 22. Medical records shall be complete and contain all required signed documentation (including physician reports) no later than 30 days following the patient’s discharge date.” The rule goes on to say, “D. 4. A. 7. History and physical examinations may be completed up to 30 days prior to admission if the examination is updated at the time of admission. The updated HPE (History and Physical Exam) must be authenticated by the attending or treating physician.” D. Review of the Arkansas State Board of Health Rules for Hospitals and Related Institutions in Arkansas revised 06/17/24, showed, “Section 14 F. Surgery Records 3. An anesthesia report including preoperative evaluation and postoperative assessment shall be documented by the Anesthesiologist and/or Certified Registered Nurse Anesthetist (CRNA). The pre-evaluation and post assessment shall be dated and timed.” E. In an interview with the Interim CEO and CFO on 11/06/24 at 2:30 the surveyor requested confirmation from the CRNA via phone call interview or email interview that a Pre-Anesthesia Assessment had been completed for the above named patients. The Interim CEO attempted to call the CRNA and left a voicemail. She followed up with an email requesting the CRNA contact the surveyor. The surveyor was not contacted by the CRNA via telephone or email as of the exit date or after the exit of the survey.”

“Safety from fire. CFR(s): (c)(1) Except as otherwise provided in this section, the REH must meet the provisions applicable to Ambulatory Health Care Occupancies, regardless of the number of patients served, and must proceed in accordance with the Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4). This Standard is not met as evidenced by: 47688 Based on observation, review of policy and procedure and interview, it was determined the facility failed to create, review on a biennial basis and implement policies and procedures for: 1) Instillation and testing of an emergency “Stop” switch 10 to 15 feet away from generator. 2) Not having battery powered emergency lights installed in the generator. The failed practice put the generator at risk of catching fire. The failed practice had the likelihood to affect all patients receiving care in the facility. Findings follow: A. Review of the facility’s policies on 11/06/2024 showed that the facility failed to create a policy regarding installation and testing of an emergency “Stop” switch 10 to 15 feet away from generator. B. Observation on 10/06/2024 at 10:13 AM showed there was no emergeny stop switch installed 10 to 15 feet away from the generator and there were no battery powered emergency lights installed on the generator. C. The findings of A and B were confirmed in an interview with the Facilities Director on 11/06/2023 at 10:20 am.”

“Building safety. CFR(s): (d)Except as otherwise provided in this section, the REH must meet the applicable provisions and must proceed in accordance with the 2012 edition of the Health Care Facilities Code (NFPA 99, and Tentative Interim Amendments TIA 12-2, TIA 12-3, TIA 12-4, TIA 12-5 and TIA 12-6). (1) Chapters 7, 8, 12, and 13 of the adopted Health Care Facilities Code do not apply to an REH. (2) If application of the Health Care Facilities Code required under paragraph (d) of this section would result in unreasonable hardship for the REH, CMS may waive specific provisions of the Health Care Facilities Code, but only if the waiver does not adversely affect the health and safety of patients. This Standard is not met as evidenced by: 47688 Based on observation, review of policies and procedures and interview, it was determined the facility failed to create, review and implement policies and procedures on a biennial based for: 1) Annual scheduled polarity and tension testing 2) Annual scheduled electrical panel infrared testing 3) Annual Legionella testing 3) Logging eye wash station checks 4) Exhaust fan checks 5) Fire door checks to include a 13 point inspection 6) Conducting gravity tests on the generator battery By not creating and reviewing the policies and procedures biennially, the facility had the likelihood to not be able to identify hazardous conditions and take steps to minimize the risks to patients and patient care staff. The failed practice had the likelihood to affect all patients seen in the facility. Findings follow: A. Review of the facility’s policy and procedures on 11/05/2024 showed that the facility failed to create and maintain a policy and procedure for scheduling annual Polarity and tension testing and having each emergency receptacle labeled. There was no evidence provided the facility conducted annual polarity and tension testing or having each emergency receptacle labeled. B. Review of the facility’s policy and procedures on 11/05/2024 showed that the facility failed to create and maintain a policy and procedure for conducting annual scheduled electrical Panel and infrared testing. There was no evidence provided the facility conducted annual electrical panel and infrared testing. C. Review of the facility’s policy and procedures on 11/05/2024 showed that the facility failed to create and maintain a policy and procedure for Legionella testing using a third party and were doing testing in house. There was no evidence provided Legionella testing was conducted by a third party vendor. D. Review of the facility’s policy and procedures on 11/05/2024 showed that the facility failed to create and maintain a policy and procedure for checking eye wash stations. There was no evidence provided the facility conducted eye wash station checks. E. Review of the facility’s policy and procedures on 11/05/2024 showed that the facility failed to create and maintain a policy and procedure for conducting and recording Exhaust fan checks. There was no evidence provided the facility conducted or recorded exhaust fan checks. F. Review of the facility’s policy and procedures on 11/05/2024 showed that the facility failed to create and maintain a policy and procedure for recording fire door checks using a 13 point check. There was no evidence provided the facility conducted fire door checks using a 13 point check. G. Review of the facility’s policy and procedures on 11/05/2024 showed that the facility failed to create and maintain a policy and procedure for conducting and recording gravity tests on the generators battery. There was no evidence provided the facility conducted gravity tests on the generator battery. H. The findings of A through G were confirmed in an interview with the Facilities Director on 11/05/2024 at 12:07 PM. Based on observation and interview, it was determined the Operating Room, Scope Room, Emergency Department, Central Supply, Pharmacy, and processing lab was not safe and maintained in a state of cleanliness. The failed practice promoted the spread of infection and had the likelihood to affect all patients and staff in the facility. Findings follow: A. Observation of the Emergency department on 11/06/2024 showed the following: 1) Linens in the clean linen room were exposed and not covered 2) The shelf next to the nurses station had a build up of dust and debris 3) The findings were verified with the Facilities Director on 11/06/2024 at 9:30 am. B. Observation of the operating room on 11/06/2024 showed the following: 1) Water leaking from the ceiling next to the air vent 2) Water leaking from ceiling above doors entering into the operating room 3) Dirty utility room had water leaking and rust under the sink 4) A build up of mold on the air vent 5) Medications stored in the Environment Services closet 6) The findings were verified with the Facilities Director on 11/06/2024 at 10:12 am C. Observation of the Processing Lab on 11/06/2024 showed the following: 1) Wall damage near the lab techs desk 2) Cracks in the floor 3) The findings were verified with the Facilities Director on 11/06/2024 10:45 am. D. Observation of the Scope room on 11/06/2024 showed the following: 1) Scopes being stored in wooden cabinet, storage needs to be sealed using enamel paint. 2) Damaged ceiling tiles in front of scope room 3) The findings were verified with the Facilities Director on 11/06/2024 at 11:15 am E. Observation of the Pharmacy Department on 11/06/2024 showed items being stored under the sink. The finding was verified with the Facilities Director on 11/06/2024 at 11:30 am F. Observation of the Central Supply area on 11/06/2024 showed the following 1) Medical supplies in multiple closets were being stored on raw or exposed wood that needs to be sealed using enamel paint. 2) A Broken electrical socket on the back room of the Central supply area 3) The findings were verified with the Facilities Director on 11/06/2024 at 1:16 PM.”

