Poplar Community Hospital

“Subsistence Needs for Staff and Patients CFR(s): §403.748(b)(1), §418.113(b)(6)(iii), §441.184(b)(1), §460.84(b)(1), §482.15(b)(1), §483.73(b)(1), §483.475(b)(1), §485.542(b)(1), §485.625(b)(1) [(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 every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following: (1) The provision of subsistence needs for staff and patients whether they evacuate or shelter in place, include, but are not limited to the following: (i) Food, water, medical and pharmaceutical supplies (ii) Alternate sources of energy to maintain the following: (A) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions. (B) Emergency lighting. (C) Fire detection, extinguishing, and alarm systems. (D) Sewage and waste disposal. *[For Inpatient Hospice at §418.113(b)(6)(iii):] Policies and procedures. (6) The following are additional requirements for hospice-operated inpatient care facilities only. The policies and procedures must address the following: (iii) The provision of subsistence needs for hospice employees and patients, whether they evacuate or shelter in place, include, but are not limited to the following: (A) Food, water, medical, and pharmaceutical supplies. (B) Alternate sources of energy to maintain the following: (1) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions. (2) Emergency lighting. (3) Fire detection, extinguishing, and alarm systems. (C) Sewage and waste disposal. This Standard is not met as evidenced by: 32381 Based on record review the facility failed to plan and implement a provision of subsistence needs for the staff and the residents. This affects all occupants in the facility. Findings include: 1. Review of the EP plan, policies, and procedures on 5/14/24, reflected the facility’s emergency plan lacked policies and procedures for subsistence needs for staff and residents, particularly specific policies describing alternate sources of energy to maintain proper temperatures, emergency lighting, and for the sprinkler and alarm systems, as well as sewage and waste disposal in a time of loss of power and/or water.”

“Based on the regulatory requirements and standards of 42 Code of Federal Regulations (CFR) 485.623(d) for Critical Access Hospitals (CAHs), a life safety code survey was performed on 5/14/24. Under this regulatory requirement, the facility must meet the applicable provisions of the National Fire Protection Association’s (NFPA) 101 Life Safety Code, 2012 Edition, and those mandatory Codes referenced by that edition. The facility was surveyed specifically using Chapter 19 Existing Health Care Occupancies of NFPA 101. The building construction type was found to be Type II (222) for the 1958 building and Type II (111) for the 1990 addition. There is a two-hour separation between the Clinic and the CAH. These requirements were not met as evidenced by the following deficiencies:”

“Egress Doors CFR(s): NFPA 101 Egress Doors Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements: CLINICAL NEEDS OR SECURITY THREAT LOCKING Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times. 18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6 SPECIAL NEEDS LOCKING ARRANGEMENTS Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation. 18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4 DELAYED-EGRESS LOCKING ARRANGEMENTS Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted. 18.2.2.2.4, 19.2.2.2.4 ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 This Standard is not met as evidenced by: 32381 Based on observation, the facility failed to ensure doors in the path of egress did not require the use of a key, a tool, or special knowledge or effort for operation from the egress side in accordance with NFPA 101-2012, Section 7.2.1.5.3, 7.2.1.5.10, and 7.2.1.6. Facilities can only lock doors and gates in the case of clinical need such as a special care unit. Findings include: 1. During an observation on 5/14/24 at 9:35 a.m., the horizontal sliding doors leaving the ER area were found to be magnetically locked, with an electronic “push to exit” button inside the door. Entry to the ER from the outside was with an electronic device using a card to unlock the doors and enter. The system is set up as an “access-controlled” egress special locking arrangement. The motion detector was not a part of the system on the egress side of the door. Whatever type of special locking arrangement they want to utilize throughout the facility, either delayed egress, or access-controlled egress, the facility must then apply all the features the code requires in NFPA 101-2012 Section 7.2.1.6. The locked doors in the lighted path of egress must also unlock and be open to occupants in the event the sprinkler or fire detection systems are activated.”

“Emergency Lighting CFR(s): NFPA 101 Emergency Lighting Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9. 18.2.9.1, 19.2.9.1 This Standard is not met as evidenced by: 32381 Based on record review, the facility failed to provide emergency lighting per NFPA 101-2012, Sections 19.2.9.1 and 7.9.3.1.1. Findings include: 1. Review of the facility records for testing of the emergency lighting documentation on 5/14/24 showed the facility had only performed a 30 second test on the emergency lighting, but failed to do the required 90 minute test annually, in a way that the battery was being tested. The last 90 minute test of the emergency lights was in February of 2023.”

