Coal County General Hospital, Inc.

“Develop EP Plan, Review and Update Annually CFR(s): §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: 46363 Based on record review and interview, the facility failed to review and update the emergency preparedness plan annually. This deficient practice affected 5 of 5 residents, who currently reside in the facility, as identified by the administrator on 04/23/25. The facility had a census of 5 residents. Findings: 1. The facility records were reviewed 4/23/2025 at 9:30 a.m.. The administrator provided an emergency preparedness policy binder. The policy had not been reviewed and updated within the past 12 months. 2. The administrator was interviewed on 4/23/2025 at 10:00 a.m., and he stated he would review and update the emergency preparedness book.”

“COMPLIANCE FED, ST, AND LOCAL LAWS AND REGS CFR(s): The CAH is in compliance with applicable Federal laws and regulations related to the health and safety of patients. This Standard is not met as evidenced by: 41506 Based on observation, interview, and record review the CAH (Critical Access Hospital): 1) failed to ensure the dedicated Emergency Room had a notice posted conspicuously in a place(s) likely to be noticed by all individuals showing the CAH had no MD or a DO present in the CAH 24 hours per day, 7 days per week, and 2) failed to ensure patients were provided with written information regarding the CAH policy on Advance Directives and information on Oklahoma’s Advance Directives prior to admit. Findings: 1) Posted Notice An observation on 03/18/25 at 2:15 p.m., with Staff B and Staff L, in the dedicated Emergency Room hallway where patients enter, revealed a posted notice indicating the dedicated Emergency Department did not have a MD or a DO present in the CAH 24 hours per day, 7 days per week. The notice was not posted in a conspicuous place. The notice was posted on the top left corner of a “busy” bulletin board area with other posted notices of the same size. The bulletin board was located in the hallway of the Emergency Department and the notice was posted above normal eye level. In an interview on 03/18/25 at 2:15 p.m. Staff B and Staff L stated they did not think there was another notice posted anywhere else in the Emergency Department and they stated the posted notice observed in the patient hallway was not very conspicuous or very large. 2) Advance Directives . A review of the CAH Admission Packet on 03/19/25 at 1:30 p.m. with Staff Q and Staff R showed no information in the packet on the CAH Advance Directives or on Oklahoma’s Advance Directives. A further review of the Admission Packet showed advance directive information would be provided to the patients, as required by Federal law. The patient would then initial if they had executed an Advance Directive or if they had not executed an Advance Directive, but that they had received information on Advance Directives. In an interview on 03/19/25 at 1:30 p.m. Staff Q and Staff R stated they were the Admissions Clerks and they were responsible for admitting all patients to the CAH and providing them with the necessary admissions paperwork. Staff Q and Staff R stated that Advance Directive Information was not part of the CAH admission paperwork. They stated they have not been providing patients with any written information on Advance Directives, and they were not sure where the information on Advance Directives was located, and would have to look for it.”

“PATIENT CARE POLICIES CFR(s): §485.635(a)(2) The policies are developed with the advice of members of the CAH’s professional healthcare staff, including one or more doctors of medicine or osteopathy and one or more physician assistants, nurse practitioners, or clinical nurse specialists, if they are on staff under the provisions of §485.631(a)(1). §485.635(a)(4) These policies are reviewed at least biennially by the group of professional personnel required under paragraph (a)(2) of this section, and reviewed as necessary by the CAH. This Standard is not met as evidenced by: 41506 Based on record review and interview the CAH failed to: 1. have a process in place to review existing patient care policies/procedures governing patient care services and 2, revise or develop patient care policies/procedures with the advice of members of the CAH’s professional healthcare staff at least biennially (every 2 (two) years), according to 485.635(a)(2)&(4). Findings: A review of the CAH Policy and Procedure (P&P) Manual, the CAH Annual Program Evaluation Report, and the CAH QAPI (Quality Assurance Performance Improvement) manual, provided by administration as the most current, showed no documented evidence that the CAH’s P&P were being reviewed on a biennial schedule. There was no documented P&P review noted in 2023, 2024, or 2025. On 03/21/25 at 11:15 a.m. Staff A stated the biennial P&P review it not up to date and has not been performed in the last 2 (two) years.”

