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Based on observation and staff interview, it was determined the CAH failed to ensure the emergency cart in the OR suite had medications that were current and ready for immediate use. This had the potential for the health and safety of patients in the OR suite to be compromised in the event of a medical emergency requiring immediate use of the emergency cart. Findings included:

The OR emergency cart was opened and reviewed on 3/12/25 beginning at 1:30 PM in the presence of the OR RN manager and the pharmacist. The following medications were identified as expired:

1. Lidocaine 2%, 100mg/5ml vial, 2 vials, expired 1/25
2. Magnesium sulfate 2grams in 50 ml bottle, expired 2/25
3. Amiodarone 150mg/3ml vial, 3 vials, expired 2/25

The OR RN manager confirmed these medications were expired. The pharmacist confirmed these medications were expired.

The CAH failed to ensure emergency medications in the OR suite were accessible and ready for use in the event of an emergency.

Based on staff interviews, medical record review, and incident report review, the facility failed to ensure adequate staffing to provide safe and effective services in the Emergency Department (ED). This failure directly affected 2 of 20 patients (Patient #16 and Patient #17) whose records were reviewed. The lack of sufficient staffing caused delayed assessment and treatment for individuals seeking emergency care. Findings included:

1. Patient #16 was a 73-year-old female who presented to the ED on 6/24/24 at 10:46 AM with severe abdominal and back pain. She was discharged at 11:59 PM the same day. The patient's ED record indicated triage at 11:01 AM. However, a subsequent clinic visit note from the RHC, documented by a PA at 11:05 AM (4 minutes after ED triage), stated, "Patient was triaged in the WIC [walk in clinic] with severe upper abdominal pain. The patient had a pulse of 40 bpm, was cold and clammy, with nausea and lightheadedness, unable to sit still or lie down. The patient was immediately transferred to the ED in a wheelchair." This showed that after triage in the ED, Patient #16 was registered and seen at an attached RHC, examined by a PA, and then transferred back to the ED.

Patient #16 received a Medical Screening Examination in the ED on 6/24/24 at 11:07 AM. The medical record confirmed the patient was admitted at 11:59 AM on 6/24/24 and underwent a cholecystectomy (surgery to remove gallbladder) at the facility.

The Quality Director was interviewed on 3/12/25, beginning at 10:30 AM, and the medical record of Patient #16 was reviewed. The Quality Director confirmed the record indicated the patient was triaged in the ED and then sent to the RHC before receiving the MSE.

The registration clerk was interviewed on 3/11/25, beginning at 3:48 PM. When asked whether a patient could be sent to the RHC upon presenting to the ED, the registration clerk confirmed, "It could happen, but not often," though the clerk did not recall Patient #16.

2. Patient #17 was a 56-year-old female who presented to the ED on 7/23/24 at 4:01 PM and was transferred to another facility via Life Flight at 3:35 AM on 7/24/24.

An incident report documented that registration had called back to the ED nurse several times over the course of an hour, expressing concern that the patient was decompensating and needed immediate attention.

Patient #17's medical record included a nursing note at 4:55 PM (54 minutes after the initial presentation), stating, "Patient in waiting area. Alert to self and date of birth, unable to recall the year. Significant others and friends with patient report that she is deteriorating. Patient recalls having a wound on the foot for 2 days. Awaiting ED bed."

At 5:01 PM (one hour after the initial presentation), a note by an ED provider, "At bedside, received orders." The medical record further noted labs were drawn at 5:10 PM, followed by vitals and an X-ray at 5:30 PM on 7/23/24. A nursing note at 5:01 PM indicated, "Patient was seen in the Walk-In Clinic and advised to come to the ED. The patient has a foot wound and altered mental status."

The Quality Director was interviewed on 3/12/25, beginning at 10:30 AM, and the medical record of Patient #17 was reviewed. The Quality Director confirmed the record demonstrated the patient presented to registration at 4:01 PM and was triaged into the ED at 5:01 PM. The record also indicated the MSE was documented at 8:07 PM, four hours after the patient's presentation to the ED. When asked about the timing of the MSE, the Quality Director stated, "There is no way to tell when the MSE was actually completed."

