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Based on record reviews, facility policies and procedures, staff training and competency documentation, and interviews with staff, it was determined the facility failed to ensure:

a) Nurses were trained and competent for job specific duties.

b) Nurses followed the hospital blood transfusion procedure.

This had the potential to negatively affect all patients served by this facility, staff, and visitors.

Findings include:

Refer to A 392 and A 410 for findings.

Based on review of facility policies and procedures, medical records (MR), staff training and competency documentation, and interviews, it was determined the facility failed to ensure critical care staff were trained and competent to provide care in emergency situations with critically ill patients.

This affected eleven of eleven Emergency Department (ED) and Medical Intensive Care Unit (MICU) staff, who provided care to critically ill patients, and included Patient Identifier (PI) # 5, PI # 12, PI # 3, PI # 7, PI # 11, which was five of seven (7) records reviewed for patients who required invasive mechanical ventilation (vent), non-invasive ventilation or BIPAP (Bilevel positive airway pressure, non-invasive ventilation therapy that delivers pressurized air through a mask or nasal pillows to help people with breathing difficulties), Arterial blood gas (ABG) collection, and moderate conscious sedation (drug-induced depression of consciousness).

This had the potential to negatively affect all patients treated at the facility.

Findings include:

Facility Policy and Procedure Title: Competency Requirements of Patient Care Services Staff
Revised Date: 3/11
No Number Documented

Requirements/Guidelines: Orientation (Hire, Six Weeks, Ninety Days, and Annually)

The level of competence of Patient Care Services employees is established during orientation...maintained/improved throughout the employment...During general orientation...the employee is given an orientation packet...includes...Population-Specific Competencies...The age specific skills checklist is also completed annually to insure continued competency...signed by the employee and the nurse manager then forward to...Human Resources.

...A competency list summary completion form is completed during the year as competency requirements are met by the employees...

Facility Policy and Procedure Title: Conscious Sedation
Revised Date: 5/94
No Number Documented

Staffing during procedures that require conscious sedation should always include...RN (Registered Nurse) with...the following skills...Successful completion of an organized course study on the administration of conscious sedation with yearly competency...

Findings include:

1. PI # 5 was admitted to the facility on 10/16/24 with diagnoses including Acute Respiratory Failure with Hypoxia.

MR review revealed PI # 5 was on the ventilator and received conscious sedation medications while in the MICU 10/16/24 to 10/20/24.

Review of personnel training and competency documentation for Employee Identifier (EI) # 20, MICU RN, EI # 21, MICU RN, and EI # 23, MICU RN, who provided care for PI # 5, revealed no education or training for BIPAP, and conscious sedation, and no competency documentation for invasive, and noninvasive mechanical ventilation, and conscious sedation.

There was no documentation EI # 21 and EI # 22 had competency for ABG collection via arterial.

An interview was conducted on 2/13/25 at 12:45 PM with EI # 2, Chief Nursing Officer (CNO), who reported the nurses received training from HealthStream computerized training modules. EI # 2 confirmed there were no competencies for ED and MICU nurses for invasive and noninvasive mechanical ventilation, and conscious sedation. EI # 2 confirmed all ED and MICU nursing staff did not have competencies for ABG collection via arterial.







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2. PI # 12 was admitted to the facility on 1/18/25 with a diagnosis of Cellulitis.

A review of the ED Visit Summary dated 1/18/25 at 7:00 PM revealed interventions to collect ABG's, and was documented as completed.

A review of the lab results dated 1/18/25 revealed the ABG's were collected and resulted via the ISTAT.

A review of the Respiratory Care CPAP/BiPAP Record revealed on 1/26/25 at 11:15 PM, EI # 24, RN House Supervisor cared for the patient while on BiPAP.

An interview was conducted on 2/13/25 at 11:50 AM with EI # 3, Quality Assurance, Infection Control, Risk Management Director, who reported EI # 24, collected the ABG's via an arterial stick. The surveyor asked for documentation of this staff member's competency for the arterial blood collection. EI # 3 confirmed EI # 24 did not have documentation of competency in his/her employee file.

