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Based on record review and interview, the hospital failed to ensure that 17 of 19 surgery patients reviewed were not routinely ordered observation status for recovery after surgical services. The facility census was eight.

Findings included:

1. Even though requested, the hospital failed to provide a policy related to observation status.

Record review of physician progress notes dated between 03/07/22 and 09/16/22 showed 17 of 19 orders for observation status showing that the patient will be admitted to extended recovery/observation following Post Anesthesia Care Unit (PACU) recovery for monitoring of the patient's condition for signs of post-surgical complication.

During an interview on 10/05/22 at 2:00 PM, Staff D, Registered Nurse (RN), stated that all of the orthopedic surgeon's patients are placed on observation status after their surgeries. She stated that the surgeon's office staff talk with the patient and family before surgery and educate them on the observation status that will be ordered by the surgeon. She stated that the patient and families are aware of the observation status before they arrived to the Medical/Surgical floor.

During an interview on 10/06/22 at 10:25 AM, Staff OO, Orthopedic Surgeon, Doctor of Osteopathic Medicine (DO), stated that all of his hips and total joints, (the damaged bone and cartilage is removed and replaced with prosthetic components), were always observation patients. He stated that the patient/families were educated by him in his office before surgery that they would be observation patients after their surgeries. He stated that was the trend for these surgeries and he wrote the order for observation status prior to the patient's surgery. He stated that a short stay was desirable due to the increased risk of infection with a longer hospital stay. He stated that he was responsible for their care as observation patients.

During an interview on 10/05/22 at 10:15 AM, Staff GG, Licensed Practical Nurse (LPN), Utilization Review (UR) Coordinator, stated that she received a list of patients for pre-registration from Staff OO, DO, who were scheduled for either hip or knee surgery the following week and all of the patients were to be placed in observation status after surgery. She stated that the patients were told prior to their surgery that they would stay overnight after the surgery.



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Based on interview, record review and policy review the hospital failed to follow their policy to ensure Emergency Room (ER) Registered Nurses (RNs) were certified in Advanced Cardiac Life Support, (ACLS, specific life saving measures taken by certified health professionals when a patient's heartbeat or breathing stops) for two of nine ER RN certifications reviewed. This failure placed all patients who presented to the ER seeking care for an emergency medical condition (EMC, an illness, injury, symptom or condition so serious one should seek care right away to avoid severe harm or serious impairment) at risk for their health and safety. The hospital census was eight. The ER had an average monthly census of 409 patients over the last six months.

Findings included:

1. Review of the hospital policy titled, "Staffing Plan - Emergency Room," reviewed 12/2019 showed that the ER was staffed with one RN for the 7:00 AM - 7:00 PM shift and one RN for the 7:00 PM - 7:00 AM shift and that the ER nurses were required to maintain a current ACLS certification.

Review of certifications for Staff H, ER RN, showed that her current Cardiopulmonary Resuscitation, (CPR, emergency life-saving procedure performed when a person's breathing or heartbeat has stopped) certification was for Basic Life Support (BLS, level of medical care for victims with life-threatening illnesses or injuries, until full medical care by more qualified individuals can be given, or at a facility that offers advance life support) only and that she had no current certification for ACLS.

Review of an untitled hospital document spreadsheet that showed nursing certifications showed that Staff XX, ER RN, CPR certification was for BLS only (class date of 05/04/22) and that her ACLS had expired in 02/2022. The spreadsheet did not list Staff H, RN.

Review of the untitled hospital document showed the staffing schedule for the ER for 10/2022. Staff H, RN was scheduled to work seven shifts and Staff XX, RN was scheduled for eleven shifts. Both staff RNs were the only RNs scheduled for their respective shifts.

During an interview on 10/06/22 at 10:05 AM, Staff DD, ER Director, stated that she was aware that some of the ER RNs were not current with their ACLS certification. She stated that because of the pandemic (a sudden increase in the number of cases of a disease above what is normally expected and has spread over several countries or continents, usually affecting a large number of people) there had not been any classes offered. Staff DD stated "they all know how to do it because they have been certified in the past." She also stated that she received a spreadsheet every year that showed her ER nursing staff and their certification status.

During an interview on 10/12/22 at 10:55 AM, Staff A, Director of Nursing, stated that she received a spreadsheet at the beginning of each year that showed the nursing staff and their CPR certifications and when they were to expire. She stated that she was aware of one ER RN not being current with ACLS but that there hadn't been any CPR classes available because of the pandemic.

Staff XX, RN received her BLS on 05/2022 (within last five months) which showed that a CPR class for BLS had occurred since the time of the pandemic. At the time of survey exit there was no ACLS class scheduled for Staff H and Staff XX, ER RNs.

