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Based on policy review, observation and interview, the hospital failed to ensure the safety and security of newborns. This deficient practice was evidenced by failure of the hospital to initiate measures to reduce the risk of infant abduction when the infants were in the mother's hospital room, in the Obstetrical Unit, after delivery.
Findings:

Review of the hospital policy tilted, Abduction Prevention and Response, revealed in part that mothers and family are to be informed of newborn security measures upon admission, such as visitor policy, checking ID bands, and transporting newborns. The policy did not indicate the plan to prevent infant abuctions from out of the OB unit.

An observation was made of the hospital's Obstetrical Unit on 11/14/22 at 11:15 a.m. with S2OB Director and S1CNO. The unit was locked and entry was by badge access. Upon entering the OB unit, observation revealed that there was no secured exit mechanism (such as badge access or keypad) upon exit from the unit. There was an exit button on the wall next to the exit door that would open the door when the button was pushed. S2OB Director stated that the post-partum mothers were housed on the Obstetrical Unit after delivery. Infants were brought out in cribs from the nursery, to their mothers' rooms, after delivery.

Further interview on 11/14/22 at 11:25 a.m. with S2OB Director revealed that she tries to make sure that a staff member is always sitting at the nurses station to monitor the exit door. When asked if staff was at the nurses station 24 hours per day, she stated no. S2OB Director confirmed there was no infant security system, currently in place, to reduce the risk of infant abductions when the newborns were in the room with their mothers on the Obstetrical Unit. S2OB Director agreed that an infant could be removed from the mother's room on the Obstetrical Unit if the mother was asleep and the nurses were busy and no staff was at the nurses station.

Based on record review and interview, the hospital failed to ensure orders for the use of restraints were not written on an as needed basis as evidenced by failing to obtain a new order for restraints after a release from restraints for 1 of 1 (#16) sampled patients reviewed for the use of restraints out of a total sample of 30 (#1-#30).

Findings:

Review of Patient #16's medical record revealed Patient #16 was a 79 year old male admitted to the emergency department on 06/13/2022 with a chief complaint of agitation. Patient #16 was placed on a PEC dated 06/13/2022 at 5:50 p.m. by S6MD.

Review of the physician's orders revealed the following orders:
Restrain patient soft ankle dated 06/13/2022 at 6:03 p.m. entered into the electronic medical record by S6MD.
Restrain patient soft wrist dated 06/13/2022 at 6:03 p.m. entered into the electronic medical record by S6MD.
D/C restraint order dated 06/14/2022 at 7:51 a.m. entered into the electronic medical record by S7MD.

Review of the nurse's notes revealed Patient #16 was placed in restraints on 06/13/2022 at 6:08 p.m. Further review revealed on 06/13/2022 at 7:29 p.m. restraints were removed due to decreased agitation/hostility, patient's ability to follow instructions. On 06/13/2022 at 9:30 p.m. restraints were removed due to decrease agitation/hostility, restraints were removed at 9:30 p.m. On 06/14/2022 at 7:52 a.m. no apparent distress. Patient is pleasant and non-combative. Restraints have been removed per S7MD. Patient stated, "Thank you. Thank you. Thank you." Patient follows commands and is requesting quietly. On 06/14/2022 at 7:57 a.m. restraints were removed due to decrease agitation/hostility, patient's ability to follow instructions, restraints were removed at 7:57 a.m.

Review of Patient #16's medical record revealed no documented evidence of a new order for restraints after each occurrence of removal.

In an interview on 11/16/2022 at 12:57 p.m. S1CNO stated the nursing staff needs to be re-educated on documentation of restraints. She stated by reviewing the documentation, it was not clearly documented rather the patient was removed from the restraints just for ROM exercises or the restraints were removed and then reapplied. S1CNO verified the nursing staff should have obtained a new order when restraints were removed from Patient #16 other than removing the restraints for ROM exercises.

Based on record review and interview, the director of nursing failed to ensure all nurses adhered to the policies and procedures of the hospital. This deficiency is evidenced by failure of the nursing staff to document checking the crash cart once per shift for 2 of 2 crash carts in the emergency department.
Findings:

Review of the hospital's policy titled "Crash Cart/Defibrillator Checks" revealed in part, the defibrillator check will be done once a shift to assure its functioning per the manufacturer's recommendation.

Review of the crash cart checklists for 2 of 2 crash carts in the emergency department revealed the crash carts including the defibrillators had not been checked on November 5, 6, 7, and 13 of 2022. Further review revealed on the days that the crash carts had been checked, the crash carts were only checked once per day.

In an interview on 11/15/22 S1CNO verified the crash carts were not checked on November 5, 6, 7, and 13 of 2022.

Based on observation, interview and policy review, the hospital failed to ensure all equipment was maintained in a manner to ensure an acceptable level of safety and/or quality as evidenced by failing to ensure the functionality of a nurse call button located on the handrails of 8 of 8 OB patient beds.
Findings:

On 11/14/22 at 11:15 a.m., an observation of 8 of 8 rooms on the OB unit revealed the patient beds had a non-functional nurse call feature (a red cross symbol) on the side rail of the beds. The red cross symbol was pressed during the observation and no alert of any type was generated when it was pressed.

An interview at that time with S2OB Director confirmed that all 8 OB patient rooms had non-functional call bell features on the beds. S2OB Director reported that patients/patient families were instructed to use the nurse call feature on the corded call light located at the patient's bedside to call for staff assistance. The surveyor discussed the possibility of patient/patient family/visitor confusion with having the non-functional nurse call feature available for use as well as the nurse call feature on the corded call light and the potential of the non-functional nurse call feature being pressed to summon help from staff. S2OB Director agreed that having the non-functional nurse call feature available for use could result in potential confusion when calling for staff assistance.

Based on observation and interview, the infection control officer failed to ensure the hospital's system for controlling infections and communicable diseases of patients and personnel was implemented. This deficient practice was evidenced by the hospital failing to maintain a sanitary environment.
Findings:

1. In an observation on 11/15/22 at 9:05 a.m., tour of the emergency department with S1CNO revealed the following:
- Room "a": Rust was observed on the metal cabinets and were unable to be disinfected.

- Room "b": Rust was observed on the metal cabinets and on the base of the rolling table and were unable to be disinfected.

- Room "c": Rust was observed on the metal cabinets and on the base of the rolling table and were unable to be disinfected. Approximately 6 inches of laminate on the edge of the counter was missing exposing the wood and was unable to be disinfected.

- Room "d": Rust was observed on the metal cabinets, on the base of the rolling table and on the frame of a chair and were unable to be disinfected. All the laminate on the edge of the counter was missing exposing the wood and was unable to be disinfected. In an interview during the observation, S1CNO verified the above stated findings.

2. On 11/15/22 at 1:00 p.m., observation of the OR with S8OR Director revealed that OR suite #2 had a rolling trash cart that had blood splatters on it. S8OR Director confirmed the blood splatters and stated this dirty equipment should not have been in the clean OR suite.

3. On 11/14/22 at 11:00 a.m., observation of the psychiatric unit revealed empty patient room e had dried spills on the floor in the bedroom and on the floor and sink in the bathroom. An interview at this time with S1CNO revealed that the patient had been discharged 3 days earlier. She further confirmed that the room should have been cleaned within 24 hours following the patient's discharge.