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Based on interview and record review, the hospital failed to ensure requested documents were provided during a Centers for Medicare and Medicaid Services (CMS-Federal Health Care agency) Complaint Validation Survey (onsite investigation to ensure the hospital meets government requirements called Conditions of Participation (CoPs) to participate in and receive federal payment). This failure resulted in impeding the Complaint Validation Survey investigation.

Findings:

During a review of employee personnel files on 7/24/23, with Human Resource Director (HRD), Registered Nurse (RN) 22's personnel file was reviewed. The file indicated RN 22 was hired on 9/19/21 as a contracted travel nurse. RN 22's personnel file did not contain an Employee Performance Review (EPR). HRD stated she did not have an EPR on file, but she would request one from RN 22's travel agency.

During a review of employee personnel files on 7/24/23, with HRD, RN 23's personnel file was reviewed. The file indicated RN 23 was hired on 1/20/18 as a contracted travel nurse. RN 23's personnel file did not contain an EPR. HRD stated she did not have an EPR on file, but she would request one from RN 23's travel agency.

During a review of employee personnel files on 7/24/23, with HRD, RN 27's personnel file was reviewed. The file indicated RN 27 was hired on 1/20/18 as a contracted travel nurse. RN 27's personnel file did not contain an EPR. HRD stated she did not have an EPR on file, but she would request one from RN 27's travel agency.

During an interview on 7/24/23 at 1:52 p.m. with HRD, HRD stated travel nurse evaluations are sent to the travel companies and the hospital does not keep copies. HRD was asked to produce copies of EPRs for RN 22, RN 23, and RN 27.

During an interview on 7/24/23 at 4:49 p.m. with HRD, HRD stated she would not produce copies of the requested EPRs until each travel nurse signed a "release."

No requested copies were provided.

During a review of the Health and Safety Code: Section 1278. Power to Enter and Inspect Premises, the Health and Safety Code indicated, "Any officer, employee, or agent of the state department may, upon presentation of proper identification, enter and inspect any building or premises at any reasonable time to secure compliance with, or to prevent a violation of, any provision of this chapter."

During a review of the hospital's policy and procedure (P & P) titled, "Employee Performance Reviews [EPRs]: Types and Purpose", dated August 2022, the P & P indicated, "Contract Employee EPRs: Contacted and agency employees are required to meet agreed upon standards of performance during thier assignment. These employees must receive an evaluation by the department manager or designee at the expiration of their contract or assignment. For contract assignements that extend beyond one (1) year, a performance evaluation will be required on an annual basis at the anniversary of their contract or assginment start date."

Based on observation, interview, and record review, the hospital failed to maintain patient's right to be comfortable in their environment for 15 of 32 sampled patient's (Patient 16, Patient 1, Patient 36, Patient 37, Patient 13, Patient 14, Patient 6, Patient 42, Patient 43, Patient 44, Patient 30, Patient 31, Patient 32, Patient 33, Patient 34) when the ambient temperatures in patient rooms reached 78-83° (degrees) Fahrenheit (F-unit of measurement temperatures) with patients complaining about the temperatures of their room . This failure resulted in patients being uncomfortable due to high room temperatures, and had the potential for heat related illnesses, mental distress, and skin infections.

Findings:

During an interview on 7/14/23 at 2:18 p.m. with Engineering Staff Member (ESM) 1, ESM 1 stated the facility has known about the temperature complaints in the "center units" of the facility. ESM 1 stated the "air handler [device used to regulate and circulate air/air conditioner (AC)]" that controls the "center units" have not been working correctly for two years. ESM 1 stated the issue had been escalated to upper management but the repair project was never approved. ESM 1 stated engineering addressed the issue "every three to four months and every summer when it gets hotter." ESM 1 stated the facility was looking at six to eight weeks to get the parts in to repair the air handler.

During an interview on 7/14/23 at 2:22 p.m. with Hospital Maintenance Manager (HMM), HMM stated there has been an issue with the AC for "a long time and hasn't been fixed due to prioritization and lack of funding."

During an interview on 7/14/23 at 2:45 p.m. with Director of Licensing and Accredidation (DLA), DLA stated the issue with the AC not working was not reported to the California Department of Public Health (CDPH). DLA stated, "Honestly, I thought I could get a handle on it, I have been bringing staff fans, I didn't know it was affecting patient care. The facility has safety huddles every Monday and this has been a known issue. The facility is aware of the AC issue on the center units of this facility and L&D [Labor and Delivery]."