Based on interview and record review, the hospital failed to ensure the lists of services provided under contracts or agreement included the nature and scope of services for 16 of 16 contracts provided. These failures increased the potential for patient care services to be inappropriately utilized. The facility census was eight.

Findings included:

1. Review of the hospital list of contracts provided by Staff B, Chief Executive Officer (CEO), showed 16 contracts or service agreements. There was no indication of the nature or scope of the services provided by 16 of 16 contractors. The list did not include whether the services were offered on or off site; if there was a limit on the volume or frequency of the services provided and when the services were available.

During an interview on 10/12/22 at 11:00 AM, Staff B, CEO, stated that the list of contracts/agreements were complete as provided.

Based on observation, interview, and policy review, the hospital failed to ensure that staff followed their hand hygiene and glove policy when caring for four current patients (#2, #12, #13 and #18) of five current patients observed. This failure increased the risk of hospital-acquired infection for all patients admitted to the facility. The facility census was eight.

Findings included:

1. Record review of the hospital policy titled, "Hand Hygiene," dated 05/2020, showed directives for staff to perform hand hygiene:
- Before moving from work on a soiled body site to a clean body site on the same patient.
- After contact with blood, body fluids, or contaminated surfaces.
- Before and after touching wounds.
- Immediately before or after touching a patient or the patient's immediate environment.

Record review of the hospital policy titled, "Use of Personal Protective Equipment," dated 05/2020, showed directives for staff to wear gloves when it is likely that hands will be in contact with non-intact skin and/or any moist body substances or items or surfaces soiled with these substances. Gloves should be changed between clean and contaminated procedures on the same patient.

Observation on 10/04/22 at 8:30 AM, in Patient #13's room, showed Staff F, Licensed Practical Nurse (LPN), placed a medication in a pill splitter and repositioned the medication with her ungloved hand. Staff F did not clean the computer on wheels (COW) when she left the room.

During an interview on 10/04/22 at 8:45 AM, Staff F stated that she should not have touched the medication with her ungloved hand.

Observation on 10/04/22 at 9:13 AM, in Patient #2's room, showed Staff I, Registered Nurse (RN), left the patient's room without performing hand hygiene. No hand hygiene was performed between administering medications or when she assessed the patient's lungs and abdomen. Staff I touched the left leg wound dressing with ungloved hands. No hand hygiene was performed when she left the patient's room after she had examined the left leg wound dressing. Staff I wore the same gloves when she removed the dirty dressing and placed the clean dressing on the left leg. Staff I did not clean the COW when she entered or left the room.

During an interview on 10/04/22 at 9:30 AM, Staff I stated that hand hygiene should have been performed between glove changes and she should have worn gloves and hand hygiene should have been performed between removing the dirty dressing and applying the clean dressing to the left leg wound.

Observation on 10/05/22 at 8:30 AM, showed Staff EE, LPN, entered Patient #18's room without performing hand hygiene. She applied gloves and administered medications and removed gloves with no hand hygiene in between glove changes. Staff EE did not clean the COW when she entered or left the room.

Observation on 10/05/22 at 9:00 AM, showed staff EE, LPN, entered Patient #13's room without performing hand hygiene. Staff EE applied gloves and administered medications to the patient. She removed the gloves and applied gloves without performing hand hygiene and cleaned the pill cutter with alcohol pads. She removed the gloves and applied gloves without performing hand hygiene and administered an inhalation medication. She removed gloves and applied gloves without performing hand hygiene and cleaned the computer key pad cover. Staff EE did not perform hand hygiene between multiple glove changes. Staff EE did not clean the COW when she entered or left the patient's room.

During an interview on 10/05/22 at 9:30 AM, Staff EE, LPN stated that she should have performed hand hygiene when she entered the room and between glove changes.

Observation on 10/05/22 at 10:00 AM, Staff C, LPN, entered Patient #12's room and examined the left leg dressing which had visible drainage. Staff C, wore the same dirty gloves and touched the patient's left shoulder bandage. Staff C opened the patient's bathroom door with the dirty gloves. Staff C did not clean the COW when she entered or left the patient's room.

During an interview on 10/05/22 at 10:30 AM, Staff C stated that gloves should be removed and hand hygiene performed after examining the left leg dressing.

During an interview on 10/12/22 at 8:56 AM, Staff D, RN, Infection Control Professional, stated that her expectation was for staff to do hand hygiene in between each glove change. She expected staff to change their gloves when they performed dressing changes and moved from a dirty dressing to a clean dressing and to clean the computer on wheels (COWs) between each patient room.





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