An interview was conducted on 2/13/25 at 1:00 PM with EI # 2, who confirmed EI # 24 did not have documentation of competency for the BiPAP.



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3. PI # 3 was admitted to the facility on 2/9/25 with a diagnosis of Pneumonia.

Review of the Patient Order Summary (POS) dated 2/9/25 revealed orders for point of care ISTAT ABG.

Review of the computer documentation provided by EI # 14, Director of Lab Services confirmed the blood sample collected for ISTAT ABG was an arterial blood sample collected by EI # 24.

The surveyor requested EI # 24's training competency for ABG (arterial) blood collection and none was provided.

An interview conducted on 2/13/25 at 11:50 AM with EI # 3, confirmed EI # 24, did not have documentation of ABG (arterial) blood collection competency in his/her employee file.



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4. PI # 7 was admitted to the facility on 2/11/25 with a diagnosis of Acute Respiratory Failure with Hypoxia.

A review of the POS dated 2/12/25 at 5:22 AM revealed orders for point of care ISTAT ABG.

A review of the computer documentation provided by EI # 14 confirmed the blood sample collected for ISTAT ABG was an arterial blood sample collected by EI # 26, RN.

The surveyor requested EI # 26's training competency for ABG (arterial) blood collection.

An interview conducted on 2/13/25 at 11:50 AM with EI # 3, confirmed EI # 26 did not have documentation of ABG (arterial) blood collection competency in his/her employee file.

A review of the NN (Nurses Note) documentation dated 2/11/25 at 6:24 PM , completed by EI # 29, ED, RN revealed PI # 7 was on a BIPAP machine.

A review of the NN documentation dated 2/11/25 at 8:10 PM, completed by EI # 28, MICU, RN, revealed the patient was on a BIPAP machine.

Review of EI # 28 and EI # 29's training record documentation revealed no education or training for BIPAP, and no competency for invasive, and noninvasive mechanical ventilation, and conscious sedation.

5. PI # 11 was admitted to the hospital on 12/7/24 with a diagnosis of Hypoxia, Respiratory Failure, Unspecified.

A review of the POS dated 12/9/24 at 5:30 AM and 12/10/24 at 5:19 AM revealed orders for point of care ISTAT ABG.

A review of the computer documentation provided by EI # 14 confirmed the blood samples collected for ISTAT ABG was an arterial blood sample collected by EI # 27, RN.

The surveyor requested EI # 27's training competency for ABG (arterial) blood collection.

An interview conducted on 2/13/25 at 11:50 AM with EI # 3, confirmed EI # 27 did not have documentation of ABG (arterial) blood collection competency in his/her employee file.

A review of the POS documented 12/7/24 at 5:13 PM, completed by EI # 31, MICU, RN, revealed the patient was on a vent, and Fentanyl infusing at 50 mcg/hr.

An interview was conducted on 2/13/25 at 12:45 PM with EI # 2, who reported there was no competencies for EI # 28, and EI # 29, and no documentation staff completed all job specific education/training to manage critical care patients.

6. An interview was conducted on 2/11/25 at 12:30 PM with EI # 31, who stated, "Respiratory normally changes vents, but if they're not here, we would get orders from the UAB doctor to change."

7. An interview was conducted on 2/12/25 at 09:32 AM with EI # 32, who stated, "I have made changes on vents with the UAB doctor."

Based on review of medical records (MR), facility procedure and interviews, it was determined the facility failed to ensure nursing staff followed the hospital transfusion procedure. This affected Patient Identifier (PI) 1, one of three records reviewed with transfusions and had the potential to negatively affect all patients who receive transfusions at the facility.

Findings include:

Facility Procedure Title: Administration of Blood/Blood Products
Revised Date: 5/2024
(No number documented)

...Procedure

...16. During transfusion, vital signs (VS-temperature, pulse, respiratory rate, and blood pressure) are to be obtained every 15 minutes x (for) 2, then in one hour and at the completion of the transfusion and documented...
18. The transfusion is to be completed within 4 hours...Infusion time should NOT exceed 4 hours...