During a concurrent observation and interview on 7/14/2, at 3:08 p.m. with Patient 16 and ESM 1, in his room, the room temperature was measured by ESM 1 to be 80° F. Patient 16 stated, "It's way too hot in here, I'm very uncomfortable."

During a concurrent observation and interview on 7/14/23 at 3:12 p.m. with Patient 1 and ESM 1, in his room, the room temperature was measured by ESM 1 to be 80° F. There was one fan and four patients in Patient 1's room. Patient 1 stated the heat caused him discomfort, nausea, and made his skin stick to the bed.

During a concurrent observation and interview on 7/14/23 at 3:53 p.m. with Patient 36 and ESM 1, in his room, there was one fan and four patients in the room. Patient 36 did not have a fan near his bed. Patient 36 stated he did not know he was allowed to have a fan. Patient 36 stated, "The heat and mugginess is miserable."

During an interview on 7/14/23 at 4 p.m. with Patient 37, Patient 37 stated she was hot and staff have not offered her a fan.

During an interview on 7/14/23 at 4:44 p.m. with DLA, DLA stated fans were supposed to be delivered to every patient but, she was unsure the reason all patient's did not receive fans.

During a concurrent observation and interview on 7/14/23 at 5:32 p.m. with Patient 13 and ESM 1, in his room, the room temperature was measured by ESM 1 to be 81° F. Patient 13 was wearing a brace over his chest. Patient 13 stated he was hot and the heat caused him to sweat under his brace.

During a concurrent observation and interview on 7/14/23 at 5:48 p.m. with Patient 14, Family Member (FM) 1, and ESM 1, in her room, the room temperature was measured by ESM 1 to be 80° F. Patient 14 stated the heat made her uncomfortable. FM 1 stated Patient 14 called and told him she was unable to sleep because of the heat and was not able to rest.

During a concurrent observation and interview on 7/18/23 at 3:26 p.m. with Patient 6 and ESM 1, in her room, the room temperature was measured by ESM 1 to be 81° F. Patient 6 was in her bed, receiving oxygen through a nasal cannula (tube that runs oxygen into nasal passages). Her bedrails were padded as a seizure (involuntary body movements) precaution. A fan was next to her bed, but was not running and faced away from her bed. Patient 6 stated she was admitted to the hospital for difficulty breathing and seizures. Patient 6 stated the heat in her room was causing her asthma (condition making it hard to breathe) to worsen. Patient 6 stated staff turn fan off and move it away from her when providing care and she doesn't feel the fan "half the time". Patient 6 stated she was afraid of overheating and having a seizure.

During a concurrent observation and interview on 7/18/23 at 3:40 p.m. with Patient 42, in his room, Patient 42's face was wet and shiny. Patient 42 stated, "It's [the heat in the room] making me sweat, I can't sleep, and it's making me nauseaous. The fan is just blowing hot air."

During a concurrent observation and interview on 7/18/23 at 3:58 p.m. with Patient 43 and ESM 1, in her room, the room temperature was measured by ESM 1 to be 83° F. Patient 43 stated it was too hot in her room which made her nauceous. Patient 43 stated she was admitted for excessive vomiting and the heat was making it worse.

During an interview on 7/18/23 at 4:06 p.m. with Patient 44, Patient 44 stated he was hot and "trying not to move too much because it is making him sweat so bad."


40516

During a concurrent observation and interview on 7/17/23 at 11:50 a.m. with Patient 30 and Hospital Maintenance Manager (HMM), in her room, Patient 30 stated, "I'm hot." The room temperature, measured by HMM, was 80.6° F. Two floor fans in her room were on. Patient 30 stated, "The fans work for a little while, then it gets hot."

During a concurrent observation and interview on 7/17/23 at 12:05 p.m. with Patient 31 and HMM, in his room, Patient 31 stated, "The fan does little good as the day goes on, then I start to sweat." The room temperature, measured by HMM was 81.5° F. Two floor fans in his room were on.

During an interview on 7/19/23 at 10:08 a.m. with Patient 31, Patient 31 stated he was not given the option to change rooms because of the heat.

During an interview on 7/19/23 at 10:10 a.m. with Patient 32, Patient 32 stated he was not given the option to change rooms because of the heat.

During an interview on 7/19/23 at 10:22 a.m. with Registered Nurse (RN) 28, RN 28 stated patients are asked if they want to move out of hot rooms. RN 28 stated some patients want to move and others do not. RN 28 stated there is no documentation of patients who refuse the offer to move out of a hot room.

