Pershing Memorial Hospital

“EMERGENCY SERVICES CFR(s): The CAH provides emergency care necessary to meet the needs of its inpatients and outpatients. This Condition is not met as evidenced by: 36473 Based on observation, interview and review of the Malignant Hyperthermia Association of the United States (MHAUS), the hospital failed to ensure the required life-saving medications were readily accessible when administering Succinylcholine (a muscle relaxant/paralytic) in the emergency department (ED). The facility census was four Acute Care patients, zero Swing Bed patients and one Observation (Observation - outpatient services provided to a patient while the patient’s physician decides whether to admit the patient to Acute Care services or to discharge the patient) patient for a total census of five. The severity and cumulative effects of these failed practices resulted in the hospital’s non-compliance with 42 CFR 485.618 CoP of Emergency Services. Please refer to C-0884 for details.”

“EQUIPMENT, SUPPLIES, AND MEDICATION CFR(s): Equipment, supplies, and medication used in treating emergency cases are kept at the CAH and are readily available for treating emergency cases. The items available must include the following: This Standard is not met as evidenced by: 36473 Based on observation, interview and review of the Malignant Hyperthermia Association of the United States (MHAUS), the hospital failed to ensure the required life-saving medications were readily accessible when administering Succinylcholine (a muscle relaxant/paralytic) in the emergency department (ED). This failure had the potential to affect all patients that presented to the ED and given Succinylcholine in an emergency.The facility census was four Acute Care patients, zero Swing Bed patients and one Observation (Observation - outpatient services provided to a patient while the patient’s physician decides whether to admit the patient to Acute Care services or to discharge the patient) patient for a total census of five. Findings included: 1.Upon request of the Malignant Hyperthermia medications, Staff D, Director of Surgical Services, stated that they had to call anesthesia to come in to access the room with the medications. 2.During an interview on 02/14/24 at 2:30 PM, upon request of the Malignant Hyperthermia medications, Staff D, Director of Surgical Services, stated the only staff with access to them were the anesthesia group and they had no surgeries that day. 3.During an interview on 02/15/24 at 8:40 AM, Staff K, ED Manager, stated that they used Succinylcholine whenever they intubated patients, and they didn’t have access to the Malignant Hyperthermia medications. 4.During an interview on 02/15/24 at 11:00 AM, Staff Q, CRNA, stated that their anesthesia group were the only staff with access to the Malignant Hyperthermia medications. 5.Review of the MHAUS recommendations, dated 2016, showed that when patients were given Malignant Hyperthermia (a life-threatening, but treatable reaction of the inhalation anesthetics and Succinylcholine triggering anesthetics), medication, the only antidote used to reverse the reaction was the medication Dantrolene (medication that uncouples the heat generating mechanism in the muscles).”

“AGREEMENTS AND ARRANGEMENTS CFR(s): §485.635(c)(4) The person principally responsible for the operation of the CAH under §485.627(b)(2) of this chapter is also responsible for the following: (i) Services furnished in the CAH whether or not they are furnished under arrangements or agreements. (ii) Ensuring that a contractor of services (including one for shared services and joint ventures) furnishes services that enable the CAH to comply with all applicable conditions of participation and standards for the contracted services. This Standard is not met as evidenced by: 16639 Based on interview and record review the facility failed to ensure services provided under contract were reviewed for quality of services. The facility census upon entrance was four Acute Care patients, zero Swing Bed patients and one Observation (Observation - outpatient services provided to a patient while the patient’s physician decides whether to admit the patient to Acute Care services or to discharge the patient) patient for a total census of five. Findings included: 1. During an interview on 02/15/24 at 9:30 AM, Staff A, Chief Executive Officer, stated contracted services did not receive an evaluation of any kind from the governing body or through the quality assurance program. Staff A had looked for a policy related to a review of contracted services and did not find one. 2. Review of governing body meeting minutes and quality assurance meeting minutes for the previous 12 months showed no mention of the quality of contracted services.”