“NURSING SERVICES CFR(s): Nursing services must meet the needs of patients. (1) A registered nurse must provide (or assign to other personnel) the nursing care of each patient, including patients at a SNF level of care in a swing-bed CAH. The care must be provided in accordance with the patient’s needs and the specialized qualifications and competence of the staff available. This Standard is not met as evidenced by: 41506 Based on record review and interview the CAH failed to ensure that patient care services were provided in accordance with acceptable professional standards of practice, as evidenced by failing to have a process in place to evaluate Skills Competency of staff who have been employed by the CAH for more than one year to access their continued competency levels, and failed to have a process in place for a staff “upon hire” Orientation to assure that the staff had appropriate qualifications/skills for the patient care tasks they were required to perform in the CAH setting in 7 (Staff B, D, G, K, L, O, P) of 7 patient care staff employee files reviewed. Findings: A review of employee files (Staff B, D, G, K, L, O, P) showed no documented evidence of periodic or annual Skills Competency for employees who were employed by the CAH for more than one year. Documentation showed no Orientation “upon hire” Skills Evaluation for new employees to assure that the staff had appropriate qualifications/skills for the patient care tasks they were required to perform in the CAH setting. In an interview on 03/21/25 at 11:30 a.m. Staff B stated responsibility for evaluating staff competencies and new staff orientation. Staff B stated staff Skills Competencies and new hire Orientation Skills Competencies were usually done verbally by the various department heads and were not documented anywhere.”

“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: 41506 Based on record review and interview the CAH failed to ensure the nursing staff developed a nursing care plan for each patient based on assessing all the patient’s nursing care needs and not solely those needs related to the admitting diagnosis for 4 of 4 (Patient #1, #2, #3, #4) medical records reviewed for nursing care plans. Findings: A review of Patient #1 medical record showed in part: Patient #1 was admitted to the hospital as an inpatient on 03/15/25 with a diagnosis of covid and compression fracture from a fall. A review of the patient’s medical history showed the patient also had a present history of dementia, hypertension, poor appetite, lethargy, and hypothyroidism. A review of the current care plan showed the patient only had a documented care plan with goals and treatment plans for falls and infection. A further review of the nursing care plan and the medical record showed no documented evidence that the patient had nursing care plans developed for the other medical diagnoses (dementia, hypertension, poor appetite, lethargy, and hypothyroidism). A review of Patient #2 medical record showed in part: Patient #2 was admitted to the hospital as an inpatient on 03/14/25 with a diagnosis of weakness and bladder infection. A review of the patient’s medical history showed the patient also had a present history of COPD, hypothyroidism, and arthritis. A review of the current care plan showed the patient only had a documented care plan with goals and treatment plans for injury and skin integrity. A further review of the nursing care plan and the medical record showed no documented evidence that the patient had nursing care plans developed for the other medical diagnoses (COPD, hypothyroidism, bladder infection, and arthritis). A review of Patient #3 medical record showed in part: Patient #3 was admitted to the hospital as an inpatient on 03/11/25 with a diagnosis of pelvic fracture. A review of the patient’s medical history showed the patient also had a present history of CAD, diabetes, and hypertension. A review of the current care plan showed the patient only had a documented care plan with goals and treatment plans for falls and skin integrity. A further review of the nursing care plan and the medical record revealed no documented evidence that the patient had nursing care plans developed for the other medical diagnoses (CAD, diabetes, and hypertension). A review of Patient #4 medical record showed in part: Patient #4 was admitted to the hospital as an inpatient on 03/09/25 with a diagnosis of weakness and bladder infection. A review of the patient’s medical history showed the patient also had a present history of hypertension, dementia, and prior stroke. A review of the current care plan showed the patient only had a documented care plan with goals and treatment plans falls, activity, and infection. A further review of the nursing care plan with Staff P revealed no documented evidence that the patient’s care plan goals and treatments had nursing care needs developed for the other diagnoses (hypertension, dementia, and prior stroke). In an interview on 03/19/25 at 12:00 p.m. Staff B stated the nurses routinely developed the patient care plans based only on the admitting diagnoses and care plans were not comprehensive and developed for all the patient’s current diagnoses upon admit.”

