HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 2 (Pt. #14) patients on the Medical/Surgical 2 unit and 1 of 4 (Pt. #18) patients on the Orthopedic/Neurological unit, reviewed for pain assessments, the Hospital failed ensure a pain assessment/reassessment was performed to evaluate the nursing care for each patient.

Findings included:

1. The Hospital's policy titled, "Pain Management (5/16/2022)" was reviewed on 2/6/2023 and required, "A. For additional information on Pain Management, refer to Perry & Potter "Clinical Nursing Skills & Techniques" [nursing educational resource] ... C. Pain assessment/reassessment will be completed: ... 5. With each new report of pain ... 6. Within a reasonable time frame after each intervention for pain."

2. The reference book, "Perry & Potter "Clinical Nursing Skills & Techniques (9th edition)" was reviewed on 2/8/2023 and required, "Pain evaluation: 1. Within 1 hour of an intervention, ask patient to describe level of relief using a scale of 0 to 10."

3. The clinical record of Pt. #14 was reviewed on 2/6/2023. Pt. #14 was admitted on 2/4/2023 with a diagnosis of UTI (urinary tact infection). The medication administration record (MAR) indicated that the following pain medications were administered without a reassessment of pain:

-2/5/2023 at 5:07 AM, Norco (oral pain medication) for a pain scale of 10 (1-10; 10 being the worst), a reassessment was not completed.
- 2/5/2023 at 8:57 AM, Percocet (oral pain medication) for a pain scale of 10, a reassessment was not completed.
- 2/5/2023 at 12:12 PM, Percocet for a pain scale of 10, the next pain assessment was completed at 6:18 PM with a pain scale of 8 (6 hours, 6 minutes), no intervention provided.
- 2/6/2023 at 1:01 AM, Percocet for a pain scale of 8, reassessment at 4:06 AM with a pain scale of 0 (3 hours, 5 minutes).

4. The clinical record for Pt. #18 was reviewed on 2/6/2023. Pt. #18 was admitted to the Hospital due to closed fracture of the left hip. The clinical record included:

- On 2/3/2023 at 1:07 PM, Pt. #18 had a pain assessment of 10 (severe pain) to her lower extremity, and Norco was administered. The pain reassessment was conducted at 2:37 PM (ninety minutes after the pharmacological intervention).
- On 2/3/2023 at 4:06 PM, Pt. #18 had a pain assessment of 5 (moderate pain), and Ultram (oral pain medication) was administered. The pain reassessment was conducted at 5:36 PM (ninety minutes after the pharmacological intervention).

5. On 2/06/2023 at approximately 10:30 AM, findings were discussed with E #6 (Nurse Manager, 2nd floor Medical Surgical Unit). E #6 stated that pain reassessment should be conducted between 30 to 60 minutes following an intervention.

6. During an interview on 2/6/2023 at approximately 10:30 AM, with E #1 (Charge Nurse/2nd floor Medical Surgical Unit) stated that patients should be reassessed for pain a minimum of 60 minutes after intervention.

A. Based on document review, observation and interview, it was determined that for dry and cold food items that were stored in the kitchen, were readily available for patient use, the Hospital failed to manage the dietary services by ensuring that food items were labeled with a use-by-date and that outdated items were discarded. This had the potential to affect 192 patients receiving meal service as of 02/08/2023.

Findings include:

1. On 02/08/2023, the Hospital's Contracted Dietary Service policy titled "Expired/Recalled Products" dated 01/02/2007 was reviewed and included, "...check expiration dates on a daily basis ...discard outdated ...products immediately ...proper label should include received date and use by date ..."

2. On 02/08/2023 between 10:30 AM - 12:45 PM, an observational tour of Food and Dietary Services was conducted and the following were observed:

- Six (6) Bagels in a plastic bag kept by the cooking area with no use-by or expiration date.
- One (1) 20 ounce bottle of frozen cherry coco-cola in a freezer by the cooking area with no date of open or use-by date.
- Produce Cooler: Two (2) bags of cut frozen broccoli with the date of expiration labeled 01/30/2023.
- Produce Cooler: One (1) tray of lettuce with prepared on label 01/06/2023 and use-by label 01/14/2023.
- Cooked Food Cooler: Fourteen (14) trays of meat patties and bacon with no label indicating date and time of preparation, and no use-by date label.
- Walk-In Freezer: One (1) two pound bag of chicken tenders with no use-by or expiration date.