“RECORDS SYSTEM CFR(s): For each patient receiving health care services, the CAH maintains a record that includes, as applicable-- (i) Identification and social data, evidence of properly executed informed consent forms, pertinent medical history, assessment of the health status and health care needs of the patient, and a brief summary of the episode, disposition, and instructions to the patient; This Standard is not met as evidenced by: 36473 Based on policy review, medical record review and interview, the hospital failed to ensure Certified Registered Nurse Anesthetists (CRNAs), completed the informed consents for anesthesia, prior to five surgical patients (#3, #4, #5, #6 and #8) out of seven reviewed. These failures had the potential to effect all patients that presented to the hospital for surgical procedures. The hospital census was four Acute Care patients, zero Swing Bed patients and one Observation (Observation - outpatient services provided to a patient while the patient’s physician decides whether to admit the patient to Acute Care services or to discharge the patient) patient for a total census of five. Findings included: 1.Review of the hospital’s policy titled, “Health Information Management Medical Record Content,” undated, showed the following information must be documented in the informed consent: - Patient identity; - Date when the patient was informed and date signed; - Nature of the procedure; and - Name of who will perform the procedure. 2.Review of Patient #3’s medical record dated 01/03/24, showed no name or authentication of the CRNA, on the Informed Consent for Anesthesia Services, prior to an endoscopy with biopsy procedure. 3.Review of Patient #4’s medical record dated 01/08/24, showed no name or authentication of the CRNA, on the Informed Consent for Anesthesia Services, prior to a Cataract Extraction with Intraoccular Lens Implant procedure. 4.Review of Patient #5’s medical record dated 08/04/23, showed no name or authentication of the CRNA, on the Informed Consent for Anesthesia Services, prior to a Cataract Extraction with Intraoccular Lens Implant with I stents procedure. 5.Review of Patient #6’s medical record dated 08/16/23, showed no name or authentication of the CRNA, on the Informed Consent for Anesthesia Services, prior to a colonoscopy procedure. 6.Review of Patient #8’s medical record dated 10/04/23, showed no name or authentication of the CRNA, on the Informed Consent for Anesthesia Services, prior to a colonoscopy procedure. 7.During an interview on 02/15/24 at 11:00 AM, Staff Q, CRNA, stated they didn’t feel they had to sign the informed consent at the same time as the patient. 8.During an interview on 02/14/24 at 8:15 AM, Staff D, Director of Surgical Services, stated the CRNAs failed to sign the informed consents.”

“ADMINISTRATION OF ANESTHESIA CFR(s): In those cases in which a CRNA administers the anesthesia, the anesthetist must be under the supervision of the operating practitioner except as provided in paragraph (e) of this section. An anesthesiologist’s assistant who administers anesthesia must be under the supervision of an anesthesiologist. This Standard is not met as evidenced by: 16639 Based on record review, interview, and policy review the facility failed to ensure physicians had been privileged to supervise Certified Registered Nurse Anesthetists (CRNA) for the administration of anesthesia for three (Staff AA, BB and CC) of three physicians reviewed. The facility census upon entrance was four Acute Care patients, zero Swing Bed patients and one Observation (Observation - outpatient services provided to a patient while the patient’s physician decides whether to admit the patient to Acute Care services or to discharge the patient) patient for a total census of five. Findings included: 1. Review of credentialing files for Staff AA, Staff BB, and Staff CC did not show a privilege for supervision of CRNA’s was on the privilege form. 2. During an interview on 02/14/24 at 2:00 PM, Staff H, Medical Staff Coordinator, stated the three physicians, AA, BB, and CC performed surgery with the assistance of a CRNA. The privilege form should have included a privilege for the supervision of CRNA’s. 3. Review of the undated facility policy titled CRNA Supervision, showed a reference to a federal law that stated CRNA’s may administer anesthesia when under the supervision of an Operating Practitioner who is immediately available.”

“INFECTION PREVENT SURVEIL & CONTROL OF HAIs CFR(s): The infection prevention and control includes 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: 36473 Based on observation, interview, and policy review, the hospital failed to ensure staff followed infection control policies and infection prevention standards of practice when staff failed to provide maintenance and a rust (reddish-brown oxidation of metal that can harbor bacteria) -free environment in the kitchen. This failed maintenance had the potential to expose all patients, visitors and staff to cross-contamination and increased the potential to spread infection. The hospital census was four Acute Care patients, zero Swing Bed patients and one Observation (Observation - outpatient services provided to a patient while the patient’s physician decides whether to admit the patient to Acute Care services or to discharge the patient) patient for a total census of five. Findings included: 1.Observation on 02/13/24 at 2:15 PM, in the kitchen, showed: - Residue on the ice machine with unclean tape on the front. - Rusted hinges on the door between the service area and the work kitchen. - Floors stained with unclean drains. - Multiple opened cracks in the wall above a sink. - Rusted ceiling tile borders. - Broken floor tile in the cooler and freezer. - A rusted vent to the left of the freezer with an old piece of tape hanging down. - Two carts with a total of eight rusted wheels. - Rust and corrosion on the outside of the dishwasher. - Cracked walls with exposed drywall in the cafeteria. - One stained ceiling tile in the cafeteria. 2.During an interview on 02/14/24 at 2:30 PM, Staff R, Infection Preventionist, stated they had seen some issues in the kitchen but did not place any work orders for repair. 3.Review of the hospital’s policy titled, “Surveillance of Infections,” undated, showed the direction for the Infection Control Nurse to conduct environmental rounds on all departments quarterly. 4.Review of the last three months of infection control rounds logs showed no kitchen surveillance.”

