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Based on document review, observation, and interview, it was determined that for 1 of 1 Adult Behavioral Health Unit (ABHU), the Hospital failed to ensure that patient information was secured, and maintained confidential to prevent unauthorized access. This had the potential to affect the privacy of 17 patients (Pts. #44-60) on census on the ABHU on 9/8/2020 .

Findings include:

1. The Hospital's policy titled, "Patient Rights and Responsibilities" (revised 8/2020), was reviewed on 9/9/2020 and required, "...Patients have the right to privacy and confidentiality, including the right to: ... Patients' medical records to be confidential..."

2. During an observational tour of the ABHU on 9/8/2020, at approximately 11:15 AM, a "Nursing Unit Census" printout (dated 9/8/2020) was left unattended on the nurses station desk and included the name, age, gender, diagnosis, admission date, attending physician's name, room/bed number, and medical record number for the 17 patients (Pts. #44-#60) on census. Two patients (unidentified) passed by the station while the document was left unsupervised.

3. An interview was conducted with the ABHU Assistant Manager (E#18) on 9/8/2020, at approximately 1:50 PM. E#18 stated, "A nurse must've left the census sheet on the desk and forgot it. It should not have been left there. Anyone could walk by and take it. That's a problem."

A. Based on document review, observation and interview, it was determined that for 2 of 2 isolation carts observed, the Hospital failed to ensure that a registered nurse supervised patient care for patients on contact and airborne isolation precautions for the management of personal protective equipment (PPE) and patient care supplies.

Findings include:

1. On 9/9/2020, the policy titled, "Special Procedure Carts", revised by the Hospital 03/01/2019, was reviewed. The policy required, "Procedure - 3. Aseptic formats must be set by nursing employees by not placing contaminated materials on the carts."

2. On 9/9/2020, the isolation cart items list was reviewed. The list did not include storage of needles, syringes or previously used reusable PPE.

3. On 9/8/2020 at approximately 10:15 AM, during an observational tour of the 5th floor Telemetry Unit, the following was observed:
-One isolation cart outside of room 534 had three unsecured needles and one solution filled syringe labeled sodium chloride inside the cart easily accessible by unauthorized individuals.
-One isolation cart outside of room 539 had one used face shield with an employee's name taped on the top of the shield and one uncovered N95 face mask (specialized face mask to prevent exposure to airborne and droplet contaminates) sitting on top of the used face shield inside the cart.

4. On 9/8/2020 at approximately 10:15 AM, an interview was conducted with the 5th floor Telemetry Unit Charge Nurse (E #6). E #6 stated that needles and syringes should be secured in a locked area and used PPE should not be stored in the isolation cart. E #6 proceeded to remove the needles, syringe and used PPE from the isolation carts.

5. On 9/9/2020 at approximately 3:15 PM, an interview was conducted with the Infection Control Coordinator (E #10). E #10 stated that isolation carts are not used to store syringes, needles or used PPE.





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B. Based on document review and interview, it was determined that for 1 of 4 patients' (Pt. #7) clinical records reviewed for assessment/reassessment in 4th floor Medical-Surgical Unit A, the Hospital failed to conduct a pain reassessment, to ensure that the registered nurse evaluated the patient care.

Findings include:

1. On 9/8/2020 at approximately 11:00 AM, the clinical record of Pt. #7 was reviewed. Pt. #7 was admitted to the Hospital for abdominal pain. The clinical record indicated that morphine sulfate 2 mg (milligram) (pain medication) intravenous injection was administered to Pt. #7 on 9/6/2020 at 10:41 PM. However, a nursing pain reassessment was not conducted, as required.

2. On 9/8/2020 at approximately 2:00 PM, the Hospital's policy titled, "Pain Assessment and Management" (revised 10/10/19) was reviewed and included, "... All healthcare professionals should assess pain utilizing the appropriate pain rating scale... 2. Pain intensity is to be described on a scale of 0-10, where a rating of 0 indicates no pain and rating of 10 is the worst pain... Pain relief from pharmacological interventions should be assessed by the healthcare professional one hour after medication administration".

3. On 9/8/2020 at approximately 11:15 AM, findings were discussed with E #11 (Nurse Educator). E #11 stated that there should be a pain reassessment 1 hour after the administration of morphine sulfate. E #11 could not provide documentation that a pain reassessment was conducted by the registered nurse.