During an interview on 7/19/23 at 2:57 p.m. with Patient 33 with Engineering Staff Member (ESM) 2, in his room, Patient 33 stated, "I have anxiety and the heat isn't helping. I've had to adjust to the room's hot temperature." The room temperature, measured by ESM 2, was 79.5° F.

During an interview on 7/19/23 at 3:06 p.m. with Patient 34 and ESM 2, in her room, Patient 34 stated, "I just got out of surgery and I'm worried I will not be able to sleep because the room is so hot." The room temperature measured by ESM 2, was 82.4° F.

During a concurrent observation and interview on 7/19/23 at 2:57 p.m. with Patient 31 and ESM 2, in his room, Patient 31 had bandages on both forearms. Patient 31 stated, "I should be in a cooler room." The room temperature measured by ESM 2, was 81.5° F.

During a review of the hospital's policy and procedure (P&P) titled, "Patient Rights and Responsibilities" dated April 2022, the P&P indicated, "It is the policy of [hospital] that all patients' rights afforded by local, federal government and other regulatory agencies and which have been adopted by [hospital] will be provided to every patient . . . V. Procedure: a. Notification of Patient: 1. Patients will receive a copy of the Rights and Responsibilities upon admission/registration to inpatient and outpatient settings of [hospital] . . . 2. Patients have a right to: a) Considerate, respectful care and to made comfortable."

The hospital failed to meet the regulatory requirements for the Condition of Participation: CFR 482.21 Quality Assessment and Performance Improvement Program as evidenced by the following:

1.Based on observation, interview, and record review, the hospital failed to have an effective Quality Assessment and Performance Improvement (QAPI) program when the hospital QAPI Committee did not meet at required intervals.

This failure resulted in hospital's inability to ensure quality of care and services were consistently assessed, performance improvement opportunities were identified, prioritized, and acted upon. (Refer to A- 0273)

2. Based on interview and record review, the hospital failed to develop and implement Performance Improvement (PI) project to address the aging heating, ventilation, and air conditioning (HVAC) system.

This failure resulted in the hospital's inability to ensure quality health care in a safe environment is provided to all patients being treated in the facility. (Refer to A-0283)

The cumulative effect of these systemic practices resulted in the hospital's inability to ensure quality health care, in compliance with the condition of Participation for Quality Assessment and Performance Improvement Program.

Based on interview and record review, the hospital failed to follow its policy and procedure (P&P) titled, "[Hospital] Quality Management and Performance Improvement Plan", when the QAPI (Quality Assessment Performance Improvement) committee did not meet at required intervals. This failure resulted in care and services not being regularly assessed for performance improvement opportunities and had the potential for the quality of patient care to be negatively impacted.

Findings:

During an interview on 7/24/23 at 2:44 p.m. with Director of Health Information Management (DHIM), DHIM stated the Quality Management Committee's initial meeting was "a couple of weeks ago" and her department had not developed any QAPI projects.

During an interview on 7/24/23 at 2:49 p.m. with Clinical Performance Improvement Manager (CPIM), CPIM stated the QAPI Committee, now known as the Quality Management Committee (QMC) and previously called the Quality Council, had not been meeting regularly. CPIM stated the QMC had a meeting on 7/5/23 but had not met previously met since 2021.

During an interview on 7/24/23 at 3:25 p.m. with Chief Operating Officer (COO), COO stated the Quality Council met previously in November 2021.

During a review of the QMC meeting minutes, dated 7/5/23, the minutes indicated, "[The Chief Medical Officer-CMO] called the meeting to order. . . CMO reviewed the function and duties of the committee. . . Meetings will be held monthly. . . [Director of Quality and Performance Improvement-DQPI] reported that [hospital's deeming organization] revised their standards and require that we have this [committee] in place."

During a review of the hospital's P&P titled, "[Hospital] Quality Management and Performance Improvement Plan", dated March 2016, indicated, "[The hospital's] performance improvement strategy will be a coordinated, comprehensive, and ongoing effort to assess the effectiveness of care and services provided. . . 2) The Committee shall meet eight (8) out of 12 months. The Chief Executive Officer shall maintain a record of all proceedings and actions."

Based on interview and record review the hospital failed to develop a Quality Assessment and Performance Improvement (QAPI) project to address the aging heating, ventilation, and air conditioning (HVAC) system. This failure had the potential to negatively impact health outcomes, safety, and quality of patient care.