“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: 41506 Based on observation, record review, and interview the CAH failed to ensure a functional and sanitary environment, according to acceptable professional standards of practice relating to infection control, as evidenced by: 1) failing to ensure staff sanitized their hands after removing their gloves and failing to ensure staff changed gloves when moving from dirty tasks to clean tasks; 2) failing to ensure staff were knowledgeable of the 2 (two) minute contact time for the EPA disinfectant wipes used to disinfect reusable patient care equipment after use; 3) failing to ensure staff did not store cardboard boxes, containing supplies, on the floor in the Central Supply storage room and failing to ensure staff stored items 18 inches from the ceiling in the sprinkled Supply room; 4) failing to ensure patient care staff did not wear artificial nail products; 5) failing to ensure staff did not prepare patient medications near a functional sink, without a partition dividing wet area and clean/sterile activities; 6) failing to ensure staff stored dietary food and supplies according to acceptable infection control practices and hospital policy. Findings: 1) Sanitized hands In an observation on 03/19/25 at 11:30 a.m. of Staff O performing a blood sugar test on a patient showed Staff O removed dirty gloves, picked up the used glucometer and waited until leaving the patient room before sanitizing hands at the hallway dispenser, while still holding the used glucometer, and then disinfected the used glucometer. In an observation on 03/19/25 at 3:15 p.m. of Staff P doing wound care on a patient showed Staff P did not remove gloves and sanitize hands and don new gloves after cleaning the wound and before proceeding to applying a clean dressing. CDC Hand Hygiene in Healthcare Settings; Hand Hygiene Guideline: March 25, 2016 showed requirements for healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: Immediately before touching a patient. Before performing an aseptic task. Before moving from work on a soiled body site (task) to a clean body site (task) on the same patient. After touching a patient or the patient’s immediate environment. After contact with blood, body fluids, or contaminated surfaces. Immediately after glove removal. Gloves do not provide complete protection against hand contamination. Pathogens presumably gain access to the caregiver’s hands via small defects in gloves. 2) Knowledgeable staff In an observation on 03/18/25 at 1:35 p.m. Staff K disinfected the room using a patient wash cloth and a non-EPA disinfectant. Staff K was also observed spraying an EPA disinfectant directly onto the surfaces to be disinfected. CDC Guideline for Disinfection and Sterilization in Healthcare Facilities, May 2019 showed requirements for: Medical equipment and patient care equipment can become contaminated with infectious agents and contribute to the spread of health-care-associated infections. For this reason, noncritical medical equipment surfaces should be disinfected with an EPA-registered low or intermediate-level disinfectant using a low-lint cloth. EPA -registered disinfectants have contact times of one to three minutes. By law, users must follow all applicable label instructions for EPA-registered products. Disinfect noncritical medical devices with an EPA-registered hospital disinfectant using the label’s safety precautions and use directions. The technique of spraying disinfectants is an unsatisfactory method of decontaminating air and surfaces and is not recommended for general infection control in routine patient-care areas. A review of the manufacturer IFU (instructions for use) for the EPA disinfectant wipes used by the CAH to disinfect reusable patient care equipment after use revealed in part: Use a clean wipe and thoroughly wet surface. Allow treated surface to remain visibly wet for 2 (two) minutes. Reapply as needed. Let air dry ... If the disinfectant does not remain in contact for the full contact time, disinfection may not be achieved. In observations on 03/18/25 Staff G, K, L were seen disinfecting patient care equipment after use. The staff were not observed allowing the equipment to remain visibly wet for the full 2 minutes, when timed by surveyor. In interviews with staff (Staff G, K, L) on 03/18/25 revealed the staff were not aware of the “wet time” for the EPA disinfectant used by the hospital when disinfecting patient care equipment