“LEADERSHIP RESPONSIBILITIES CFR(s): (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. This Standard is not met as evidenced by: 36473 Based on interview, record review and nationally-recognized standards, the hospital failed to provide a current Infection Control Plan approved by the Governing Body. This failure had the potential to effect all patients and staff that presented to the hospital for treatment. The hospital census was four Acute Care patients, zero Swing Bed patients and one Observation (Observation - outpatient services provided to a patient while the patient’s physician decides whether to admit the patient to Acute Care services or to discharge the patient) patient for a total census of five. Findings included: 1. Although requested, the hospital failed to provide a current Infection Control Plan approved by the Governing Body. 2. During an interview on 02/14/24 at 2:30 PM, Staff R, Infection Preventionist, stated they did not have a current Infection Control Plan. 3. Review of the Centers for Disease Control and Prevention (CDC), titled, “Core Infection Prevention and Control Practices for Safe Healthcare Delivery”, dated 11/29/22, showed the required ensurance of the Governing Body’s accountability for the success of infection prevention activities in a health care facility.”

“COMP ASSESSMENT, CARE PLAN & DISCHARGE CFR(s): §485.645(d)(5) Comprehensive assessment, comprehensive care plan, and discharge planning (§483.20(b), and §483.21(b) and (c)(2) of this chapter), except that the CAH is not required to use the resident assessment instrument (RAI) specified by the State that is required under §483.20(b), or to comply with the requirements for frequency, scope, and number of assessments prescribed in §413.343(b) of this chapter). “ §483.20(b) Comprehensive assessments- (1) Resident assessment instrument. A facility must make a comprehensive assessment of a resident’s needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS. The assessment must include at least the following: (i) Identification and demographic information. (ii) Customary routine. (iii) Cognitive patterns. (iv) Communication. (v) Vision. (vi) Mood and behavior patterns. (vii) Psychosocial well-being. (viii) Physical functioning and structural problems. (ix) Continence. (x) Disease diagnoses and health conditions. (xi) Dental and nutritional status. (xii) Skin condition. (xiii) Activity pursuit. (xiv) Medications. (xv) Special treatments and procedures. (xvi) Discharge planning. (xvii) Documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS). (xviii) Documentation of participation in assessment. The assessment process must include direct observation and communication with the resident, as well as communication with licensed and nonlicensed direct care staff members on all shifts. (2) When required. Subject to the timeframes prescribed in §413.343(b) of this chapter, a facility must conduct a comprehensive assessment of a resident in accordance with the timeframes specified in paragraphs (b)(2) (i) through (iii) of this section. The timeframes prescribed in §413.343(b) of this chapter do not apply to CAHs. (i) Within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident’s physical or mental condition. (For purposes of this section, “readmission” means a return to the facility following a temporary absence for hospitalization or for therapeutic leave.) (ii) Within 14 calendar days after the facility determines, or should have determined, that there has been a significant change in the resident’s physical or mental condition. (For purposes of this section, a “significant change” means a major decline or improvement in the resident’s status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the resident’s health status, and requires interdisciplinary review or revision of the care plan, or both.) (iii) Not less often than once every 12 months. “ §483.21(b) Comprehensive care plans. (1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident’s medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following: (i) The services that are to be furnished to attain or maintain the resident’s highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25, or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25, or §483.40 but are not provided due to the resident’s exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (i) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident’s medical record. (ii) In consultation with the resident and the resident’s representative(s)- (A) The resident’s goals for admission and desired outcomes. (B) The resident’s preference and potential for future discharge. Facilities must document whether the resident’s desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. (2) A comprehensive care plan must be- (i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to- (A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident’s representative(s). An explanation must be included in a resident’s medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident’s care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident’s needs or as requested by the resident. (iii) Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. (3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (i) Meet professional standards of quality. (ii) Be provided by qualified persons in accordance with each resident’s written plan of care. (iii) Be culturally-competent and trauma-informed. “ §483.21(c)(2) Discharge summary. When the facility anticipates discharge a resident must have a discharge summary that includes, but is not limited to, the following: (i) A recapitulation of the resident’s stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results. (ii) A final summary of the resident’s status to include items in paragraph (b)(1) of §483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident’s representative. (iii) Reconciliation of all pre-discharge medications with the resident’s post-discharge