Based on document review and interview, it was determined that for 1 of 3 (Pt. #18) patient records reviewed for blood transfusions, the Hospital failed to ensure that vital signs were monitored in accordance with approved medical staff policies and procedures while blood products were administered.

Findings include:

1. On 9/8/2020, the policy titled, "Blood Product Administration & Management for Blood Transfusion Reactions", revised by the Hospital on 1/3/19, was reviewed. The policy required, "III. Policy/Procedure 12. Vital signs are taken pre-transfusion, within 15 minutes after the blood enters the vein, hourly throughout the transfusion and post-transfusion."

2. On 9/8/2020, Pt. #18's clinical record was reviewed. Pt. #18 was admitted on 9/6/2020, with the diagnoses of dehydration, acute kidney infection, anemia, and weakness. The clinical record included a physician's order dated 9/7/2020 at 12:09 AM, to transfuse a unit of Fresh Frozen Plasma/FFP (blood product) stat (immediately). The specimen inquiry record included documentation that one unit of FFP was initiated on 9/7/2020 at 3:30 AM and ended on 9/7/2020 at 6:10 AM. The blood administration record included a set of vital signs at 3:31 AM (one-minute after the initiation of the FFP), 3:49 AM and 5:04 AM (one hour and six minutes before the completion of the FFP), but lacked documentation of pre-transfusion, hourly and post-transfusion vital signs during the time the FFP was administered.

3. On 9/8/2020 at approximately 10:45 AM, an interview was conducted with the 5th floor Telemetry Unit Charge Nurse (E #6). E #6 stated that vital signs must be documented on the blood administration record per Hospital policy. E #6 stated that patients receiving blood products must be monitored for safe administration.

Based on document review, observation and interview it was determined the Hospital failed to ensure unused and outdated medications in the pharmacy were removed from the medication dispensing shelf.

Findings include:

1. On 09/10/2020, the Hospital's policy titled, "Beyond Use Dating for Pharmacy Preparation" (dated 09/2020) was reviewed and included, "...Beyond Use Date (BUDs) are the date or time after which a medication may not be used, stored or transported and are calculated from the date or time of compounding or opening ...patient specific: BUD 24 hours from packaged date ..."

2. On 09/09/2020 between 10:30 AM - 11:30 AM, an observational tour of the pharmacy was conducted. During the tour following was observed:

- Tobramycin (antibiotic) Eye Drops - 5 ml (milliliters) vial with patient name, medical record number and labeled as date of dispense 10/22/2019, found on the dispensing medications shelf.

- Keppra (anti-seizure) oral solution 2.5 ml (milliliters) syringe labeled as date of preparation 08/30/2020 and date of expiration 08/30/2020, found on the dispensing medications shelf.

3. On 09/09/2020 at approximately 10:45 AM, the Senior Pharmacy Manager (E #16) was interviewed. E #16 stated that, these medications should not have been re-shelved.

4. On 09/10/2020 at approximately 10:00 AM, the Pharmacy Director (E #17) was interviewed. E #17 stated that, the patient label was not removed, and it was restocked for dispensing. The eye drops should have been tossed. E #17 continued to state that, the expired oral solution syringe should not have been shelved.

A. Based on document review, observation, and interview, it was determined that the Hospital failed to manage dietary services by not ensuring that expired food products were discarded and equipment was cleaned, stored, and dried as required. This has the potential to affect all 26 patients receiving oral diets on 9/8/2020.

Findings include:

1. The Hospital's policy titled, "Food Storage" (dated 1/21/19), was reviewed on 9/9/2020, and required, "It is the policy of the Food and Nutrition Services Department to develop a mechanism to ensure the safe and accurate storage of food and nonfood products...Receiving clerk will: a. check expiration dates of food items daily and will denature then discard items beyond their expiration dates..."

2. The Hospital's policy titled, "Sanitation Program" (dated 1/21/19), was reviewed on 9/9/2020, and required, "To maintain a clean, safe and effective environment of care, and to prevent the transmission of disease-carrying organisms. The Food and Nutrition Services Department maintains a sanitation program...General Guidelines for Manual Cleaning: Daily Cleaning: Slicer-When used, clean, and sanitize...Robot Coupe [food processor]-Wipe clean after each use..."