“Exit Signage CFR(s): NFPA 101 Exit Signage 2012 EXISTING Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system. 19.2.10.1 (Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.) This Standard is not met as evidenced by: 32381 Based on observation, the facility failed to ensure all exit passageways were marked in accordance with NFPA 101 2012 Edition, Section 7.1.10.2.1, and Section 7.10.1.2.2. Findings include: 1. During an observation on 5/14/24 at 10:36 a.m., the corridor from the swing-bed wing to the hospital was inspected for egress and signage. It was found to be missing an internally lit exit sign to guide occupants out of the swing-bed corridor and into the hospital.”

“Hazardous Areas - Enclosure CFR(s): NFPA 101 Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322) This Standard is not met as evidenced by: 32381 Based on observation, the facility failed to ensure hazardous rooms/areas had doors which were able to close, and latch under the power of a self-closing device, in accordance with NFPA 101, 2012 Edition, Sections 19.3.2.1 and 19.3.2.1.3. Findings include: 1. During an observation on 5/14/24 at 10:01 a.m., patient room 117 was being used a storage room. The corridor door would not close and latch under the power of a self-closer. 2. During an observation on 5/14/24 at 10:03 a.m., the med-surge inventory room was a storage room over 50 square feet in size. The corridor door was lacking the necessary self-closing device. 3. During an observation on 5/14/24 at 10:33 a.m., the swing bed clothing storage room was inspected. The room is over 50 square feet and was lacking the necessary self-closing device on the corridor door.”

“Laboratories CFR(s): NFPA 101 Laboratories Laboratories employing quantities of flammable, combustible, or hazardous materials that are considered a severe hazard are protected by 1-hour fire resistance-rated separation, automatic sprinkler system, and are in accordance with 8.7 and with NFPA 99. Laboratories not considered a severe hazard are protected as hazardous areas (see K321). Laboratories using chemicals are in accordance with NFPA 45, Standard on Fire Protection for Laboratories Using Chemicals. Gas appliances are of appropriate design and installed in accordance with NFPA 54. Shutoff valves are marked to identify material they control. Devices requiring medical grade oxygen from the piped distribution system meet the requirements under 11.4.2.2 (NFPA 99). 19.3.2.2, 8.7, 8.7.4.1 (LSC) 9.3.1.2, 11.4.3.2, 15.4 (NFPA 99) This Standard is not met as evidenced by: 32381 Based on observation, the facility failed to ensure the laboratory had doors which were able to close, and latch under the power of a self-closing device, in accordance with NFPA 101, 2012 Edition, Sections 19.3.2.2 and 8.7.1.3. Findings include: 1. During an observation on 5/14/24 at 9:15 a.m., the laboratory was inspected. The corridor door to the lab was found to be wedged open. The corridor door is on a self-closer, as the lab must be protected as a hazardous area.”

“Alcohol Based Hand Rub Dispenser (ABHR) CFR(s): NFPA 101 Alcohol Based Hand Rub Dispenser (ABHR) ABHRs are protected in accordance with 8.7.3.1, unless all conditions are met: * Corridor is at least 6 feet wide * Maximum individual dispenser capacity is 0.32 gallons (0.53 gallons in suites) of fluid and 18 ounces of Level 1 aerosols * Dispensers shall have a minimum of 4-foot horizontal spacing * Not more than an aggregate of 10 gallons of fluid or 135 ounces aerosol are used in a single smoke compartment outside a storage cabinet, excluding one individual dispenser per room * Storage in a single smoke compartment greater than 5 gallons complies with NFPA 30 * Dispensers are not installed within 1 inch of an ignition source * Dispensers over carpeted floors are in sprinklered smoke compartments * ABHR does not exceed 95 percent alcohol * Operation of the dispenser shall comply with Section 18.3.2.6(11) or 19.3.2.6(11) * ABHR is protected against inappropriate access 18.3.2.6, 19.3.2.6, 42 CFR Parts 403, 418, 460, 482, 483, and 485 This Standard is not met as evidenced by: 32381 Based on observation, the facility failed to ensure alcohol-based hand rub (ABHR) dispensers were not mounted over ignition sources in accordance with NFPA 101, 2012 Edition, Section 19.3.2.6 (8). Findings include: 1. During an observation on 5/14/24 at 9:20 a.m., the trauma room was inspected. There was an ABHR mounted on the wall above a light switch in the room. 2. During an observation 5/14/23 at 9:44 a.m., the soiled utility room in the ER was inspected. There was an ABHR station mounted over a light switch in the room.”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 32381 Based on observation, interview, and record review, the facility failed to: a) complete an internal inspection every five years, in accordance with NFPA 25, Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Sections 13.2.7.1 and 13.2.7.2, b) maintain the monthly gauge readings on the sprinkler riser per NFPA 25-2011, Section 5.2.4.2. c) maintain sprinkler heads free of foreign materials per NFPA 25 Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 5.2.1.1.1, d) maintain spare sprinklers in accordance with NFPA 25 Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 5.4.1.5. e) inspect and maintain the sprinkler system in accordance with NFPA 13, 2010 Edition, Section 6.2.7.2. f) ensure the inspector’s test orifice was installed in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.17.4.2.1. Findings include: 1. Review of the facility’s sprinkler reports and through observation on 5/14/24 at 9:00 a.m., revealed the facility had not completed a 5-year internal inspection of the control valve and piping. The vendor kept stating it was due on the quarterly inspections, but the facility did not ensure it was completed. 2. During a review of facility sprinkler records and an interview on 5/14/24 at 8:00 a.m., staff member A, stated the facility was not actively documenting the sprinkler pressures at the standpipe. 3. During an observation on 5/14/24 at 9:20 a.m., the ER was inspected. There was a sprinkler head in the room that was choked with debris to the point you could not see the fusible bulb. 4. During an observation on 5/14/24 at 9:40 a.m., the sprinkler system standpipe was inspected. The box of spare sprinkler heads was found to be lacking the sidewall or directional type sprinkler heads. The facility had many sidewall heads in use. 5. During an observation on 5/14/24 at 9:42 a.m., the private exam room was inspected, an escutcheon ring was missing from a sprinkler head in the room. 6. During an observation on 5/14/24 at 10:25 a.m., the inspector’s test valve and orifice in the boiler room were inspected. The valve was a 1” valve on a 1” pipe. This is too large to be a legitimate test. The testing orifice cannot be larger than the smallest orifice on the system.”