NOTE:

...Blood must be started within 30 minutes after obtaining it from the Blood Bank.
If, for any reason, there is a delay in administration of the blood, it must be returned to the lab within 30 minutes for storage in the Blood Bank refrigerator...The lab will not accept returned blood if it has been out of the lab longer than 30 minutes...blood will be discarded...

1. PI # 1 was admitted to the facility on 1/10/25 with diagnosis (chief complaint), anemia.

Review of the Patient Order Summary dated 1/10/25 at 3:43 PM revealed orders to type and screen stat (in medical terms, "stat" is an abbreviation for "immediately" or "right now," used to indicate that something needs to be done without delay), and transfuse one-unit red blood cells stat.

Review of the Red Blood Cells (RBC) Unit issue documentation revealed the unit was issued by the laboratory on 1/10/25 at 10:15 PM to the nurse unit. There was no reason for the 7-hour 32-minute delay from order to issue for the stat type, and screen.

Review of the Unit Transfusion Card revealed the transfusion began 1/10/25 at 11:25 PM, which was 1 hour 10 minutes after the lab issued the RBC unit, and greater than 30 minutes per facility procedure.

MR review revealed VS were documented at transfusion initiation at 11:25 PM, the first set of 15-minute VS were documented at 11:36 PM, the second set of 15-minute VS was documented at 11:40 PM which was 4 minutes later.

Record review revealed VS were documented on 1/11/25 at 12:10 AM, and at 12:40 AM. There was no hourly VS documented at 12:55 AM per procedure.

Further review of the Unit Transfusion Card documentation revealed the transfusion ended 1/11/25 at 3:50 AM which was 4 hr. 25 minutes after transfusion initiation, and not within four hours per policy.

An interview was conducted on 2/13/25 at 11:03 AM with Employee Identifier # 18, Director of the Medical Surgical Unit, who confirmed there was no reason for the stat type/screen and transfuse delay, the blood was outside the lab greater than 30 minutes before the transfusion began, the VS were not completed per procedure, and the blood administration time was greater than 4 hours.

Based on observations, policies and procedure, temperature and humidity monitoring documentation, and interviews with staff, it was determined the facility was not maintained to ensure patient safety. This had the potential to negatively affect all patients served by this facility, staff, and visitors.

Finding include:

Refer to A 701 for findings.

Based on observation, facility repair issues policy and procedure, and staff interviews, it was determined the facility failed to ensure the hospital environment was maintained in a manner that the safety and well-being of patients are assured. This had the potential to negatively affect all patients treated at the facility.

Findings include:

Facility Policy and Procedure: Reporting Equipment Malfunctions and Facility Repair Issues
Policy Number : 2014
Date: 6/21

Policy:

It is the policy to maintain equipment and the facility in working order all times.

Procedure:

...contact Facility Operations if the issue is a facility issue.

Institute other alternative procedures required to ensure patient care is not compromised.

...notification of facility issues can be made by calling Facility Operations (on call personnel after hours) for immediate safety issues.

1. The tour of the Sterile Supply Room in the surgical service department was conducted on 2/12/25 at 10:00 AM with Employee Identifier (EI) # 6, Surgery Services Director. There was a hole in the edge of one ceiling tile, and another ceiling tile was stained.

The tour of Operating Room (OR) 2 revealed cracks in the floor tile, and exposed ceiling sheet rock in 3 places surrounding a ceiling vent where ceiling paint had peeled.

The tour of OR 1 revealed cracks in the floor tile, and exposed ceiling sheet rock, where paint on the ceiling had peeled.

An interview was conducted on 2/12/25 at 11:00 AM with EI # 6, who confirmed the surgery service department environment had not been maintained.

2. On 2/12/25 at 10:50 AM, a tour was conducted of the Med Surg area located on the third floor of the hospital. The tour revealed an active water leak in the corner just outside the medication room at the nurses station. The area of water damage included loose and damaged sheetrock and paint on the ceiling and wall. The surveyor observed water streaking down the wall from the recent rain.