Findings:

During an interview on 7/18/23 at 11:35 a.m. with Chief Executive Officer (CEO), CEO stated he was not made aware of areas of the hospital not be adequately cooled until 7/14/23.

During an interview on 7/19/23 at 2:44 p.m. with Director of Population Health Quality (DPHQ), DPHQ stated the poorly performing HVAC systems was not a current QAPI project.

During an interview on 7/19/23 at 3:36 p.m. with Chief Medical Officer (CMO), CMO stated he was a member of the Quality Management Committee (QMC). CMO stated the QMC is made aware of environmental concerns. CMO stated hospital should have had a plan in place in the event the HVAC was not cooling adequately.


42148

During an interview on 7/14/23 at 2:18 p.m. in unit 2C with Engineering Staff Member (ESM) 1, ESM 1 stated the hospital had known about the temperature complaints in the center sections (2C, 3C, 4C, 3B, and 4B) of the hospital. ESM 1 stated the "air handler [device used to regulate and circulate air/air conditioner]" that controls the center sections had not been working correctly for two years. The issue had been escalated to upper management, but the repair project was never approved. The Engineering department addressed the issue "every three to four months and every summer when it gets hot. the facility is looking at six to eight weeks to get the parts in." ESM 1 stated the process for staff when there is a known issue, staff will place a work order in the computer, call the engineering department, an engineer will be dispatched to the area to assess the issue. ESM 1 stated there have been multiple work orders put in for the units being too hot.

During an interview on 7/14/23 at 2:22 p.m. on unit 2C with Hospital Maintenance Manager (HMM), HMM stated, there has been an issue with the air conditioner (AC) for a long time and "hasn't been fixed due to prioritization and lack of funding."

During an interview on 7/14/23 at 2:45 p.m. on unit 2C with Director of Licensing, and Accreditation (DLA), DLA stated she knew about the AC not working properly. DLA stated, "We have safety huddles every Monday and this has been a known issue."

During a concurrent observation and interview on 7/18/23 at 3:06 p.m. with Charge Nurse (CN) 1 and ESM 1, in Unit 3C, temperature taken by ESM 1 in the nursing station was 83.5°F. CN 1 stated, "It is still hot up here. It gets hot every year and I have never seen anything done by the facility."

During an interview on 7/20/23 at 11:20 a.m. with Senior Director of Engineering (SDE), SDE stated the center section air handler project had been requested for two years now and kept getting denied in favor of other projects.

During an interview on 7/20/23 at 11:30 a.m. with Construction Manager (CM), CM stated the hospital had been working on the center section for nine months. CM stated the AC unit had been part of the capital budget a few times and kept getting denied.

During a review of the hospital's policy and procedure titled, "[hospital] Quality Management and Performance Improvement Plan," dated March 2016, indicated, " It is the policy of the [hospital] to develop and implement a Quality Management program that will promote continuous and measurable improvement of processes, customer service, and service quality based on the . . . Mission, Vision and Values of the organization."

Based on interview and record review, the hospital failed to ensure one of 17 sampled patients (Patient 8) had a pain management care plan (method used to guide nursing care including goals and outcome) developed. This failure had the potential for Patient 8's pain management needs to go unmet.

Findings:

During a concurrent interview and record review on 7/18/23 at 9:30 a.m. with Registered Nurse (RN) 1, Patient 8 was admitted for Gunshot wound to jaw, was receiving PRN (as needed) pain medication. Patient 8's "Plan of Care", undated, was reviewed. RN 1 stated there was no care plan for pain management, because the nursing staff only develop care plans based on primary diagnosis. RN 1 stated nursing staff should be updating care plans as patient care needs change.

During a review of the hospital's policy and procedure (P&P) titled, "Interdisciplinary Plan of Care (IPOC) (Non-Psychiatric Patients)" dated February 2021, the P&P indicated, "To provide guidelines for documentation and communication of the active plan of care (POC) for each hospitalized patient. It is the policy of [hospital] that all inpatients will have an interdisciplinary plan of care (IPOC) to assist in setting priorities of care that promote health, wellbeing and healing, and to provide for continuity of care between all disciplines."

Based on interview and record review, the hospital failed to ensure Licensed Vocational Nurses (LVN- provides basic patient care under the supervision of a [RN-registered nurse]) practiced within their scope of practice when LVN 1 completed assessments on seven of seven sampled patients (Patient 20, Patient 21, Patient 22, Patient 23, Patient 24, Patient 25, and Patient 26). This failure had the potential for patient assessments to be incorrect, or inaccurate.