“Fire Drills CFR(s): NFPA 101 Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 19.7.1.4 through 19.7.1.7 This Standard is not met as evidenced by: 32381 Based on record review, the facility failed to ensure the fire safety plan and subsequent drills documented all requirements listed in the the code for responding to a fire drill per NFPA 101. 2012 Edition, section 19.7.1.2. Findings include: 1. Review of the facility fire drills going back a year reflected the facility lacked documentation in regards to all the elements required by code for the fire safety plan. Some of the fire drill sheets were also not filled out in regards to what the scenario of the drill was, whether the hallway was cleared, and the smoke compartments evacuated or not, or whether there was a simulated call to the fire department as to whether the fire was real or not, and where it was located per the fire panel.”

“Maintenance, Inspection & Testing - Doors CFR(s): Maintenance, Inspection & Testing - Doors Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability. Written records of inspection and testing are maintained and are available for review. 19.7.6, 8.3.3.1 (LSC) 5.2, 5.2.3 (2010 NFPA 80) This Standard is not met as evidenced by: 32381 Based on record review, the facility failed to test the fire doors in fire assemblies annually in accordance with NFPA 101-2012, Sections 7.2.1.15.1, 4.6.12 and in accordance with NFPA 80-2010, Section 5.2 (written report). Findings include: 1. Review of the fire safety maintenance records on 5/14/24, reflected the facility had not completed inspections of the fire doors on an annual basis. The facility must identify the required fire/smoke barriers, as well as electronically controlled doors and doors with special locking arrangement in the building and show inspections of all components of the doors in those barriers as related to NFPA 80. The facility copied the requirements listed in NFPA 80 chapter 5.”

“Gas Equipment - Cylinder and Container Storag CFR(s): NFPA 101 Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum “CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING.” Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99) This Standard is not met as evidenced by: 32381 Based on observation the facility failed to maintain gas cylinders per NFPA 99-2012, Section 11.6.2.3. Findings Include: 1. During an observation on 5/14/24 at 10:24 a.m., the oxygen storage room was inspected. There was a free-standing E-sized tank in the room with the other tanks. There were other slots in the rack which were open for the tank to have been placed.”