“Medical staff. The governing body must: CFR(s): (2) Appoint members of the medical staff after considering the recommendations of the existing members of the medical staff. This Standard is not met as evidenced by: 41508 Based on review credential files, Board meeting minutes review, and interview, it was determined the Board failed to document the appointment or reappointment of six of six medical staff members reviewed to the medical staff. The failed practice did not ensure the hospital staff had completed information on the member of the medical staff and had the likelihood to affect all patients treated by the medical staff. The findings follow: A. Review of the credential files for six of six medical staff members, the Board approval document did not include appointment status. The form titled Physician Credentialing Appointment Status provided an option for the Board of Governors to select “Appointment Recommended”, “Appointment Not Recommended” or “Appointment Deferred” and also has a blank for Comment and a signature. Four of six had a signature and did not include a selection of one of the three options. Two of six did not have a signature and did not include a selection of one of the three options. B. Review of the Board meeting minutes from April 2023 to April 2024 showed there was no evidence of actions by the Board regarding medical staff appointment. C. The findings of A and B were confirmed in an interview with the Chief Executive Officer on May 15, 2024 at 2:30 PM.”

“Eligibility and process for appointment CFR(s): (a)(1) The medical staff must periodically conduct appraisals of its members. This Standard is not met as evidenced by: 41508 Based on physician credential file review, Medical Staff Bylaws review and interview, it was determined the Medical Staff failed to reappraise the privileges for six of six Medical Staff members reviewed. The failed practice did not ensure the medical staff was practicing with appropriate credentials and had the likelihood to affect all patients treated by the medical staff. The findings follow: A. Review of medical staff credential files showed the delineation of clinical privileges list (a list indicating the care and treatment medical staff have been given authority to perform at this facility) for five of six medical staff members were incomplete. The medical staff credential files contained several different versions of a delineation of clinical privileges list (LIST). 1) One of the LIST had a line at the top of the page to document the physicians’s name. In two of six this line was blank. 2) One of the LIST had the option for the physician to indicate which privilege was “requested” with a second and third section to document if the privilege was “approved” or “denied”. The “approved” or “denied” was not completed for any of the privileges “requested” in one of six files reviewed. 3) The letter sent from the facility to the medical staff member indicating appointment or re-appointment stated the appointment was for a two year term. The clinical privileges for one of six medical staff members had a form dated 12/12/15 with Medical Executive Committee approval. The file did not contain a form indicating Governing Body approval. There were letters dated February 1, 2018, June 19, 2021, and March 23, 2023 granting re-appointment for a two year term. The time between each of the four dates exceeded two years. Interview with the Chief Executive Officer (CEO) confirmed the medical staff member was providing patient care during the times exceeding two years. B. The findings were confirmed in an interview with the CEO on May 15, 2024 at 2:30 PM.”