During the tour, staff revealed the area had been leaking for several months and leaks occur with heavy rain at the nurses station as well as in the medication room. The surveyor observed the area the staff identified as leaking in the medication room and water was observed on the floor.

An interview conducted on 2/12/25 at 11:00 AM with EI # 13, Chief Operating Officer (COO) confirmed the hospital had difficulty with correcting the water leaks throughout the hospital which had been ongoing for several months. The surveyor asked for all documentation concerning requests for repairs and work orders for the water leak at the nurses station and medication room on the Med Surg floor and no documentation was provided.

3. On 2/12/25 at 11:07 AM, a tour was conducted of the Medical Intensive Care Unit (MICU). The tour revealed rooms # 2, # 3, and # 6 with active water leaks and towels placed in each window to absorb the rain. The area of water damage to MICU room # 6 included damaged sheetrock and paint on the wall beneath the window.

During the tour, staff revealed the windows had been leaking for approximately one year and surveyor noted active water leaks with towels observed in the windows to collect the rain.

Documentation obtained from COO on 2/12/25 showed MICU rooms #2, #3, and # 6 were reported by the ICU Supervisor as leaking on 2/11/24.

PI # 13 was admitted to the hospital on 2/3/25 with a diagnosis of Sepsis, Unspecified Organism.

Review of MICU room # 2 on 2/12/25 at 11:07 AM revealed the room was occupied by PI # 13.

PI # 14 was admitted to the hospital on 2/3/25 with a diagnosis of Acute Kidney Failure, Unspecified.

Review of MICU room # 3 on 2/12/25 revealed the room was occupied by PI # 14.

An interview was conducted on 2/13/25 at 10:05 AM with EI # 13, who confirmed windows were actively leaking.

An interview was conducted on 2/13/25 at 8:40 AM with EI # 30, MICU RN, who reported all windows in the MICU on the east side of the building leaked when it rained heavily. EI # 30 stated the windows had leaked since 2021 and have been changed out more than two times due to leaking.

An interview was conducted on 2/13/25 at 2:00 PM, and EI # 1, Chief Executive Officer, confirmed the facility had failed to ensure the patient care environment was maintained.

Based on observations of care, facility hand hygiene policy and procedure, and staff interviews, it was determined the facility failed to ensure staff performed hand hygiene according to the facility policy and procedure. This affected four of seven medication (med) preparation (prep) and administration observations, including four unsampled patients and had the potential to negatively affect all patients treated at the facility.

Findings include:

Facility Policy and Procedure: Hand Hygiene
Revised Date 3/2020

Policy:

A. Objective:
...to outline indications for and methods of hand hygiene for personnel in a patient care setting...All staff will adhere to this policy to reduce the transmission of microorganisms to patients and other personnel.

...Procedure
A. Hand Hygiene Indications:

1. Hand hygiene with either waterless hand sanitizer or soap and water is required:
Upon entering and leaving a patient room
Between patient contacts if more than one patient is on a room...
Before donning and after removing gloves
Before handling an invasive device (regardless of whether or not gloves are used)
After contact with body fluids or excretions, mucous membranes...or wound dressings...

C. Routine Hand Hygiene Techniques

...2. Handwashing with soap and water...It can be accomplished in the following manner:
a. Wet hands with water
b. Apply soap...
f. Use a dry paper towel to turn off faucets to avoid contamination...

1. Observations for med prep and administration was conducted on 2/11/25 at 1:40 PM in the Geriatric Behavioral Health Unit (GBHU) with Employee Identifier (EI) # 8, Licensed Practical Nurse. At the sink in the medication (med) preparation (prep) room, EI # 8 performed hand hygiene, turned off the faucet with bare hands, and not paper towels as per facility hand hygiene techniques.

EI # 8 exited the med prep room and the nurse station to the patient room. EI # 8 scanned the patient's wristband and returned to the nurse station. EI # 8 failed to perform hand hygiene upon leaving the patient room per facility policy.