“INFECTION PREVENT & CONTROL & ABT STEWAR PROG CFR(s): The CAH must have active facility-wide programs, for the surveillance, prevention, and control of HAIs and other infectious diseases and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic-resistant organisms. Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in coordination with the facility-wide quality assessment and performance improvement (QAPI) program. This Condition is not met as evidenced by: 47752 Due to the manner and degree of the deficient practice, the facility failed to meet the Condition of Participation for Infection Prevention and Control. Based on interview and record review, the facility failed to: -Ensure the individuals employed as the Infection Prevention and Control Specialists were qualified through education, training, experience, and/or certification in infection prevention and control practices. (See C1204) -Ensure specific tracking and trending of infections were established for the Infection Prevention and Control Program. (See C1208) -Ensure an antibiotic stewardship program was established and adhered to nationally recognized guidelines. (See C1221) -Ensure the facility had a system in place for active surveillance, prevention, and control of all infections, to include antibiotic use. (See C1225) -Ensure the individuals employed as the Infection Prevention and Control Specialists were qualified to develop and implement a facility wide infection control, surveillance, and prevention program based on nationally recognized guidelines. (See C1231) -Ensure complete documentation of the infection prevention and control program, to include surveillance, and tracking of infections. (See C1235) -Ensure the individuals employed as the Infection Prevention and Control Specialists provided competency-based training and education to all personnel and staff, including the medical staff, on the practical applications of antibiotic stewardship guidelines, policies, and procedures. (See C1250)”

“GOVERNING BODY AND TELEMEDICINE SERVICES CFR(s): §485.616(c)(3) The governing body of the CAH must ensure that when telemedicine services are furnished to the CAH’s patients through an agreement with a distant-site telemedicine entity, the agreement is written and specifies that the distant-site telemedicine entity is a contractor of services to the CAH and as such, in accordance with §485.635(c)(4)(ii), furnishes the contracted services in a manner that enables the CAH to comply with all applicable conditions of participation for the contracted services, including, but not limited to, the requirements in this section with regard to its physicians and practitioners providing telemedicine services. §485.616(c)(4) When telemedicine services are furnished to the CAH’s patients through an agreement with a distant-site telemedicine entity, the CAH’s governing body or responsible individual may choose to rely upon the credentialing and privileging decisions made by the governing body of the distant-site telemedicine entity regarding individual distant-site physicians or practitioners. The CAH’s governing body or responsible individual must ensure, through its written agreement with the distant-site telemedicine entity, that the following provisions are met: (i) The distant-site telemedicine entity’s medical staff credentialing and privileging process and standards at least meet the standards at (c)(1)(i) through (c)(1)(vii). (ii) The individual distant-site physician or practitioner is privileged at the distant-site telemedicine entity providing the telemedicine services, which provides a current list to the CAH of the distant-site physician’s or practitioner’s privileges at the distant-site telemedicine entity. (iii) The individual distant-site physician or practitioner holds a license issued or recognized by the State in which the CAH whose patients are receiving the telemedicine services is located. (iv) With respect to a distant-site physician or practitioner, who holds current privileges at the CAH whose patients are receiving the telemedicine services, the CAH has evidence of an internal review of the distant-site physician’s or practitioner’s performance of these privileges and sends the distant-site telemedicine entity such information for use in periodic appraisal of the distant-site physician or practitioner. At a minimum, this information must include all adverse events that result from the telemedicine services provided by the distant-site physician or practitioner to the CAH’s patients and all complaints the CAH has received about the distant-site physician or practitioner. This Standard is not met as evidenced by: 41652 Based on interview and record review, the facility failed to ensure practitioners providing telemedicine services were appointed to the facility’s medical staff and granted privileges associated with the provision of telemedicine services. Findings include: Review of the credentialing file for staff member AA failed to show current documentation of the Governing Board’s approval of staff member AA’s membership on the medical staff, and the granting of the necessary privileges for the provision of telemedicine services. Staff member AA’s most recent Governing Board approval was dated December of 2021. The current approval should have been completed by December of 2023. Review of the credentialing file for staff member BB failed to show current documentation of the Governing Board’s approval of staff member BB’s membership on the medical staff, and the granting of the necessary privileges for the provision of telemedicine services. Staff member BB’s most recent Governing Board approval was dated January of 2021. The current approval should have been completed by January of 2023. Review of the facility’s teleradiology services agreement, dated 8/11/23, showed, “Each Physician ...shall be appointed to the Facility’s Medical Staff, ... and thereby obtain clinical privileges to carry out the duties described herein ...” Review of the facility’s Medical Staff By-Laws. dated 9/29/22, showed, “1. Telemedicine Service Physicians shall be considered Courtesy Staff under these By-Laws ...” During an interview on 5/9/24 at 9:05 a.m., staff member A stated he had reviewed the minutes from the Governing Board, dated from January of 2023 through April of 2024. Staff member A stated he was not able to find current Governing Board approval for staff members AA and BB.”