“Infect prevent & control program org & policy CFR(s): (a)(2) 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 REH and between the REH and other health care settings; This Standard is not met as evidenced by: 28438 Based on policy and procedure review, Infection Prevention and Control Committee Meeting minutes review and interview, it was determined the facility failed to conduct bi-monthly (every two months) infection prevention and control meetings for two (November 2023 and March 2024) of six (May 2023 through March 2024) meetings reviewed. The failed practice did not ensure the infection control committee was up-to-date on the infection control concerns in the facility. The failed practice had the likelihood to affect all patients seen in the facility. Findings follow: A. Review of the facility’s policy titled, “Infection Control Manual,” with a revision date of 6/2023 showed the Infection Control Committee was responsible for the determination of all hospital policy related to infection control including bi-monthly meeting were required but may be held more often if necessary. B. Review of the facility’s policy titled, “Infection Control Officer Duties,” with a revision date of 6/2023 showed, “Bimonthly: hold an Infection Control meeting every other month.” C. Review of the Infection Control Committee Meeting minutes from May 2023 to March 2024 showed there was no evidence an infection control committee meeting was conducted in November 2023 or March 2024. D. The findings in A through C were confirmed in an interview with the Chief Nursing Officer on 05/15/2024 at 10:00 AM. Based on policy and procedure review, Infection Prevention and Control Committee Meeting minutes review and interview, it was determined the facility failed to ensure a physician member of the infection control committee was present during the infection control committee meetings for six of six (May 2023 through March 2024) meetings reviewed. The failed practice did not ensure physician input and involvement was given to direct the infection control committee. The failed practice had the likelihood to affect all patients seen in the facility. Findings follow: A. Review of the facility’s policy titled, “Infection Control Manual,” with a revision date of 6/2023 showed, “Infection Epidemiologist/Chairman job description and requirements: Physician with knowledge of epidemiology and infectious disease and familiarity of fundamental biostatistics; Must be a member of Infection Control Committee, rotation of this is position will be infrequent as possible so skills and familiarity can be developed.” B. Review of the Infection Control Committee Meeting minutes from May 2023 to March 2024 showed there was no evidence an infection control committee meeting was conducted in November 2023 or March 2024. There was no evidence of a physician present during the meetings on 05/12/2023, 07/21/2023, 09/25/2023 or 01/19/2024. C. The findings in A and B were confirmed in an interview with the Chief Executive Officer on 05/25/2024 at 3:25 PM.”

“Facilties. CFR(s): (b)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 28438 Based on observation, review of the Daily Hydrocollator Temperature Record and interview, it was determined the facility failed to ensure the hydrocollator’s temperature was verified daily to be in a safe operating temperature range when in use for 44 of 44 (04/01/2024 to 05/14/2024) days. The failed practice placed patients at risk of skin burns from heating pads being used out of established temperature ranges. The failed practice had the likelihood to affect all patients on which a heating pad from the hydrocollator was used. Findings follow: A. Observation of the Physical Therapy Department on 05/14/2024 at 1:10 PM showed a hydrocollator being used to heat pads for patient use. B. Review of the Daily Hydrocollator Temperature Record on 05/14/2024 showed there was no evidence the hydrocollator’s temperature was recorded from 02/23/2024 to 05/14/2024. C. In an interview with Physical Therapy Director on 05/14/2024 at 1:10 PM, he stated the hydrocollator had not been used for patient care from 02/23/2024 to 04/01/2024. The Physical Therapy Director checked the temperature of the hydrocollator at that time and the temperature was 145 degrees Fahrenheit. He confirmed there was no evidence the temperature was recorded from 04/01/2024 to 05/14/2024. Based on observation and interview, it was determined the facility failed to ensure expired supplies (Intravenous (IV) solutions) were not available for patient use. The failed practice did not ensure the efficacy of the IV solutions and had the likelihood to affect all patients receiving IV fluids. Findings follow: A. Observation of the Supply Room on 05/14/2024 at 1:40 PM showed the following expired IV solutions: 1) Five D5NS (Dextrose 5% and Normal Saline) 1000 mL (milliliters) expired April 2024. 2) Three LR (Lactated Ringers) 1000 mL expired January 2024 3) One D5 1000 mL expired November 2023 4) Fiver D5 1000 mL expired April 2023 B. The findings in A were confirmed in an interview with the Chief Nursing Officer on 05/14/2024 at 1:40 PM.”