3. The Hospital's policy titled, "Service ware handling and storage" (dated 1/21/19), was reviewed on 9/9/2020, and required, "Ensure proper storage of all service ware, including plates, utensils, and smallwares...Place cups, bowls, and glasses upside down in the proper compartment racks-always one layer per rack..."

4. On 9/8/2020 at 12:15 PM, a tour of Dietary Services was conducted. The following observations were made:

- A Reach-In Cooler contained (4) cups of prepared salad with an expiration date of 9/7/2020.

- A Walk-In cooler contained (2) pans of celery with expiration date of 9/6/2020, and one pan of mixed celery, onions, and carrots with an expiration date of 9/7/2020.

- The meat slicer was uncovered and contained a piece of meat from previous use.

- The food processor (that was currently not being used by staff) was in an upright position and contained standing liquid at the bottom.

- The ice machine was visibly soiled with a sticky substance on the external surface.

- A whisk was placed in the handwashing sink.

- Approximately 20 cleaned salad bowls were stacked on top of each other and uncovered.

5. On 9/8/2020 at approximately 12:30 PM, an interview was conducted with the Director of Dietary Services (E #8). E #8 stated that food should be discarded if it is expired. E #8 stated that the staff check daily for expired food products. E #8 stated that the meat slicer should be cleaned after use and there should not be any meat remaining after it was cleaned. E #8 stated that there should not be any standing liquid in the food processor when not in use. E #8 stated that the whisk should not have been placed in the handwashing sink. E #8 stated the salad bowls should not have been stacked as high and should have been covered while stored. E #8 stated that, the ice machine maintenance is done by an outside vendor.

B. Based on document review, observation, and interview, it was determined that the Hospital failed to manage dietary services by not ensuring that staff adhered to the PPE (personal protective equipment) policy as required. This has the potential to affect all 26 patients receiving oral diets on 9/8/2020.

Findings include:

1. The Hospital's policy titled, "Infection Prevention COVID-19 Protocol for PUI [persons under investigation/pending results] and COVID Positive Patients" (dated 8/2020), was reviewed on 9/10/2020, and required, "...8. Personal Protective Equipment (PPE): Caregivers (all employees) must adhere to the universal PPE requirements that include a surgical mask..."

2. On 9/8/2020 at 12:15 PM, a tour of Dietary Services was conducted. The Dietary Manager (E #14) and the Cook (E #15) who were preparing food, were not wearing face masks properly. E #14's face mask was on the chin and E #15's mask was under the nose.

3. On 9/8/2020 at approximately 12:30 PM, an interview was conducted with the Director of Dietary Services (E #8). E #8 stated that employees should wear masks properly in the kitchen by covering their nose and mouth.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of a Full Survey Due to a Complaint conducted on September 8-10, 2020, the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710.

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 on September 8-10, 2020, 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, interview, and document review, it was determined that for 1 of 1 Wound Care Nurse (E #5) in the Intensive Care Unit (ICU) observed performing wound care to a patient (Pt. #2), the Hospital failed to ensure infection control practices were followed for prevention and controlling the transmission of infections.

Finding include:

1. On 9/8/2020 at approximately 10:20 AM, an observational tour of the Intensive Care Unit (ICU) was conducted. During the tour, a Wound Care Nurse (E #5) was observed removing a soiled dressing from Pt. #1's left knee. E #5 discarded the soiled dressing, then proceeded to turn Pt. #2 on their side and removed a soiled dressing from a sacral wound. E #5, cleansed the sacral wound with a solution, then patted dry with a gauze, and then covered the wound with a Mepilex dressing (absorbent foam dressing). During the wound care provided by E #5, no hand hygiene was observed and remained with the same pair of gloves for both dressing changes.

2. An interview was conducted with the Unit Manager (E #4) on 9/8/2020 at approximately 11:00 AM. E #4 stated that the Nurse should have removed her gloves and performed hand hygiene after removing the soiled dressings and prior to applying a new dressing.

3. The Hospital's policy titled, "Hand Hygiene" (revised 2/2020), was reviewed on 9/8/2020 and required, " ...Hand Hygiene is known to reduce patient morbidity and mortality from healthcare associated infections ...Moments for Hand Hygiene ...After care involving contact with blood, body fluids, secretions and excretions of a patient, even if gloves are worn ...When moving from a contaminated body site to a clean body site during healthcare activities ..."