medications (both prescribed and over-the-counter). (iv) A post-discharge plan of care that is developed with the participation of the resident and, with the resident’s consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment. The post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident’s follow up care and any post-discharge medical and non-medical services. This Standard is not met as evidenced by: 18018 Based on policy review, document review, record review, and interview, the facility failed to: - Complete a comprehensive quality of life activities assessment, which identified specific individualized, activity interest for two of two current Swing Bed (Swing Bed - a Medicare program in which a patient can receive acute care services, then if needed Skilled Nursing Home Care) patients (#20 and #21) and for two of two discharged Swing Bed patients (#22, and #23) reviewed for a complete comprehensive quality of life activities assessment. - Provide specific, individualized activity interests that stimulated the patient’s physical and mental well-being for two of two current Swing Bed patients (#20 and #21) and for two of two discharged Swing Bed patients (#22 and #23) reviewed for specific, individualized activity interests. - Develop a comprehensive activity care plan, which included activity interests and interventions for two of two current Swing Bed patients (#20 and #21) and for two of two discharged Swing Bed (#22 and #23) patients reviewed for a comprehensive activity care plan. These failed practices had the potential to affect all Swing Bed patients by failing to stimulate their minds, body and social interests. The facility census upon entrance was four Acute Care patients, zero Swing Bed patients and one Observation (Observation - outpatient services provided to a patient while the patient’s physician decides whether to admit the patient to Acute Care services or to discharge the patient) patient for a total census of five. Findings included: 1. Review of the facility’s policy titled, “Nursing Care Plan,” undated showed in part staff directives: - To establish a uniform guide for establishing individualized patient nursing care plans. - The RN (Registered Nurse) is to utilize input from other delegated health care team members in the initiation and the revision of the plan. - The RN is also responsible for the coordination and implementation of the patient’s plan of care following completion of the Admission Assessment. - The plan is updated and revised periodically based on evaluation of patient progress/achievement of goals. - The patient/family may be included in the planning, evaluation, and revision of the plan. 2. Review of the facility document titled, “Swing Bed Program,” dated 11/23, provided to patients admitted to the facility’s Swing Bed Program showed services provided to patients under Activities/Social Services: The hospital will provide for an ongoing program of activities and medically related social services designed to meet the interest and the physical, mental, and psychosocial well being of each patient. 3. Review of Patients’ Electronic Medical Health Records (EMHR) showed: - Patient #20 was admitted to the facility’s Swing Bed program on 02/13/24, with complaints of falls at home and weakness; - Patient #21 was admitted to the facility’s Swing Bed program on 01/05/24, with complaints of pneumonia and generalized weakness; - Patient #22 was admitted to the facility’s Swing Bed program on 01/19/24, with complaints of status post right hip fracture/repair; and - Patient #23 was admitted to the facility’s Swing Bed program on 01/28/24 with complaints of chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Patients’ #20, #21, #22, and #23 EMHR showed staff failed to conduct a comprehensive quality of life activity assessment of the patients to assist in identifying the patients’ activity interests and staff failed to develop a comprehensive activity care plan for the patients during the patients stay in the facility’s Swing Bed program. 4. During an interview on 02/14/24 at 11:45 AM, Staff P, Registered Nurse (RN), Analytics Nurse, acknowledged the patients admitted to the facility’s Swing Bed program did not have neither an activity assessment nor activity care plan in the patients’ EMHR. 5. During an interview on 02/14/24 at 12:10 PM, Staff B, RN, Chief Nursing Officer, stated the facility received information from the Hospital Association that the Swing Bed Program was no longer required to perform either an activity assessment or include activities in the patient’s care plan because the activity requirement was no longer a regulatory requirement for a facility’s Swing Bed Program. Staff B stated the facility stopped performing activity assessments and including activities in patients’ care plan after receiving notice activities were no longer a regulatory requirement for patients admitted to a facility’s Swing Bed Program.”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS. This Standard is not met as evidenced by: 16639 Based on observation and interview the facility failed to ensure two of three fire/smoke walls observed were able to resist the passage of smoke or fire due to the presence of penetrations. The facility census upon entrance was four Acute Care patients, zero Swing Bed patients and one Observation (Observation - outpatient services provided to a patient while the patient’s physician decides whether to admit the patient to Acute Care services or to discharge the patient) patient for a total census of five. Findings included: 1. Observation on 02/14/24 at approximately 9:00 AM of a wall near zone E1 showed one two inch in diameter hole in the wall above the ceiling. The wall near zone C1 had two one half inch in diameter holes. 2. During an interview on 02/14/24 at approximately 9:00 AM, Staff I, Facility Services Supervisor, confirmed the walls were not smoke tight due to the presence of holes which had not been repaired.”