Findings:

During an interview on 7/19/23 at 2:08 p.m. with Chief Nursing Officer (CNO), CNO stated the hospital used LVNs as part of nurse staffing. CNO stated LVNs are not given patient assignments, but are only used to give the RN breaks.

During an interview on 7/19/23 at 4:05 p.m. with Director of Maternal/Child Services (DMCS) and Manager of Operations for Maternal/Child Services (MOMCS), DMCS stated LVNs in the Post Partum unit (area of hospital for women and their newborn babies) are given patient assignments. DMCS stated some of the tasks LVNs can do are heel sticks (method used to draw labs on newborns), administer oral medications, and complete newborn hearing screening. DMCS stated LVNs cannot give IV (intravenous- in the vein) medication, or perform physical assessments.

During a concurrent interview and record review on 7/20/23 at 8:43 a.m. with Director of Licensing and Accreditation (DLA), the following was noted:

Patient 20's physical assessment was completed by LVN 1 on 7/18/23 at 7:48 a.m.
Patient 21's physical assessment was completed by LVN 1 on 7/18/23 at 7:50 a.m. and reviewed by RN 1
Patient 22's physical assessment was completed by LVN 1 on 7/18/23 at 8:04 a.m. and reviewed by RN 1
Patient 23's physical assessment was completed by LVN 1 on 7/18/23 at 8:07 a.m. and reviewed by RN 1
Patient 24's physical assessment was completed by LVN 1 on 7/18/23 at 8:14 a.m. and reviewed by RN 1
Patient 25's physical assessment was completed by LVN 1 on 7/18/23 at 8:15 a.m.
Patient 26's physical assessment was completed by LVN 1 on 7/18/23 at 8:21 a.m. and reviewed by RN 1

DLA stated LVN 1 completed the assessments. No physical assessments completed by an RN on 7/18/23 for Patient 20, Patient 21, Patient 22, Patient 23, Patient 24, Patient 25, or Patient 26 were provided.

During a concurrent interview and record review on 7/20/23 at 9:02 a.m. with DMCS and Director of Staff Development (DSD), Patient 20's, Patient 21's, Patient 22's, Patient 23's, Patient 24's, Patient 25's, and Patient 26's nursing physical assessments dated 7/18/23 were reviewed. DMCS stated, "The RN is supposed to do assessments, LVNs are only to do tasks within their scope." DSD stated, "LVNs do not have the training to synthesize the data collected from physical assessments." DMCS stated, "RN has to do the assessment."

During an interview on 7/24/23 at 1:38 p.m. with LVN 1, LVN 1 stated, "LVNs are expected to do assessments. The only thing I cannot do is push IV medications." LVN 1 stated she was never told she could not do assessments.

During a review of the facility's policy and procedure (P&P) titled, "Assessment/Reassessment of Patients", dated September 2020, the P&P indicated, "I. Purpose: To ensure each patient's need for care and treatment are assessed according to relevant physical, educational, psychosocial and spiritual needs. . . V. Procedure: A. Assessments/Reassessments, General: 1. Qualified individuals will perform an initial assessment and continued reassessments of each patient in order to determine the need for care."

During a review of the hospital's job description titled, "Vocational Nurse I and II Option I - General Nursing . . . Essential Functions: Option I: Performs the more responsible patient care functions utilizing broad knowledge in the techniques, methods, procedures and equipment required in support of the registered nurse and medical staff in patient treatment; demonstrates knowledge and use of the nursing process; performs general nursing care in various departments; uses the mechanical lift in moving patients; performs minor dressing changes, cauterizations, deep tracheal suction, tracheotomy care, bathing, colostomy care, and traction care; takes and records temperature, pulse and respiration; observes and keeps records and reports unusual conditions or behavior; participates in development of nursing care plans; maintains records reflecting patient's condition, medication, and treatment; prepares patients for examinations and treatments; administers special diets, and treatments as prescribed; gives medications if certified; assists staff with dressings; dependent upon area of practice or department assignments, demonstrates clinical knowledge and skill in the care for the newborn, infant, toddler, child, adolescent, adult and geriatric patient ranging up to 100+ years of age."

Based on interview and record review, the hospital failed to follow their policy and procedure (P&P) titled "Pain Management" for two of 17 sampled patients (Patient 16, Patient 17). This failure resulted in patients not being assessed for the effectiveness of the pain medication.