EI # 8 removed medication from the Omnicell at the nurse station and scanned the medication. EI # 8 placed the medication in a cup, laid the med on the nurse desk at the nurse station, returned to the med prep room, obtained a cup of water, exited the room and nurse station, to the patient room.

EI # 8 failed to perform hand hygiene upon entering the patient room per facility policy.

EI # 8 administered the medication to an unsampled patient, returned to the med prep room, performed hand hygiene, and turned the faucet off with bare hands.

EI # 8 failed to follow the facility hand hygiene policy and procedure.

An interview was conducted on 2/13/25 at 11:10 AM with EI # 3, Quality Assurance, Infection Control, and Risk Management Director, who confirmed staff failed to follow the facility hand hygiene policy and procedure.

2. Observations for med prep and administration was conducted on 2/11/25 at 2:34 PM in the Adult BHU with EI # 7, Registered Nurse (RN). Following hand hygiene at the sink in the med prep room, EI # 7 removed Clindamycin from the Omnicell, retrieved water in a cup, clean gloves, then exited the med prep room to the nurse station.

EI # 7 summoned the patient to the nurse desk, donned gloves without first performing hand hygiene, scanned the patient bracelet, medication, and administered the medication to an unsampled patient.

EI # 7 failed to follow the procedure and perform hand hygiene before donning gloves.

An interview was conducted on 2/13/25 at 11:10 AM with EI # 3, who confirmed staff failed to follow the facility hand hygiene policy and procedure.

3. Observations for med prep and administration was conducted on 2/11/25 at 2:50 PM in the GBHU with EI # 9, RN. In the med prep room, EI # 9 performed hand hygiene in the med prep room, exited the med prep room to the nurse station, and retrieved the medication from the Omnicell in the nurse station.

EI # 9 then gloved, but failed to perform hand hygiene before donning gloves. EI # 9 exited the nurse station to the patient room and administered medication to the unsampled patient.

An interview was conducted on 2/13/25 at 11:10 AM with EI # 3, who confirmed staff failed to follow the facility hand hygiene policy and procedure.

4. Observations for med prep and administration via a gastrostomy tube (GT) was conducted on 2/12/25 at 9:00 AM in the GBHU with EI # 10, RN, and EI # 11, RN.

EI # 10 retrieved meds from the Omnicell, placed the meds in a cup and laid on a clip board, exited the nurse station to the patient room, scanned the patient wristband, then returned to the nurse station with the clip board and meds.

EI # 10 failed to perform hand hygiene before entering and after exiting the patient room.

EI # 10 entered the med room, performed hand hygiene, crushed and mixed meds with water for administration via GT, and exited to the patient room.

EI # 10 donned gloves without performing hand hygiene, and began med administration. Liquid that contained meds was draining out of an uncovered GT valve.

EI # 11 exited the patient room, returned with gloves on, and assisted EI # 10, as more liquid and meds poured out of the uncovered GT valve. EI # 11 removed his/her gloves, exited the patient room and the unit. EI # 11 failed to perform hand hygiene after glove removal.

An interview was conducted on 2/13/25 at 11:10 AM with EI # 3, who confirmed staff failed to follow the facility hand hygiene policy and procedure.

Based on observations in the surgery department, review of facility surgery policies and procedures, monitoring logs, and interview with staff, it was determined the facility failed to monitor and document temperature and humidity levels in the Operating Rooms, Procedure Room, and Sterile Supply and Equipment Storage.

This had the potential to negatively affect all surgical patients served by the facility.

Refer to A 951 for findings.

Based on observations in the surgery service department, review of the surgery policy and procedure, department Temperature and Humidity logs, and interviews with staff, it was determined the facility failed to monitor and document temperature and humidity levels in the surgical services and procedural areas.

These deficient practices have the potential to affect all surgical patients served by the hospital.