“NURSING SERVICES CFR(s): A nursing care plan must be developed and kept current for each inpatient. This Standard is not met as evidenced by: 41652 47752 Based on interview and record review, the facility failed to complete a comprehensive, person-centered care plan for inpatient admissions for 9 (#s 1, 2, 7, 12, 13, 14, 21, 40, and 42) of 21 sampled patients admitted into inpatient status. This deficient practice had the potential to affect all patients admitted to the hospital as an inpatient. Findings include: Review of patient #1’s EMR, dated 5/3/24 to 5/6/24, showed patient #1 was admitted to inpatient status with the diagnoses of nausea, vomiting and weakness. Patient #1 was discharged on 5/6/24. No comprehensive, person-centered care plan was implemented and failed to identify or address the areas of nausea, vomiting or weakness. Review of patient #2’s EMR, dated 4/9/24 to present, showed the patient was admitted with end-stage liver disease, ascites, heart failure, community-acquired pnuemonia, and multi-system organ failure. The care plan focus areas were for pain management and fall prevention. The care plan failed to identify the liver disease, the need for frequent paracenteses to drain the re-occurring ascites, antibiotic usage, and respiratory issues related to the pneumonia. Review of patient #7’s EMR, dated 4/6/24 to 4/7/24, showed patient #7 was admitted to inpatient status with the diagnoses of alleged assult, rib fracture, alcohol intoxication, seizures, perinephric hematoma, and intravenous drug use. Patient #7 was discharged on 4/7/24. No comprehensive, person-centered care plan was implemented and failed to identify or address the areas of alleged assult, alcohol intoxication, perinephric hematoma, or intravenous drug use. Review of patient #12’s EMR, dated 11/21/23 to 11/24/23, showed the patient was admitted with diagnoses of community-acquired pneumonia, chronic kidney disease, a urinary tract infection, bilateral lower extremity cellulitis, and metabolic encephalopathy. The patient’s care plan failed to identify any of the problem areas listed above. Review of patient #13’s EMR, dated 10/16/23 to 10/24/23, showed the patient was admitted with altered mental status, a urinary tract infection, sepsis, and dehydration. The patient’s care plan identified fall prevention and VTE prophylaxsis. The care plan failed to identify any of the focus areas from the patient’s diagnoses. Review of patient #14’s EMR, dated 10/13/23 to 10/16/23, showed the patient was admitted with bladder cancer with questionable metastasis and a urinary tract infection. The patient’s care plan failed to identify the genitourinary system. Review of patient #21’s EMR, dated 9/13/23 to 9/22/23, showed the patient was admitted with diagnoses of end-of-life care, metastatic liver cancer, and HIV. The patient’s care plan failed to identify any of the focus areas associated with his diagnoses. Review of patient #40’s EMR, dated 5/4/23 to 5/7/23, showed patient #40 was admitted to inpatient status with the diagnosis of abdominal pain. Patient #40 was discharged on 5/7/23. No comprehensive, person-centered care plan was implemented and failed to identify or address the area of abdominal pain. Review of patient #42’s EMR, dated 4/7/24 to 4/8/24, showed patient #42 was admitted to inpatient status with the diagnoses of alcohol abuse and detoxing. Patient #42 was discharged on 4/8/24. No comprehensive, person-centered care plan was implemented and failed to identify or address the areas of alcohol abuse or detoxing. During an interview on 5/8/24 at 1:10 p.m., staff member B stated care plans were started on admission by the nursing staff. During an interview on 5/8/24 at 2:03 pm., staff member F stated when a patient was admitted to acute care, nursing staff started the care plans. Staff member F stated the care plans are also to be documented on for progression and completion of patient goals. During an interview on 5/9/24 at 8:00 a.m., staff member F stated the EMR system did not provide a wide variety of options for care plan focus areas. Staff member F stated this made having comprehensive, patient-centered care plans difficult. During an interview on 5/9/24 at 8:15 a.m., staff member B stated the EMR system had a limited amount of choices for care plan focus areas. Review of a facility document titled, “Care Plans/IPOCs,” with a revision date of 1/12/16, showed: “It is the policy of [Name of Service] to provide an individualized interdisciplinary plan of care (IPOC) for all patient through the use of care planning... A. Upon admission all patients shall have an IPOC generated by the admitting nurse under the supervision of the charge nurse.””