Findings:

During a concurrent interview and record review on 7/18/23 at 11:55 a.m. with Registered Nurse (RN 1), Patient 16's "Medication Administration Record" (MAR), dated July 2023 was reviewed. The "MAR" indicated, Hydromorphone (potent, highly addictive pain medication) 1 mg (milligram-unit of measurement) was given on 7/13/23 at 5:39 p.m. RN 1 stated there was no documentation of pain level reassessment after medication was given. RN 1 stated, "It should be followed up in 1 hour."

During a concurrent interview and record review on 7/19/23 at 10 a.m. with RN 1, Patient 17's "MAR", dated July 2023 was reviewed. The "MAR" indicated:

Norco (potent, highly addictive pain medication) 5 mg was given on 7/13/23 at 10:26 p.m. RN 1 stated there was no documentation of pain level reassessment until 7/14/23 at 6:21 a.m., RN 1 stated pain level reassessment should be completed 1 hour after giving pain medication.

Norco 5 mg was given on 7/14/23 at 7:54 a.m. RN 1 stated There was no documentation for medication follow up. RN 1 stated pain level reassessment should be completed 1 hour after giving pain medication.

Morphine (medication given to control pain) 2 mg (milligram-measurement of unit) was given on 7/14/23 at 11:10 a.m. RN 1 stated There was no documentation for medication follow up. RN 1 stated pain level reassessment should be completed 1 hour after giving pain medication

Morphine 2 mg was given on 7/15/23 at 5:50 p.m. RN 1 stated There was no documentation for medication follow up. RN 1 stated pain level reassessment should be completed 1 hour after giving pain medication.

During a review of the facility's P&P titled, "Pain Management" dated February 2021, the P&P indicated, "Patients receiving treatment/intervention (e.g., pharmacological [use of medication] or non-pharmacological [using alternate methods for pain management]) will have their pain reassessed within one hour to determine the effectiveness of the interventions."

Based on interview and record review, the hospital failed to follow their Policy and Procedure (P&P) titled, "Informed Consent [the process in which a health care provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention], How to Obtain" for one of 17 sampled patients (Patient 4) when the informed consent did not have a date and time. This failure resulted in Patient 4 having incomplete and inaccurate medical record.

Findings:

During a concurrent interview and record review on 7/17/23, at 2:11 p.m., with Registered Nurse (RN) 1, Patient 4's "BLOOD OR BLOOD PRODUCTS-EDUCATION AND CONSENT FORM" (consent), dated 7/5/23 was reviewed. The "consent" indicated, Patient 4's signature was not dated and timed. RN 1 stated there is no date and time on Patient 4's consent.

During a review of the facility's P&P titled, "Informed Consent, How to Obtain" dated October 2021, the P&P indicated, "After the informed consent discussion is completed, authorized [hospital] staff will ask the consent giver to sign the consent to surgery or Special Procedure Form, indicating the date and time."

Based on interview and record review, the hospital failed to follow their policy and procedure (P&P) titled "Reporting Critical [out of range laboratory (lab) result that could be life threatening] Test Results" for two of 17 sampled patients (Patient 14 and Patient 16). This failure resulted in patients' critical lab results not being reported to the Medical Provider, and acted upon timely.

Findings:

During a concurrent interview and record review on 7/18/23 at 11:20 a.m. with Registered Nurse (RN) 1, Patient 14's "Flowsheet Print Request" (FPR), dated 7/5/23 was reviewed. The "FPR" indicated, Hgb (Hemoglobin- protein in red blood cells that carries oxygen) 5.8 (normal range 7.0-19.9) and Hct (Hematocrit-percentage of red cells in your blood) 17.8 (normal range 21-60). RN 1 stated the "FPR" indicated the results marked by an asterisk indicated it was a critical test result. RN 1 stated, "No documentation done" to show medical provider was informed of abnormal lab results. RN 1 stated lab results were not reported.

During a review of the facility's P&P titled, "Reporting Critical Test Results" dated May 2021, the P&P indicated, "The critical test result will be called to the physician, their resident, or Advance Practice Provider (APP) within fifteen (15) minutes of the results becoming available by the Diagnostic Department. The total timeframe for critical test results to the physician or their resident is sixty (60) minutes from the time of the result becoming available in the diagnostic area."