3. On 02/08/2023 at 12:30 PM, the Dietary Manager (E #15) was interviewed. E #15 stated that those foods should not be in the freezer. E #15 stated that expired food could be contaminated and cannot be used. E #15 stated that it is not acceptable to have any food item without a use-by label if the food item had been opened from the box.

B. Based on observation, document review, and interview, it was determined that for 2 of 13 (E #16 and E #17), dietary staff observed for hairnets, the Hospital failed to ensure that staff adherence to dress code by failing to ensure that staff wore hairnets while working in the kitchen.

Findings include:

1. On 02/08/2023 the Hospital's contracted dietary services policy titled, "Dress Code" dated 07/01/2009, was reviewed and included, "....Hairnets ...must be worn before entering the kitchen ...all hair must be contained within the hairnet ..."

2. On 02/08/2023 between 10:30 AM - 12:45 PM, an observational tour of Food and Dietary Services was conducted and the following were observed:

- E #16 (Dietary Aide) standing by the out-put end of the dish washing machine removing the clean dishes from the line tray without a hairnet.
-E #17 (Dietary Aide) standing by the input end of the dish washing machine placing the dirty dishes into the machine without a hairnet.

3. On 02/08/2023 at 12:15 PM, both the dietary aides (E #16 and E #17) were interviewed. Both of them stated they forgot to wear the hairnet.

4. On 02/08/2023 at 12:20 PM, the Dietary Manager (E #15) was interviewed. E #15 stated that all staff in the kitchen must wear hairnets.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety code portion of the Full Survey Due to a Complaint conducted February 6 & 7, 2023, the surveyors find that the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety code portion of the Full Survey Due to a Complaint conducted February 6 & 7, 2023, the surveyors find that the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags.

Based on observation, document review and interview, it was determined that the Hospital failed to ensure an effective Infection Control Program, with adherence to infection control practices and sanitary conditions maintained to prevent cross contamination. This has the potential to affect all staff and patients, who receive care by the Hospital. As a result, it was determined the Condition of Participation, 42 CFR 482.42, Infection Prevention Control Antibiotic Stewardship was not met.

Findings include:

1. The Hospital failed to ensure that the dishwasher temperature were maintained as required to ensure a clean and sanitary environment to avoid sources and transmission of infection. See deficiency A-750-A.

2. The Hospital failed to ensure the staff adhered to prevention of infection by disinfecting equipment after use. See deficiency A-750-B.

3. The Hospital failed to ensure that hand hygiene was performed as required to prevent transmission of infection. See deficiency A-750-C.

A. Based on document review, observation, and interview, it was determined that for 1 of 1 dishwashing machine, the Hospital failed to ensure that the dishwasher temperature were maintained as required to ensure a clean and sanitary environment to avoid sources and transmission of infection. This potentially affects 192 patients on census receiving meals service as of 02/08/2023.

Findings include:

1. On 02/08/2023, the Hospital's contracted dietary services policy titled, "Sanitation Program" dated 01/02/2007, was reviewed and included, "...The Food Service ...equipment ...dishwashing temperature ...are maintained and monitored ...equipment that are not in compliance to ensure food safety..."

2. On 02/08/2023, the Hospital's Dishwashing Machine Temperature Log, dated February 2023, was reviewed and included, "...For High Temperature Machine: (Refer to machine data plate for temperature requirements) Temperature Requirements: Wash - 150, Final Rinse - 180 ..."

3. On 02/08/2023 between 10:30 AM - 12:45 PM, an observational tour of Food and Dietary Services was conducted and the following were observed:

- At 11:30 AM, the dishwasher was washing dirty dishes with plate temperatures showing - Wash: 156 degrees, and Final Rinse at 169 degrees.
- At 11:36 AM, the dishwasher was washing dirty dishes with plate temperatures showing - Wash: 152 degrees, and Final Rinse at 174 degrees.
- At 11:40 AM, the dishwasher was washing dirty dishes with plate temperatures showing - Wash: 157 degrees, and Final Rinse at 178 degrees.
-At 11:47 AM, the dishwasher was washing dirty dishes with plate temperatures showing - Wash: 156 degrees, and Final Rinse at 169 degrees.