“RECORDS SYSTEM CFR(s): The records are legible, complete, accurately documented, readily accessible, and systematically organized. This Standard is not met as evidenced by: 47752 Based on interview and record review, the facility failed to ensure an admission consent form was completely filled out at the time of admission for 1 (#8) of 21 sampled patients who were admitted to the hospital. This deficient practice had the potential to affect all patients admitted to the hospital. Findings include: A review of patient #8’s EMR, dated 3/9/24 to 3/12/24, showed patient #8 had signed the admission consent form. The admission consent form was not completely filled out with the required information. Patient #8’s admission consent form did not contain a printed name, date of birth, mailing address, phone number, or the name of a primary provider. During an interview on 5/8/24 at 1:30 p.m., staff member B stated all admission consent forms should be completely filled out by the staff member who was admitting the patient. During an interview on 5/9/24 at 9:30 a.m., staff member W stated her department was responsible for making sure the medical records were complete. Staff member W stated, “We check medical records in our daily work. We check to make sure consents are properly filled out. I now realize this is not accurately being completed.” Staff member W stated, “It is usually the admitting nurse or ward clerks responsibility to make sure documents are complete, but my department is supposed to double check for completeness before it is placed in the medical record.””

“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: 41652 Based on interview and record review, the facility failed to ensure properly executed informed consents were completed for procedures performed for 1 (#2) of 21 sampled patients who were admitted to the hospital. Findings include: Review of patient #2’s EMR showed the patient had multiple paracenteses, two of which occurred on 4/12/24 and 4/13/24. Review of patient #2’s informed consents, dated 4/12/24 and 4/13/24, showed the provider who performed the procedure did not sign or date either of the consents. During an interview on 5/9/24 at 9:35 a.m., staff member W stated it was the responsibility of the HIM department to ensure informed consents were completed properly. Staff member W stated they should have identified patient #2’s informed consents, dated 4/12/24 and 4/13/24, were not properly completed.”

“RECORDS SYSTEM CFR(s): Reports of physical examinations, diagnostic and laboratory test results, including clinical laboratory services, and consultative findings; This Standard is not met as evidenced by: 41652 47752 Based on interview and record review, the facility failed to ensure a physician co-signed the history and physical for acute inpatient admissions for 4 (#s 1, 8, 10, and 12) of 21 sampled patients who were admitted to the hospital. This deficient practice had the potential to affect all patients admitted to the hospital. Findings include: Review of patient #1’s EMR, dated 5/3/24 to 5/6/24, showed patient #1 was admitted to inpatient status on 5/3/24 by staff member O. No physician co-signature was noted on the admission history and physical. Review of patient #8’s EMR, dated 3/9/24 to 3/12/24, showed patient #8 was admitted to inpatient status on 3/9/24 by staff member Z. No physician co-signature was noted on the admission history and physical. Review of patient #10’s History and Physical form, dated 2/12/24, showed it was completed by staff member O, who was an APRN. The form failed to show an MD or DO co-signature. Review of patient #12’s History and Physical form, dated 11/21/23, showed it was completed by staff member O, an APRN. The form failed to show the co-signature of an MD or DO. During an interview on 5/8/24 at 3:00 p.m., staff member Q stated he was responsible for co-signing acute inpatient history and physicals, and acute care notes. Staff member Q stated he provided oversight to the mid-level providers in the hospital. Staff member Q stated if he was notified through the medical record, he could sign off on documentation pretty quickly. He stated if he was not messaged through the medical record, it took a little longer to review and sign off on the documentation. Staff member Q stated if he was not notified directly through the medical record, the mid-level provider would call and notify him of admissions. Staff member Q stated, “I do not manage in real time, but I do get all of the notes and can answer any questions in real time.””

“INFECTION PREVENT & CONTROL ORG & POLICIES CFR(s): Infection prevention and control program organization and policies. The CAH 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: 47752 Based on interview and record review, the facility failed to ensure the individuals employed as the Infection Prevention and Control Specialists were qualified through education, training, experience, and/or certification in infection prevention and control practices. This deficient practice had the potential to affect all patients receiving care and staff providing care at the facility. Findings include: During an interview on 5/7/24 at 2:06 p.m., staff members E and L stated they had not been doing Infection Prevention and Control for very long, and had no education, training, or certification in Infection Prevention. Staff member E stated her and staff member L were not appointed to their positions by the Governing Board. Staff member E stated, “The staff member that was hired for Infection Prevention left and now [Staff Member L Name] and I have taken it (Infection Prevention and Control Program) over. I am going to the APIC conference this week and hopefully I will learn more about Infection Prevention.” Record review of the facility’s personnel files for staff members E and L did not show documentation of education, training, certification, or experience in Infection Prevention.”

“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: 47752 Based on interview and record review, the facility failed to ensure specific tracking and trending of infections were established for the Infection Prevention and Control Program. This deficient practice had the potential to affect all patients receiving care within the facility. Findings include: During an interview on 5/7/24 at 2:03 p.m., staff member E stated there was not any documentation which tracked or trended infections or antibiotic use within the facility. Review of a facility policy titled, “Infection Control Program,” with a revision date of May 2024, showed: “ ... The program director has the responsibility for implementing, coordinating, and directing a program of surveillance, prevention, and control of infection and associated adverse events ...””