Findings include:

Surgical Services Policy and Procedure: Temperature, Humidity
Original Date: 10/22
No number documented

Purpose:

To adhere to all regulatory requirements providing methods for monitoring the surgical services and procedural areas temperature, and relative humidity. The following guidelines are to be followed when the stated measurements are outside of the designated parameters.

Temperature:

...should be between 68-73 degrees (Fahrenheit). If the temperature is above or below the parameters, adjust the temperature in the room or call plant operations. Wait 20 minutes to determine if the temperature is at acceptable levels. If not postpone the case and notify Director for guidance. Temperatures will be documented daily in the appropriate log for each area that contains sterile supplies.

Humidity:

Humidity checks...are performed...for each area that contains sterile supplies...documented in the appropriate logs. The normal range for humidity levels is 20%-60%. In the event the humidity is out of range the...Director will be notified ...the case will be delayed until the humidity is within range or another suite with appropriate humidity levels...is available...If the humidity is not within range within 20 minutes and corrective action have been taken, Plant Operations and Administration will be notified...All supplies and packages and will be checked for...integrity and discarded or reprocessed...if...compromised...

Sterile Processing Policy and Procedures: Sterile Supplies
Revised: 10/22
No number documented

...Events that may affect the sterility of a package include, but are not limited to...Storage conditions...temperature, humidity, traffic control...

Sterile packages should be stored under environmentally controlled conditions. Sterile storage area temperature...between 68-73 degrees...humidity...between 20 %-60%. Temperature and humidity is documented daily on Humidity and Temperature Log...

A tour of the surgery service department was conducted on 2/12/25 at 10:00 AM with Employee Identifier (EI) # 6, Surgery Services Director. EI # 6 reported two surgeries had been performed this morning.

The surveyor asked EI # 6 to review temperature and humidity logs for all areas of surgery services.

The tour of OR 1 revealed the humidity was 65.5 %, which was greater than 60 %.

The tour of the equipment room which stored robotic surgery and sterilized equipment revealed the thermometer was not working.

Review of the OR schedule for 2/12/25 revealed a total of 5 procedures and 2 surgeries were scheduled.

Review of the Humidity and Temperature (H/T) Logs revealed no H/T was recorded on the surgery day for OR 1, OR 2 and OR endo. No log was provided for Sterile Supply Storage.

Review of OR 1 H/T log documentation revealed:

a). 5 of 7 days during February 2025 the humidity was greater than 60 %.
b). 10 of 21 days during January 2025 the temperature was less than 68 degrees.
c). 6 of 16 days during December 2024 the temperature was written over, not legible, and 1 day the humidity was greater than 60 %.
d). 3 of 21 days during November 2024 the temperature was written over, not legible, and 3 days the temperature was less than 68 degrees.
e). 11 of 23 days during October 2024 the temperature was written over, not legible, and 1 day the humidity was written over, and not legible.
f). 5 of 20 days during July 2024, there was no H/T values documented.

There were no 20 minute rechecks, and no corrective action documented.

Review of OR 2 H/T log documentation revealed:

a). 3 of 21 days in January 2025 the temperature was less than 68 degrees.
b). No H/T log documentation was provided for December, November, and October 2024.
c). 2 of 21 days in September 2024 the temperature was less than 68 degrees, and 3 days the humidity was written over, and not legible.
d). 10 of 19 days in July 2024 the temperature was less than 68 degrees.

There were no 20 minute rechecks, and no corrective action documented.

Review of OR Endo H/T log documentation revealed:

a). No H/T log documentation for December, November, October 2024.
c).1 day in September 2024 temperature was less than 68 degrees.
d. No H/T log documentation for August and July 2024.

There were no 20 minutes rechecks, and no corrective action documented.

There were no H/T logs provided to the surveyor for the sterilized equipment storage and sterile supply from 7/1/24 to 2/12/25.

The facility failed to ensure staff monitored the H/T in all surgery services and procedural areas.

An interview was conducted on 2/12/25 at 11:00 AM with EI # 6, who confirmed staff failed to monitor, and document surgery service H/T values, adjust when outside the acceptable range, recheck and document the corrective action response.