An ED RN was interviewed on 3/11/25, beginning at 3:15 PM. When asked whether there would ever be a situation in which a patient would wait an hour in the waiting area before being seen by an ED nurse, the RN responded, "I would lay eyes on them, especially if registration had called back." The RN further confirmed, "I would document laying eyes on the patient."

It was unclear through documentation why Patient #17 had to wait for an hour before being seen by the ED nurse or ED provider and why four hours elapsed between registration and the documented MSE.

An interview was conducted with an ED provider on 3/12/25, beginning at 3:30 PM. The provider explained that they were required to cover both the ED and several RHC visits during the same shift. The provider stated this workload was overwhelming and exceeded what could be managed effectively, particularly during times of increased patient volume.

A Staff RN was interviewed on 3/13/25, beginning at 9:40 AM. When asked about staffing levels in the ED, the RN stated staffing was generally adequate, though there were occasions when additional help was needed. When asked about the challenges of having one provider cover both the ED and RHC during the same shift, the RN explained, "It's frustrating waiting for the doctor to come up from the clinic, and patients in the ED must wait for the doctor to see them."

The hospital did not provide sufficient staffing coverage in the ED to ensure timely and effective patient care. Staff interviews revealed extended wait times for triage and treatment, delays in administering potentially critical interventions, and periods when the ED was left with insufficient personnel to handle patient volume safely. Furthermore, the hospital operated a RHC that provided both scheduled and walk-in care. The ED physician was expected to cover both the ED and the RHC during the same shift, further compromising the physician's ability to provide continuous and immediate emergency medical care. This dual responsibility increased the risk of delayed treatment and patient safety concerns.

The hospital failed to ensure adequate staffing in the ED.

Based on observation and staff interview, it was determined the CAH failed to ensure all medications used in the infusion unit were properly labeled and stored. This had the potential to cause harm to all patients using infusion and/or wound care services. Examples included:

A tour of the infusion center and wound care center was conducted on 3/12/25 beginning at 1:30 PM with the Director of Quality. The wound care area contained the following on the counters and in the cabinets:

1. Anasept skin and wound cleanser, 12 ounce bottle, open, not dated or initialed
2. Ultrasound gel, 8.5 ounce bottle, open, not dated or initialed
3. Dakin solution, 16 ounce bottle, open, not dated or initialed
4. Deep Prep II, soft tissue massage cream, 15 ounce jar, open, not dated or initialed
5. Vaseline, 3.75 ounce jar, open, not dated or initialed
6. Medihoney gel, 1.5 ounce tube, open, dated 12-6

The wound care RN present at the time of the tour confirmed these listed items were not labeled appropriately.

The Director of Quality was interviewed on 3/12/25 beginning at 1:45 PM. She confirmed the items listed above were not appropriately labeled or stored correctly.

The CAH failed to ensure medications were stored and labeled properly.

Based on observation, a review of CDC, AORN, and FDA guidelines, and staff interviews, it was determined the hospital failed to maintain a sanitary environment. This failure had the potential to place all patients receiving care at the facility at an increased risk for infection. Findings included:

1. The facility failed to follow CDC and AORN guidelines for the storage of surgical attire and patient linens.

The CDC Guidelines for Environmental Infection Control were reviewed at https://www.cdc.gov/healthcare-associated-infections/hcp/cleaning-global/appendix-d.html. The guidelines stated clean and sterile textiles must be stored in a manner that minimized exposure to moisture, dust, and other contaminants. Additionally, the CDC guidelines specified: "Sort, package, transport, and store clean linens in a manner that prevents risk of contamination by dust, debris, soiled linens, or other soiled items."

The AORN Guidelines for Perioperative Practice were reviewed. The guidelines stated, "Laundered scrub apparel in enclosed carts, cabinets, or dispensing machines that are cleaned and disinfected regularly." The guidelines further specified that perioperative textiles, including surgical scrubs, must be stored in a controlled, clean environment to prevent microbial contamination and ensure patient and staff safety. These guidelines were not followed. Examples included:

During an observation on 3/10/25, beginning at 3:15 PM, a tour of the facility's clean linen storage was conducted. Patient gowns, sheets, towels, and OR surgical attire were stored in an unfinished basement with bare concrete walls and floors. Directly above patient clean linens, multiple pipes were covered in a thick layer of dust and debris. Additionally, an approximately 10-inch circular penetration in the wall allowed air to blow directly into the storage area, increasing the risk of contamination from dust, debris, and other airborne particles.

