Jefferson County Hospital

“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: 45467 Based on observation, interview, and policy and procedure review, the facility failed to post signs which specify the rights of individuals with emergency medical condition’s (EMC’s) and women in labor in a place or places likely to be noticed by all individuals entering the emergency department on three (3) of three (3) days of survey. Findings Include: Observation of the Emergency Department (ED) revealed there were no visible postings of the Emergency Medical Treatment And Labor Act (EMTALA) at the ED entrance, admitting area, waiting room or treatment areas. During an interview with Registered Nurse (RN) #1 on 05/01/2024 at 2:54 p.m., it was confirmed that there are no signs available to be posted in any areas of the ED. Review of facility policy and procedure EMTALA Transfer Policy dated 06/01/2023 revealed, “ ...policy is to provide guidance and processes to comply with the laws and regulations applicable to patients with an Emergency Medical Condition (EMC) who either request or require transfer to a receiving facility following the EMTALA ...to ensure the public has access to emergency services regardless of their ability to pay ...This includes active labor as well ...”. During the exit conference held on 05/03/2024 at 5:00 p.m., findings were discussed with the Administrator and Payroll Clerk. No further documents submitted for review.”

“Delivery of services. CFR(s): (b)(3) Outdated, mislabeled, or otherwise unusable drugs and biologicals must not be available for patient use. This Standard is not met as evidenced by: 45467 Based on observation, staff interviews, policy and procedure review, the facility failed to remove outdated medications available for patient use from the crash cart in the Emergency Department on three (3) of three (3) days of survey. Findings Include: Observation of the crash cart in the Emergency Department at 2:40 p.m. on 05/01/2024 with RN #1 and Certified Respiratory Therapist revealed; expired medication in the Crash Cart are as follows: Three (3) Procainamide Hydrochloride injection 100 milligrams (mg) per milliliter (ml), Lot #KS074D2, Expiration date 03-24 (March 2024). Five (5) Clopidogrel 75 mg tablets, Lot # 1008081, expiration date 04/24 (April 2024). Three (3) Potassium Chloride injection 20 milliequivalents (mEq) per 10 ml, lot #6025748, expiration date 04/24 (April 2024). Calcium Gluconate 1000 mg per 50 ml, 20 mg per ml for infusion, lot # 10031 expiration date 01/2024 (January 2024). During an interview with RN #1 on 05/01/2024 at 2:40 p.m. RN #1 confirmed the above expired medications in the crash cart. During an interview with Pharmacist on 05/01/2024 at 3:52 p.m. it was confirmed that the nursing staff are responsible for monitoring expired medications in the crash cart. Review of facility policy and procedure Medication Management Policy dated 06/01/2023 revealed, “ ...medication management process ...ensure medications are ...monitored according to nationally evidenced-based practice and standards of care ...Ensure compliance with federal and state laws and regulations ...all expired ...medications ...to prevent them from being administered ...”. During the exit conference held on 05/03/2024 at 5:00 p.m., the findings were discussed with the Administrator and Payroll Clerk. No further documents submitted for review.”

“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: 46164 Based on observation and staff interview, the facility failed to appoint an individual qualified through education, training and experience or certified in infection prevention and control as the infection preventionist(s)/infection control professional responsible for the infection control program for three (3) of three (3) days of survey. Findings Include: During an interview with the Administrator on 05/01/2024 at 4:15 p.m., it was confirmed the designated infection preventionist resigned March 31, 2024, and an appointment for replacement has not been made and no one has been temporarily appointed to fulfill the role of infection preventionist. No documented evidence of a policy and procedure regarding the designation of an infection preventionist/infection control professional or letter of appointment for an infection preventionist/infection control professional available for review. During the exit conference on 05/02/2024 at 5:10 p.m. with the Administrator and the payroll clerk, survey findings were discussed, and no further documentation was submitted for review.”

“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: 40118 Based on staff interviews and review of the Board of Trustees meeting minutes, the Rural Emergency Hospital (REH), established in June 2023, failed to provide established polices, to implement and furnish services in accordance with those policies and procedures consistent with state law on two (2) of two (2) survey days. Findings Include: Interview on 03/20/2024 at 5:05 p.m. with Registered Nurse #2 confirmed she had not been educated on or provided a copy of the REH policy and procedures. Interview on 03/21/2024 at 1:00 p.m. with the Administrator confirmed he does not currently have any REH policies and procedures for the facility. Interview on 03/21/2024 at 4:20 p.m. with the Payroll Clerk confirmed the facility was unable to locate the REH policies and procedures. Interview on 03/21/2024, at 4:34 p.m. with Chairman of the Board revealed she requested to see the facility’s REH policy and procedures during the September 20, 2023, Board of Trustees meeting and was told she could see them, but denies ever being provided access to or a copy of the facility’s REH policy and procedures. Review of the facility’s requested and submitted documentation for review revealed no documented evidence of the facility’s REH policy and procedure manual was provided for review. Review of the facility’s, “Board of Trustees Meeting Minutes.” from January 2023 to September 2023 revealed no documented evidence of approval or presentation of the facility’s REH policy and procedures. Review of the facility’s “Board of Trustees Meeting Minutes,” dated September 20, 2023, page 3 of 4 further revealed, the Chairman of the Board “ ...asked since we are almost there, will we be able to see the policies...” The former Administrator replied, “ ...Absolutely ...”. Exit conference held on 03/21/2024 at 5:00 p.m. with the Administrator and Payroll employee to discuss survey findings with no further information submitted.”