The hospital failed to meet the regulatory requirements for the Condition of Participation: CFR 482.25 Pharmaceutical Services as evidenced by the following:

1. Based on observation, interview, and record review, the hospital failed to ensure responsibility and oversight of medication storage by the Director of Pharmacy (DOP) when medication storage temperatures were not maintained and/or monitored according to the "Medication Storage and Security" policy and procedure (P&P) and the "Ambient Room Temperature Log" (ARTL) for six of nine medications storage areas. These failures had the potential to affect medication stability, potency, integrity, efficacy, and patient safety. (Refer to A-0491)

2. Based on observation, interview, and record review, the hospital failed to ensure responsibility and oversight of pharmacy staff's education by the Director of Pharmacy (DOP) when Pharmacy Technicians (PT) did not receive education on the process of completing and reporting unacceptable medication storage area temperatures on the "Ambient Room Temperature Log" (ARTL). This failure resulted in having unqualified staff not maintaining accurate and complete data in the ARTL, report out of range storage room temperature, and had the potential to result in medication ineffectiveness. (Refer to A-0492)

The cumulative effect ot these systemic problems resulted in the hospital's inability to ensure the provision of quality health care, in compliance with the Condition of Participation for Pharmaceutical Services.

Based on observation, interview, and record review, the hospital failed to ensure responsibility and oversight of medication storage by the Director of Pharmacy (DOP) when medication storage temperatures were not maintained and/or monitored according to the "Medication Storage and Security" policy and procedure (P&P) and the "Ambient Room Temperature Log" (ARTL) for six of nine medications storage areas. These failures had the potential to affect medication stability, potency, integrity, efficacy, and patient safety.

Findings:

During a concurrent interview and record review on 7/24/23 at 1:42 p.m. with Emergency Department Clinical Director (EDD) and Emergency Department Nurse Supervisor (EDNS), the ICC/fast track medication room "ARTL," dated July 2023 was reviewed. EDNS stated the ICC/fast track medication storage room was closed on 7/20/23 when documented room temperatures were out of range. EDD stated the pharmacy staff recorded the ambient temperatures for the medication storage room on the ARTL and pharmacy staff were to request the work orders if the temperatures were out of range. EDNS stated the pharmacy staff were to report out of range temperatures to the supervisor or engineering. EDNS and EDD stated nursing staff do not take the ambient temperatures for the medication storage room in ICC/fast track. The "ARTL" dated July 2023 indicated, "(acceptable range 68-77° F) Date Current temperature (CT) Minimum temperature (Min T- minimum- lowest temperature in medication room in the past 24 hours) Maximum temperature (MT-maximum highest temperature in medication room in past 24 hours) initials, if temperature is out of acceptable range indicate the name of the Engineer and Pharmacist notified. The ARTL also indicated:

7/1/23 CT 79° F MT 81° F - ticket in place (engineer work order requesting repair was entered by staff member)
7/2/23 MT 79° F
7/3/23 MT 79° F
7/4/23 MT 79° F
7/5/23 CT 81° F MT 82° F - PLACED TICKET
7/6/23 CT 81° F MT 82° F
7/7/23 CT 82° F Min T 79° F MT 82° F - called
7/8/23 CT 82° F Min T 81° F MT 82° F - ticket will be placed
7/9/23 CT 82° F Min T 81° F MT 84° F - ticket
7/10/23 CT 79° F Min T 79° F MT 84° F
7/11/23 CT 79° F MT 82° F
7/12/23 MT 81° F
7/13/23 CT 79° F MT 79° F
7/14/23 MT 82° F
7/15/23 MT 81° F
7/16/23 CT 79° F MT 79° F
7/17/23 MT 79° F
7/19/23 MT 79° F
7/20/23 - No meds [medications] in room

Procedure: Temperature log is to be filled out daily. . . Temperature is to be recorded as current, as well as the 24 hour minimum and maximum temperatures, initialed. Engineering is to document any corrective action on reverse side of this log."

During a concurrent observation and interview on 7/24/23 at 1:45 p.m. with EDD, in the ICC/fast track medication storage area, signage stating "Stop Pyxis [electronic medication dispensing device] is down use MAIN ED Pyxsis" was posted on the pyxis and refrigerated medication storage units. EDD stated she was notified by the DOP on 7/20/23 regarding the out of range ambient temperatures in the ICC/fast track medication storage area. EDD stated she was informed by DOP, the ICC/ fast track medication storage room was to be closed and medications removed. EDS and EDD stated they were unaware the ambient temperatures for the medication storage room were out of range until notified by pharmacy staff on 7/20/23.