after use, and/or that the disinfectant should remain visibly wet for 2 (two) minutes prior to allowing it to air dry. 3) Storage of boxes An observation on 03/18/25 at 3:30 p.m. of the Materials Management Department showed over 25 cardboard boxes containing sterile/clean supplies stored on the floor. The observation also showed the department had a sprinkler system in place and there were several items that were stored on shelves where the items were less than 18 inches from the ceiling. In an interview on 03/19/25 at 9:50 a.m. Staff M stated the boxes should not be on the floor, but was not aware of the 18 inches from a ceiling with sprinklers. In an interview on 03/19/25 at 11:00 a.m. Staff N stated the boxes should not be on the floor and confirmed there were several items that should not be stored on shelves where they were less than 18 inches from the ceiling. A review of the CDC Guideline for Environmental Infection Control in Healthcare Settings 2019 showed requirements to: comply with fire code regulations ( in a sprinkled room) and reduce the risk of contamination, sterile/clean supplies should be stored at least 18 inches from the ceiling, and at least 2 inches from outside walls. Fire codes specify minimum distances below the ceiling to ensure the effectiveness of sprinkler systems. The CDC advises against storing cardboard boxes, especially those used for shipping, on the floor in healthcare settings due to the potential for dust, moisture, and bacterial contamination. 4) Staff wearing artificial nails An observation on 03/19/25 at 11:50 a.m. showedStaff P, patient care nurse, wearing artificial nail products. A review of the CMS (Centers for Medicare and Medicaid Services) Hospital Infection Control Worksheet showed requirements for personnel do not wear artificial fingernails products and/or extenders when having direct contact with patients. Natural nails should not extend past the fingertip. 5) Preparation of medication An observation on 03/19/25 at 12:15 p.m. of the nurse’s medication prep area showed a functioning hand washing sink was located on the counter within 3 (three) feet of the medication prepping area. In an interview on 03/19/25 at 12:15 p.m. Staff B stated the medication room was too small for medication preparation, so the nurses used the counter space by the sink. A review of the CMS Hospital Infection Control Worksheet showed medications should not be prepared near areas of splashing water (e.g. within 3 feet of a sink). Alternately when space is limited, a splash guard can be mounted beside the sink. 6) Storage of food An observation on 03/18/25 at 11:30 a.m. of the Dietary Department showed many items (cracker packets, condiments, juices, canned goods, boxed foods, spices) were not marked with the date they were received and/or labeled with a discard date after opening. A review of the CAH policy titled, “Food Storage,” showed requirements for food and supplies shall be received and stored in proper areas. All food shall be marked with the date the item was received by Nutritional Services. Ready-to-eat food shall be marked with a discard date at the time of opening or preparation. The discard date shall be 7 days after the food has been opened. Single serve snack foods items (cookies, crackers, chips, condiment packages) will be discarded 3 months after the date received. Dry seasonings, spices, gravies, and sauces will be discarded 6 months after the date received. Dry boxed goods will be discarded 6 months after the date received and canned goods will be discarded 1 year after the date received. In an interview on 03/18/25 at 11:30 a.m. Staff G stated being the Dietary Manager and over the Dietary Department and the dietary aides. Staff G stated all foods items were supposed to be dated when they were received, but the dietary aides were not consistent with labeling the items when they were received or rotating the items when restocking the department. Staff G was not sure of the “received dates” on many of the food items or when some items were opened. In an interview on 03/19/25 at 1:30 p.m. Staff D was made aware of the above identified infection control breaches. Staff D was not aware of all the above identified infection control breaches, but had previously identified some of the observed infection control breaches in surveillance rounds and thought that they had been addressed. Staff D stated the hospital followed nationally accepted infection control guidelines.”