4. On 02/08/2023 at 11:55 AM, the Dietary Manager (E #15) was interviewed. E #15 stated that on 02/03/2023 there was a problem with the dishwasher and he had called the "Ecolab" to repair the issue of the final rinse temperature not being achieved. E #15 stated that he was not sure why the final rinse temperatures were not achieved even after the repair. E #15 stated that it is essential that the final rinse temperature is achieved for the proper disinfection of the utensils since, it was high-temperature machine.

5. On 02/08/2023 at 1:30 PM, the Manager of Infection Prevention (E #21) was interviewed. E #21 stated that it is not acceptable that the dishwasher does not meet the required temperature during the final rinse.

B. Based on document review, observation, and interview, it was determined that for 1 of 1 (E#18) blood glucose testing observed, the Hospital failed to ensure the staff adhered to prevention of infection by disinfecting equipment after use.

Findings include:

1. On 02/08/2023 the Hospital's policy titled, "POCT [point-of-care-testing] Bedside Glucose" dated 09/12/2012 was reviewed and included, "...A. Clean/disinfect meter: ...2. Using the hospital approved germicidal bleach wipe, thoroughly wipe the external surface of the meter ...minimum 3 times horizontally followed by 3 times vertically ...wipe the surface area ...for one minute ...allow to air dry for an additional minute ..."

2. On 02/06/2023 between 9:15 AM to 11:45 AM, during the observational tour of the Intensive Care Unit (ICU), the following was observed:

- At 11:00 AM, the Registered Nurse (E #18) completed the blood glucose testing for Pt. #3, removed gloves and E #18 wiped the glucometer with one alcohol pad and placed the glucometer back on the docking station outside the room.

3. On 02/06/2023 at 11:15 AM, the Registered Nurse (E #18) was interviewed. E #18 stated that she (E #18) always cleans it with the alcohol pad.

4. On 02/08/2023 at 1:00 PM, findings was discussed with the Manager of Infection Prevention (E #21). E #21 stated that it is not acceptable to clean the glucometer with alcohol wipes/pads.



39802


C. Based on document review, observation, and interview, it was determined that for 4 of 7 staff (E#9, E#10, E#12, and MD#2) observed for hand hygiene on the Intermediate Care Unit (ICA) and GI (Gastrointestinal) Lab, the Hospital failed to ensure that hand hygiene was performed as required to prevent transmission of infection.

Findings include:

1. The Hospital's policy titled, "Hand Washing Technique and Nail Care" (last reviewed by Hospital approximately 12/15/2022), was reviewed on 2/8/2023 and required, "Hand washing is essential for the prevention of infection and the control of cross-infection between personnel and patients. All personnel providing direct patient care or having any physical contact with patients or their equipment shall practice hand hygiene frequently. This shall include, but is not limited to: ... Before and after any physical contact with patient's equipment or patient's personal articles that are likely to be contaminated virulent microorganisms or hospital pathogens... Before and after any procedure with patients and the collection of specimens... After glove removal..."

2. During an observational tour of the ICA on 2/6/2023, at approximately 11:11 AM, an Environmental Services Staff (E#9) was observed wearing gloves, a gown, and mask while cleaning a patient's room, who was on isolation for COVID-19. After cleaning the room, E#9 exited the room with the same gloves on and touched the door handle to the room. E#9 then removed the gloves, gown, and mask and went to get a new pair of gloves and a new mask without first performing hand hygiene.

