Wagoner Community Hospital

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 53719 Based on observation, record review, and interview, the facility failed to ensure safe maintenance of sharps containers for one (Outpatient Room) of one patient care areas observed. On 04/15/26 at 3:50 pm during a tour of the Outpatient Room used for contracted dialysis services, three sharps containers were observed to be at or above the fill line. Two of the sharps containers were closed showing “Full”. One sharps container was partially closed showing “Full” but could still be accessed. Review of an informational fact sheet titled “Protecting Yourself When Handling Contaminated Sharps” from the Occupational Safety and Health Administration, dated 01/2011, read in part, “The sharps containers must be replaced routinely and not be overfilled, which can increase the risk of needlesticks or cuts.” On 05/28/26 at 3:58 pm, Staff D observed the sharps containers and stated housekeeping should have removed them.”

“PHARMACY ADMINISTRATION CFR(s): 482.25(a) [§482.25 Condition of Participation: Pharmaceutical Services .....The medical staff is responsible for developing policies and procedures that minimize drug errors. This function may be delegated to the hospital’s organized pharmaceutical service.] §482.25(a) Standard: Pharmacy Management and Administration The pharmacy or drug storage area must be administered in accordance with accepted professional principles. This Standard is not met as evidenced by: 53719 Based on record review and interview, the hospital failed to ensure safe and appropriate use of medications for a patient with a documented allergy for one (Patient 11) of 15 patient charts reviewed. Findings: Patient 11 A review of the ED Nursing Initial Assessment note showed at 10:30 am on 01/16/26, an allergy to “Penicillins”. There was no severity level or reaction type listed with the allergy. A review of the ER Provider Assessment note showed at 10:59 am on 01/16/26 an allergy to “Penicillins”. There was no severity level or reaction type listed with the allergy. A review of the Patient Discharge Instructions dated 01/16/26 showed the patient was to start taking amoxicillin 500 mg capsule. On 05/28/26 at 2:23 pm, Staff B reviewed the chart and stated: 1. Allergies entered by nurses flow into the provider’s note. 2. The allergy to “Penicillins” was listed in the ED provider assessment note. 3. There was no criticality of the allergy listed in the chart. 4. Usually, the staff would have put what type of reaction in the chart if the patient knew it. The patient’s previous reaction could have been bad.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 42140 Based on observation, record review and interview, the facility failed to ensure infection prevention and control for one (Outpatient Room) of one patient care areas observed. Findings: On 05/28/26 from 3:40 pm to 4:10 pm, during a tour of the Outpatient Room used for contracted dialysis services, the following items were observed: 1. Sharps above the fill line 2. Full and overflowing trash receptacles 3. Clutter: trash on the floor, towels in the floor, bedside table piled with linens 4. Floor with dried, white substance present 5. Sink with dry, white and brown caked on substance present Review of the facility Quality Assurance Performance Improvement Plan for Environmental Hygiene read in part: 1. “Goal: Improve environmental hygiene as evidenced by criteria driven observation as well as ATP monitoring.” 2. “Applicable Units: All” 3. “Rationale: Environmental hygiene is a key performance indicator for infection prevention necessary for delivery of safe patient care. “ On 05/28/26 at 3:48 pm, Staff D observed the Outpatient Room used for contracted dialysis services and stated: 1. The room was last used yesterday [05/27/26] and would be needed again in the morning [05/29/26]. 2. Housekeeping staff were to clean the room after use. 3. Housekeeping should have removed the full sharps containers. On 05/28/26 at 4:20 pm, Staff C reviewed the surveyor’s pictures of the Outpatient Room used for contracted dialysis services and stated: 1. They had not been to the Outpatient Room used for contracted dialysis services recently. 2. The expectation for the dialysis room cleaning was that the dialysis nurse performed a quick clean when services were complete followed by a terminal clean by the facility housekeeping staff. 3. The room had not been terminally cleaned. 4. The room should have been terminally cleaned after the last treatment was completed and that did not happen. On 05/28/26 at 4:50 pm, Staff A reviewed the surveyor’s pictures of the Outpatient Room used for contracted dialysis services and stated that they had not been to the room in a while and it was not clean.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 39648 Based on observation and interview, the hospital failed to ensure services were provided in a setting that was safe for patients three (patients #1, 2, and 4) of five patients reviewed and for all Mental Health Unit patients currently receiving care and services. Findings: On 10/09/25 at 9:19 AM an observational tour was made of the MHU unit that showed the following: 1) Room #40. Metal window frames had sharp corners. There were unwrapped crackers on top of a plastic container and on the floor. The heat and air vent in the room was coated with a a white, fuzzy substance. Two cobwebs were noted on the ceiling. 2) Room #23. The bed frame in the room showed a crack to the top rail on the right side of frame near the head of the bed and a crack on the left side of the top rail near the foot of the bed. Metal window frames had sharp corners. 3) Room #24. The corner in the bathroom beside the toilet had loose molding and a large area of peeling paint. The area beside the bedside storage unit was covered in a white, fuzzy substance. 4) The women’s shower room had peeling paint and crumbling drywall. 5) The men’s shower room had areas of tile that had no grout, tile trim was detaching from the wall. The zero-entry shower base was cracked. On 10/09/25 at 9:23 am, Staff A observed the white, fuzzy substance on the heat and air vent and stated the susbstance could cause breathing problems for patients. On 10/09/25 at 09:35 am, Staff C stated peeling paint could be eaten by patients. On 10/09/25 at 9:40 am, Staff B stated: 1) The cracked shower base could grow pathogens. 2) The grout gone in the men’s shower room can be a risk for self-harm or others. On 10/09/25 at 12:45 pm, Staff E stated patients shouldn’t eat in a room due to the risk of choking, it is a unit rule.”