“ABT STEWARD PROGRAM AND NATIONAL GUIDELINES CFR(s): 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: 47752 Based on interview and record review, the facility failed to ensure an antibiotic stewardship program was established and adhered to nationally recognized guidelines. This deficient practice had the potential to affect all patients receiving care at the facility. Findings include: During an interview on 5/7/24 at 2:03 p.m., staff member E stated the facility did not have an established Antibiotic Stewardship Program. During an interview on 5/7/24 at 2:05 p.m., staff member L stated there were no facility policies or procedures regarding antibiotic stewardship. A request for the Antibiotic Stewardship policy and procedure was requested on 5/7/24 at 3:07 p.m., and was not received prior to the end of the survey.”

“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: 47752 Based on interview and record review, the facility failed to ensure they had a system in place for active surveillance, prevention, and control of all infections, to include antibiotic use. This deficient practice had the potential to affect all patients and staff within the facility. Findings include: During an interview on 5/7/24 at 2:03 p.m., staff member E stated the facility did not have documentation of surveillance, tracking or trending of infections, or antibiotic use. Staff member E stated the facility was not using any criteria for antibiotic use. Staff member E stated she was not sure what criteria for antibiotic use was. Review of a facility policy titled, “Infection Control Program,” with a revision date of May 2024, showed: “ ...The program director has the responsibility for implementing, coordinating, and directing a program of surveillance, prevention, and control of infection and associated adverse events...””

“LEADERSHIP RESPONSIBILITIES CFR(s): (2) The infection prevention and control professional(s) is responsible for: (i) The development and implementation of facility-wide infection surveillance, prevention, and control policies and procedures that adhere to nationally recognized guidelines. This Standard is not met as evidenced by: 47752 Based on interview and record review, the facility failed to ensure the individuals employed as the Infection Prevention and Control Specialists were qualified to develop and implement a facility-wide infection control, surveillance, and prevention program based on nationally recognized guidelines. This deficient practice had the potential to affect all patients and staff providing care within the facility. Findings include: During an interview on 5/7/24 at 2:03 p.m., staff members E and L stated they had not been doing Infection Prevention and Control for very long, and had no education, training, or certification in Infection Prevention. Staff member E stated she and staff member L were not appointed to their positions by the Governing Board. Staff member E stated, “The staff member that was hired for Infection Prevention left and now [Staff Member L Name] and I have taken it (Infection Prevention and Control Program) over. I am going to the APIC conference this week and hopefully I will learn more about Infection Prevention.” During an interview on 5/7/24 at 4:43 p.m., staff member A stated staff members E and L were not approved or appointed by the Governing Board. A request was made for Govening Board minutes showing the approval of staff members E and L as the Co-Infection Prevention and Control Specialists, and was not received prior to the end of the survey.”

“LEADERSHIP RESPONSIBILITIES CFR(s): (2) The infection prevention and control professional(s) is responsible for:] (ii) All documentation, written or electronic, of the infection prevention and control program and its surveillance, prevention, and control activities. This Standard is not met as evidenced by: 47752 Based on interview and record review, the facility failed to ensure complete documentation of the infection prevention and control program, to include surveillance, and tracking of infections. This deficient practice had the potential to affect all patients and staff within the facility. Findings include: During an interview on 5/7/24 at 2:03 p.m., staff member E stated the facility did not have any documentation of the infection prevention and control program, surveillance, tracking or trending of infections or antibiotic use. Review of a facililty document titled, “Infection Control Program,” with a revision date of May 2024, showed: “... Provide documentation of recognition and compliance...””

“LEADERSHIP RESPONSIBILITIES CFR(s): (3) The leader(s) of the antibiotic stewardship program is responsible for:] (iv) Competency-based training and education of CAH personnel and staff, including medical staff, and, as applicable, personnel providing contracted services in the CAHs, on the practical applications of antibiotic stewardship guidelines, policies, and procedures. This Standard is not met as evidenced by: 47752 Based on interview and record review, the facility failed to ensure the individuals employed as the Infection Prevention and Control Specialists provided competency-based training and education to all personnel and staff, including the medical staff, on the practical applications of antibiotic stewardship guidelines, policies, and procedures. Findings include: During an interview on 5/7/23 at 2:03 p.m., staff member E stated she had not done any kind of education with staff or providers. Staff member E stated any education was provided through employee education. Staff member E stated, “I do not do that.” Staff member E stated she had never spoken with the medical staff or any staff about any type of antibiotic stewardship guidelines. Staff member E stated there were no policies, procedures, or guidelines in place for antibiotic stewardship. Review of a facility document titled, “Infection Control Program,” with a revision date of May 2024, showed: “... Provide education and other services...””