3. A tour of the Outpatient GI Lab was conducted on 2/7/2023, at approximately 9:10 AM and the following was observed:
- Staff were in procedure room #1 working with a patient receiving an EGD (esophagogastroduodenoscopy) and colonoscopy. The Circulating Nurse (E#10) was observed touching the patient and/or handling specimen containers from the patient with gloved hands and did not remove gloves and perform hand hygiene prior to documenting on the computer. The Certified Nurse Anesthetist/CRNA (E#12) was observed touching the patient and adjusting the patient's tubing/lines and did not remove gloves and perform hand hygiene prior to documenting on the computer. After the procedure, at approximately 9:17 AM, staff wiped down the procedure table/carts prior to the next patient's procedure; however, the computers were not wiped down during the room turnover.
- At approximately 9:30 AM, another patient was in the procedure room for an EGD and colonoscopy. E#10 and E#12 were observed going between patient care/contact and documenting on the computers without removing gloves and performing hand hygiene. At approximately 9:39 AM, the GI Physician (MD#2) was observed changing gloves when transitioning from the EGD to colonoscopy. MD#2 did not perform hand hygiene after glove removal. At approximately 9:41 AM, the CRNA removed gloves after contact with the patient and did not perform hand hygiene prior to retrieving a medication vial and supplies from the clean medication cart. At approximately 9:54 AM, the procedure was completed and MD#2 removed gloves and gown and did not perform hand hygiene prior to documenting on the computer.

4. An interview was conducted with the Manager of Oncology Services (E#20) on 2/6/2023, at approximately 11:53 AM. E#20 stated that staff should remove PPE (i.e. gloves and gown) before exiting the room and perform hand hygiene right after removal.

5. An interview was conducted with the Manager of the GI Lab (E#14) on 2/7/2023, at approximately 10:00 AM. E#14 stated that generally staff should remove gloves and perform hand hygiene prior to documenting on the computers or accessing the omnicell (medication dispensing system). E#14 stated that hand hygiene should be performed after removing PPE. E#14 stated that if they forget to do so, then the computers/equipment they touched should be disinfected after the procedure (between cases).

Based on document review and interview, it was determined that for 1 of 3 (Pt. #42) clinical records reviewed of expired patients, the Hospital failed to ensure that the written protocol for timely notification of the designated OPO (organ procurement organization) was followed.

Findings include:

1. On 2/08/2023, the Hospital's policy titled, "Organ and Tissue Donation" (reviewed by the Hospital on 1/2023) included, "... Procedure. 1. Timely Notification/Referral to Gift of Hope/GOH (designated organ procurement organization). Organ and/or tissue donation may be possible... dependent upon... other factors. The patient's nurse shall notify a GOH Referral Coordinator via the 'donor hotline'... according to the following criteria and/or established triggers to be considered 'timely notification'... b. For ventilated (machine to assist breathing) patients, notify GOH as soon as possible after the identification of a ventilator-dependent patient with non-survivable illness... according to the following triggers... v... code status change to DNR (do not resuscitate)..."

2. On 2/08/2023, the clinical record for Pt. #42 was reviewed. Pt. #42 was admitted to the Hospital with a diagnosis of acute respiratory failure with hypoxia (oxygen deficiency). On 1/25/2023, Pt. #42 was mechanically intubated and the code status was changed from full code to DNR. GOH was notified for possible organ and/or tissue donation on 1/30/2023 (five days later).

3. On 2/08/2023, findings were discussed with E #7 (Director of Spiritual Care/Organ Procurement Program) and E #8 (Nurse Manager, Intensive Care Unit). E #7 and E #8 stated that GOH should have been notified sooner when Pt. #42 was placed on mechanical ventilator and the code status was changed to DNR.

Based on document review and interview, it was determined that for 1 of 1 Surgical Technician (E #4) and 1 of 1 Operating Room Nurse (E #3), the Hospital failed to ensure that the policy regarding surgical attire was not followed by not ensuring hair was completely covered by a head covering in the operating room.

Findings include:

1. On 2/7/2023, the Hospital's policy titled, "Surgical Attire for Restricted and Semi-Restricted Procedural Areas" (dated 3/6/2006) was reviewed and indicated, "...All personnel should cover the totality of head and facial hair when in the semi-restricted and restricted areas..."

2. On 2/7/2023 at 9:15 AM, the Surgical Technician (E #4) was observed setting up surgical instruments in the OR (operating room) #1 wearing a head covering that did not cover her hair completely.

3. On 2/7/2023 at 9:20 AM, the OR nurse (E #3) was observed wearing a head covering that did not cover her hair completely.

4. On 2/7/2023 at 10:00 AM, an interview was conducted with the OR Clinical Nurse Manager (E #2). E #2 stated that staff in the OR should have their hair covered completely with a head covering.