“DISCHARGE PLANNING - EARLY IDENTIFICATION CFR(s): 482.43(a) The hospital’s discharge planning process must identify at an early stage of hospitalization 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: 39648 Based on record review and interview, the hospital failed to ensure that an assessment was completed for a patient to aid in discharge planning for one (Pt #3) of twenty patients. Findings: Review of a policy titled, “Discharge Planning” dated 02/2018 read in part: “1) All patients will be screened as soon as possible after admission to identify continuing care needs. 2) The Case manager will complete an assessment to identify further needs and options. 3) The Case Manager will develop and document on each patient, a Discharge Plan utilizing information obtained in the assessment and needs identification process and communicate findings to the physician and to the patient/representative.” Patient #3 Review of the patient record showed an admission to the Mental Health Unit 04/18/25 to 04/23/25. No initial interview or assessment was found in the record that showed what the patient’s continuing care needs after hospital discharge. On 09/25/25 at 12:58 Staff G stated: 1) the initial interview for the patient is not in the record, 2) no social worker is assigned to the Mental Health Unit to assist with placement. On 09/25/25 at 1:30 pm, Staff I stated: 1) the initial interview was not done to identify the patient’s continuing care needs after discharge.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 39648 Based on observations and interview, the hospital failed to ensure services were provided in a setting that was safe for patients 20 (patients #1-20) of 20 patients reviewed and for all patients currently receiving care and services. Findings: On 08/13/24 at 10:25 AM an observational tour was made of the MHU, ED and Medical surgical units that showed the following: 1. Observations of the MHU observation room #1. The bed frame in the room showed a crack to the top rail on the top right side of frame with what appeared to be a screw in the crack. A metal plate in the room at lower wall level that did not fully cover an open area in the wall. An exposed screw in the wall by the door and 2. the cover over the camera was no longer in place. On 08/13/24 at 1:25 PM another observational tour was made of the MHU and Medical/Surgical Units that showed: 1. The women’s shower room on the MHU showed an area of trim that was made of a rigid plastic that was damaged (broken and splintered with sharp edges). 2.Seclusion room #1 showed multiple exposed screws in the sheet rock and an exposed wall outlet due to improperly fitted strike plate. 3. Observation of an unoccupied room on the Medical/Surgical Unit showed areas to the lower walls on either side of the shower that were cracked and crumbling. 4. Med/Surg room 80 showed drywall was cracked and crumbling at the base of the shower. During an interview on 8/13/24 at 1:30 PM, Staff A stated: 1, “I don’t know how long the bed frame in the seclusion room has been damaged, it was dangerous and has been reparied.” 2. “Damaged furniture should be reported immediately. An exposed screw could be an issue. Drywall should be inspected periodically and reported. An availablility of parts should result in repairs being initiated within 24-48 hours.” 3. “ Damage should be reported when it is noted. 4. “This is not new and organisms can grow in nooks and crannies (re: damaged drywall).” 5. “I don’t know when or why the outlet cover was removed. During an interview with hospital staff Bon 8/13/24 at 1:24 PM, Staff B stated, “The damaged trim in the women’s shower room was a safety issue.””

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 39648 Based on record review and interview the RN failed to evaluate pain at least twice daily utilizing a pain intensity scale for two (Patient # 15H and 18E) of 20 medical records reviewed. Findings: Patient 15H A review of the clinical record showed patient was admitted to MHU 2/23/24 and transferred to another hospital 2/26/24. Discharge Summary documented “patient complained of abdominal pain. X-ray of the abdomen showed a foreign body in rectum. Patient was seen in the emergency room and he developed a perforation and was trasferred....” Abdomnial x-ray 2/26/24 impression: There is a radio-opaque foreign body in the rectum and rectosigmoid. It measures 18 cm in length. Clinical documentation showed no nursing assessment from 2/23/24 - 2/26/24 that documened assessing a pain level and no VS record for this patient reflects a pain level from 2/23/24 - 2/26/24. Patient 18E A review of the clinical record showed patient was admitted to MHU 12/29/23 and discharged 1/2/24. The Nursing Assessment dated 8/27/23 at 8:00 AM was the only assessment that documented “no pain.” ANursing Assessment dated 8/27/23 at 3:06 PM documented pain but no pain rating on a scale of 1-10. The patient was in-patient for four days and showed one documented pain assesment in the nursing assessments and none in the VS record. On 08/14/24 at 2:50 PM, Staff A stated: 1. “A patient’s pain level should be assessed at every shift and if pain medicaton was administered and 2. “ain level should be assessd again within 30 minutes to an hour after medication administration.””

“CONTENT OF RECORD: HISTORY & PHYSICAL CFR(s): 482.24(c)(4)(i)(A) All records must document the following, as appropriate: (i) Evidence of-- (A) A medical history and physical examination completed and documented no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services, and except as provided under paragraph (c)(4)(i)(C) of this section. The medical history and physical examination must be placed in the patient’s medical record within 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services. This Standard is not met as evidenced by: 39648 Based on record review and interview, the hospital failed to ensure physicians and licensed independent practitioners completed a history and physical (H&P) within twenty-four (24) hours of admission for two (Patient # 14I and 19D) of 20 patient medical records reviewed . Findings: A review of Patient #14I and 19D showed the H&Ps were not completed and documented in the patient’s EMR within 24 hours of admission. On 08/14/24 at 10:30 AM, Staff F stated, H&Ps were completed by medical staff within 48 hours for patient 19D and 72 hours for patient 14I instead of within 24 hours of the patients’ admission.”