“DISCHARGE PLANNING EVALUATION CFR(s): (3) The discharge planning evaluation must be included in the patient’s medical record for use in establishing an appropriate discharge plan and the results of the evaluation must be discussed with the patient (or the patient’s representative). This Standard is not met as evidenced by: 47752 Based on interview and record review the facility failed to initiate discharge planning for 3 (#s 6, 7, and 8) of 21 sampled patients who were admitted to inpatient status. This deficient practice had the potential to affect all patients that were admitted into acute care. Findings include: Review of patient #6’s EMR, dated 4/16/24 to 4/18/24, showed patient #6 was admitted to inpatient status on 4/16/24 and was discharged on 4/18/24. No documentation of discharge planning was found for patient #6. Review of patient #7’s EMR, dated 4/6/24 to 4/7/24, showed patient #7 was admitted to inpatient status on 4/6/24, and was discharged on 4/7/24. No documentation of discharge planning was found for patient #7. Review of patient #8’s EMR, dated 3/9/24 to 3/12/24, showed patient #8 was admitted to inpatient status on 3/9/24 and was discharged on 3/12/24. No documentation of discharge planning was found for patient #8. During an interview on 5/8/24 at 2:03 p.m., staff member F stated the nurses did not usually do discharge planning. Staff member F stated, “We have two gals that do the discharge planning, but they do not work in the building. They are based out of [Hospital Name].” Staff member F stated if the discharge planners were not available, nursing staff went over any discharge instructions, discharged the patient, and set up any required follow up appointments. During an interview on 5/8/24 at 4:03 p.m., staff member T stated she helped with discharge planning. Staff member T stated discharge planning was supposed to be started the day the patient was admitted, unless it was a weekend. Staff member T stated discharge planning was started on the next business day if an admission occured over the weekend. Staff member T stated the process for discharge planning for inpatients was to meet with the patient if needed, and talk with the nursing staff to find out what the patient’s needs were. Staff member T stated she did not usually have to go to [Hospital Name] very often. Staff member T stated once discharge planning was implemented, all the paperwork and documentation was scanned into the patient’s electronic medical record, and any notes or assessments were noted in the patient’s medical record. Review of the facility’s policy titled, “Discharge of Patient - Planning, Summary, Implementation,” dated December of 2017, showed discharge planning was the responsibility of nursing staff and was to be done for all inpatients.”

“ORGAN, TISSUE, & EYE PROCUREMENT CFR(s): Ensure that the CAH works cooperatively with the designated OPO, tissue bank and eye bank in educating staff on donation issues, reviewing death records to improve identification of potential donors, and maintaining potential donors while necessary testing and placement of potential donated organs, tissues, and eyes takes place. §485.643(f) For purpose of these standards, the term “organ” means a human kidney, liver, heart, lung, pancreas, or intestines (or multivisceral organs). This Standard is not met as evidenced by: 47752 Based on interview and record review, the facility failed to review death records with the OPO (Organ Procurement Organization) for 5 (#s 9, 12, 21, 22, and 34) of 8 sampled patients who expired in the facility. Findings include: Review of patient #9’s EMR, dated 2/15/24 to 2/16/24, showed the patient expired in the facility on 2/16/24. The electronic medical record showed the OPO was notified of the death in the facility. Review of patient #12’s EMR, dated 11/21/23 to 11/24/23, showed the patient expired in the facility on 11/24/23. The electronic medical record showed the OPO was notified of the death in the facility. Review of patient #21’s EMR, dated 9/13/23 to 9/22/23, showed the patient expired in the facility on 9/22/23. The electronic medical record showed the OPO was notified of the death in the facility. Review of patient #22’s EMR, dated 1/29/24 to 1/30/24, showed the patient expired in the facility on 1/30/24. The electronic medical record showed the OPO was notified of the death in the facility. Review of patient #34’s EMR, dated 3/8/24 to 3/8/24, showed the patient expired in the facility on 3/8/24. The electronic medical record showed the OPO was notified of the death in the facility. During an interview on 5/8/24 at 8:42 a.m., staff member B stated she had not done any death reviews with the OPO. Staff member B stated, “The only time the death records are reviewed is when there was a problem.” Staff member B stated she had received the monthly list of patients from the OPO but had never reviewed any of the deaths with the OPO.”