Every finding on record at The Evangelical Lutheran Good Samaritan Society

Based on record review and staff interview it was determined the Hospice failed to provide evidence of an emergency disaster drill for the last two years. This deficient practice has the potential that the Hospice would not be prepared in the event of an emergency posing the risk for serious patient and staff safety issues. --- Findings Include: A review of the Emergency binder revealed no evidence of completed disaster drills for the past two years. In an interview conducted on 12/6/2023 with Employee #1, he/she confirmed that emergency drills for 2022 could not be produced. A combined table top drill was initiated on 12/6/2023 with supervisors for both Home Health and Hospice, no clinical staff were involved. No attendance sheet or evaluation of the drill was available for review.

Based on record review, observation, and staff interview it was determined the Hospice failed to label and store medications properly. This deficient practice has the potential that medications could unsafely be administered beyond the medication expiration date leading to negative patient outcomes. --- Findings Include: A review of the Sanford Policy ENTERPRISE table of contents revealed no policy for medication labeling and storing. A tour of the facility revealed three cabinets to have medications without proper labeling: 100 clear plastic containers with "Calmo/A&D", 64 clear plastic containers with "Biotene", and 28 clear plastic containers with "Periwash". The aforementioned containers had no expiration date and could not provide the original packaging for the "Calmo/A&D" and "Biotene". In interview was conducted on 12/7/2023 with Employee #2, he/she confirmed the original packaging for the "Calmo/A&D" was unavailable. He/she provided expiration dates from unopened tubes. These cannot be confirmed as the original packaging for aforementioned medications. In interview was conducted on 12/7/2023 with Employee #2, he/she confirmed the original packaging for the "Biotene" was unavailable. He/she provided expiration dates from unopened bottle. This cannot be confirmed as the original packaging for aforementioned medication.

Based on record review, observation, and staff interview it was determined the administrator failed to provide a sanitary environment by following current standards of practice, including following manufacturer instructions for proper cleaning and proper use of glucometer. This deficient practice has the potential risk to expose and transmit infectious agents to multiple patients leading to negative patient outcomes. --- Findings Include: A review of the manufacturer instructions for the Contour Next GEN blood glucose monitoring system revealed, "...The meter and lancing device are for single-patient use. Don not share them with anyone including other family members! Do not use on multiple patients...Cleaning Your Meter, Supplies needed for cleaning: Clorox Germicidal Wipes containing 0.55% sodium hypochlorite (bleach)...Disinfecting Your Meter, Supplies needed for disinfecting: Clorox Germicidal Wipes containing 0.55% sodium hypochlorite (bleach)...". A review of Sanford Policy ENTERPRISE Hospice: Medical Equipment and Supplies - Hospice revealed, "...Reusable medical equipment is cleansed between patient use with disinfectant approved and supplies by the host location or 1:10 bleach solution, covered and then stored in clean utility room...". A tour of the medication room revealed the Contour Next GEN blood glucose monitoring system was the only glucometer available for patient use. Upon observation of the medication room the Super Sani-Cloth was visible on the counter and no other cleansing/disinfecting wipes were visible within the medication room. An interview conducted on 12/7/2023 with Employee #1, he/she confirmed the aforementioned glucometer was the only glucometer available for patient use. He/she also confirmed the current wipes being used to clean/disinfect the glucometer were not the proper wipes per manufacturer instructions for use. He/she acknowledged the current glucometer in use was being used on multiple patients. An interview conducted on 12/7/2023 with Employee #2, he/she confirmed the aforementioned glucometer was the only glucometer available for patient use. He/she also confirmed the current wipes being used to clean/disinfect the glucometer were not the proper wipes per manufacturer instructions for use. He/she acknowledged the current glucometer in use was being used on multiple patients.

Based on observation it was determined the facility failed to fill penetrations in the smoke barrier. Failing to the penetrations, holes in the smoke barriers will allow smoke and heat to penetrate other wings or possibly the whole facility which could cause harm to the patients in time of a fire. NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a fire resistance rating of at least ½ hour." Chapter 8, Section 8.5.6.2 Penetrations for cables cable trays, conduits, pipes, tubes, vents wires and similar items to accommodate electrical, plumbing and communications systems that pass through a wall , floor or /ceiling assembly constructed as a smoke barrier , or through the ceiling membrane of the roof /ceiling of a smoke barrier assembly shall be protected by a system or material capable of restricting the transfer of smoke. Findings include: Observations during a facility tour conducted on December 6th, 2023, revealed unsealed penetrations, located in the smoke barrier between the oxygen corridor and the office/support area. This area was designed as a fire/smoke barrier but the construction holes were never filled. Employees # 1 and #2 confirmed during the tour that the barrier had holes above the ceiling that needed to be filled.

Based on record review and interview with staff, it was determined the facility failed to have written documentation of the Annual Inspection and Testing of Door openings in accordance with NFPA 80, 2010 Edition, "Standard for Fire doors and Other Opening Protectives." Failing to inspect and test fire-rated door assemblies in accordance with NFPA 80 annually could cause harm to the patients. NFPA 101 2012 Life Safety Code Section 8.3.3. Fire door and Windows Section 8.3.3.1 "Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening protective, except as otherwise specified in this code." NFPA 80 Section 5.2* Inspections Section 5.2.1*"Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for the AHJ. Section 5.2.3 Functional Testing. Section 5.2.3.1 Functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing." Findings include: During a review of the facility's annual fire-rated door assembly inspection records on Dec 6, 2023, the following deficiency was revealed: 1. The facility did not have written records for the Annual Inspection and Testing of Door Openings in accordance with NFPA 80 Standards for Fire Doors and Other Opening Protectives. Employees #1 and #2 confirmed during the tour that no door inspections had been performed in the last year.

Based on observation and staff interview the facility failed to provide a record of electrical equipment tests, repairs, and modifications. Failing to conduct maintenance on patient care appliances could cause harm to the resident if the appliance malfunctions. NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 2012 Edition Chapter 10, Section 10.5.6 Record Keeping-Patient Appliances Electrical Equipment - Testing and Maintenance Requirements"The physical integrity, resistance, leakage current, and touch current tests for fixed and portable patient-care related electrical equipment (PCREE) is performed as required in 10.3. Testing intervals are established with policies and protocols. All PCREE used in patient care rooms is tested in accordance with 10.3.5.4 or 10.3.6 before being put into service and after any repair or modification. Any system consisting of several electrical appliances demonstrates compliance with NFPA 99 as a complete system. Service manuals, instructions, and procedures provided by the manufacturer include information as required by 10.5.3.1.1 and are considered in the development of a program for electrical equipment maintenance. Electrical equipment instructions and maintenance manuals are readily available, and safety labels and condensed operating instructions on the appliance are legible. A record of electrical equipment tests, repairs, and modifications is maintained for a period of time to demonstrate compliance in accordance with the facility's policy. Personnel responsible for the testing, maintenance and use of electrical appliances receive continuous training." Findings include: Observation, record review, and staff interview on December 6, 2023, revealed the facility was unable to produce policies protocols, or documentation to identify all electrical equipment tests, repairs, and modifications. but stated they were unaware of checking for leakage current on other equipment that makes contact with the facility's patients. Employees #1, and #2 confirmed during the tour and at the document review on December 6, 2023, that the facility failed to test some electrical equipment it was using.