Storing patient linens and surgical attire in an unfinished basement with exposed concrete surfaces and an open penetration allowing unfiltered air to enter the storage area which exposed them to potential contamination from dust, moisture, and environmental debris, did not comply with these infection control standards.

On 3/11/25, beginning at 11:30 AM, the facility's Quality Director and Environmental Services Supervisor were interviewed. The facilities Quality Director confirmed the facility followed CDC guidelines and AORN guidelines. During the interview, both confirmed the above observations and acknowledged patient linens and surgical attire were stored in an unfinished basement with a 10-inch circular wall penetration allowing unregulated airflow into the storage area. Additionally, they confirmed the room where hospital linens and clean OR scrubs were stored was not cleaned regularly.

This failure to adhere to CDC and AORN guidelines placed patients and staff at risk for healthcare-associated infections due to potential contamination of linens and surgical attire.

2. Hospital staff failed to perform appropriate hand hygiene.

CDC guidelines were reviewed at https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html. The CDC outlined hand hygiene for healthcare workers and recommended handwashing:

- After touching a patient or the patient's surroundings.
- After contact with blood, body fluids, or contaminated surfaces.
- Immediately after glove removal.

This standard was not followed. Examples included:

On 3/10/25 at 3:15 PM, during an observation of a blood draw on a patient, the phlebotomist failed to remove gloves and perform hand hygiene after the procedure. The phlebotomist continued wearing gloves while performing other laboratory tasks and touched multiple clean work surfaces before removing the dirty gloves. Upon glove removal, the phlebotomist did not perform hand hygiene.

On 3/12/25 at 1:30 PM, the Quality Director was interviewed, and the above observations were reviewed with her. She confirmed the hospital followed CDC guidelines, and stated hand hygiene should be performed after removing gloves and before touching clean surfaces.

The facility failed to provide a sanitary environment through proper hand hygiene practices as outlined by the CDC.

3. The hospital failed to ensure sharps containers were utilized appropriately. This placed patients and staff at risk for accidental needle sticks and potential exposure to blood and body fluids.

FDA guidelines for sharps disposal containers were reviewed at https://www.fda.gov/medical-devices/safely-using-sharps-needles-and-syringes-home-work-and-travel/sharps-disposal-containers-health-care-facilities. The guidelines stated sharps disposal containers must have a "puncture-resistant lid with an opening to accommodate depositing a sharp but not large enough for a hand to enter." This standard was not followed. Examples included:

On 3/10/25 at 3:15 PM, during an observation of a blood draw on a patient, the phlebotomist disposed of a needle into a large sharps disposal container on the floor next to the patient chair. The lid of the sharps container was not secure, and half of the container was open. The unsecured lid created a wide enough opening for a hand to enter, increasing the risk of potential blood or other body fluid splashes.

On 3/12/25 at 1:30 PM, the Quality Director was interviewed, and the above observations were reviewed with her. She confirmed that the sharps disposal container lid should have been secured.

The facility failed to ensure appropriate sharps disposal practices, leading to an unsanitary environment and increased risk of exposure to bloodborne pathogens.

4. The hospital failed to ensure patient procedural areas were cleaned and disinfected between patients.

CDC cleaning guidelines were reviewed at https://www.cdc.gov/healthcare-associated-infections/hcp/cleaning-global/procedures.html#cdc_generic_section_3-4-2-general-patient-areas. The CDC recommended cleaning minor procedural areas in outpatient wards "before and after (i.e., between) each patient." This standard was not followed. Examples included:

On 3/10/25 at 3:15 PM, during an observation of two separate blood draws on two different patients, the phlebotomist failed to clean the patient chair used for venipuncture after the first patient and before the second patient.

On 3/12/25 at 1:30 PM, the Quality Director was interviewed, and the above observations were reviewed with her. She confirmed the hospital followed CDC guidelines and the chair should have been cleaned prior to the second patient.

The facility failed to adhere to CDC cleaning guidelines, placing patients at increased risk for healthcare-associated infections due to inadequate environmental sanitation.