During a concurrent interview and record review on 7/24/23 at 2:45 p.m. with Engineering Staff Member (ESM) 2 the "ARTL," dated July 2023, for ICC/fast track medication storage room was reviewed. ESM 2 stated if the temperatures in the medication storage room was out of range (less than 68° F or greater than 77° F) the staff member was to place a work order ticket. ESM 2 stated when the work order was received, a stationary engineer would be assigned to fix the issue. If the stationary engineer was not able to fix the issue the job would be referred to the HVAC (Heating, ventilation, air conditioning) department. ESM 2 stated once the issue is fixed the room temperature would be rechecked in 30 minutes and if it was within normal range the stationary engineer would "sign off" (indicate the temperature issue was corrected) on the "ARTL." The work order tickets were requested from ESM 2 for 7/1/23, 7/5/23, 7/7/23, 7/8/23, 7/9/23. ESM 2 stated there was no sign off by the stationary engineer documented on the July 2023 "ARTL".

During a concurrent interview and record review on 7/24/23 at 4:10 p.m. with Licensing and Accreditation (LARN) the "ARTL" dated 7/2023 was reviewed. LARN stated, Engineering Department provided one work order for the ICC/fast track medication area dated 7/5/23 at 3:21 p.m. LARN also stated the engineering department did not receive additional work orders for out of range temperatures on the July 2023 "ARTL."


42148

During a concurrent observation and interview on 7/18/23 at 3:15 p.m. with Charge Nurse (CN) 1, in unit 3C hallway at the Pyxis 2 and code cart (a cart with emergency medications and airway supplies), the room temperature was checked by Engineering Staff Member (ESM) 1 and read 82° F. CN 1 stated the "ambient temperature log" for the Pyxis has been out of range for the entire month of July and engineering has been notified and nothing has been done. CN 1 stated she did not know if the pharmacy had been notified of the issue. CN 1 stated the temperature range should be between 68°F and 77°F.

During a concurrent interview and record review on 7/18/23 at 3:48 p.m. with DOP, the "ARTL", dated July 2023 was reviewed. The ARTL indicated, "Acceptable range 68-77° F. If temperature is out of acceptable range indicate the name of the Engineer and Pharmacist notified." The ARTL indicated:

7/1/23 CT 77° F MT 79° F
7/2/23 CT 79° F MT 79° F
7/3/23 CT 79° F MT 81° F
7/4/23 CT 79° F MT 81° F
7/5/23 CT 77° F MT 81° F
7/6/23 CT 79° F MT 81° F - Engineering Notified
7/7/23 CT 77° F MT 81° F
7/8/23 CT 79° F MT 81° F - Engineering Notified
7/9/23 CT 79° F MT 79° F - Engineering Notified
7/10/23 CT 77° F MT 79° F
7/11/23 CT 77° F MT 79° F
7/12/23 CT 77° F MT 79° F
7/13/23 CT 79° F MT 81° F - Engineering Aware
7/14/23 CT 79° F MT 81° F - Engineering notified
7/15/23 CT 79° F MT 81° F
7/16/23 CT 79° F MT 81° F
7/17/23 CT 81° F MT 81° F - will follow up with engineering
7/18/23 CT 81°F MT 82° F - Engineering called, no answer

DOP stated, "This is unacceptable. I am going to have to close this Pyxis and figure out how to destroy the medications that are in there." DOP stated to staff, "How long has it been hot up here?" DOP stated pharmacy staff will have to call the pharmaceutical companies for guidance regarding medication storage temperatures. DOP stated the nursing staff completes the ARTL and is suppose to notify pharmacy when temperatures on the ARTL are out of range. DOP stated the medications in the crash cart in the hallway of this unit will have to be destroyed as well.

During an interview on 7/18/23 at 2:50 p.m. with ESM 1, ESM 1 stated the engineering department was not aware of any work orders regarding the room temperatures around the Pyxis being out of range.

During an interview on 7/18/23 at 3 p.m. with CN 1, CN 1 stated Pyxis 2 has liquid antibiotics, vials of medications, tablets, and aerosol medications and serves as the backup to Pyxis 1. CN 1 stated patients receive medications from Pyxis 2 throughout the day.


46958


During an interview on 7/18/23 at 4 p.m. with RN 1, RN 1 stated there is no ARTL for the Pyxis in unit 3B because they have no refrigerator.

During a review of the hospital's P&P titled, "Medication Storage and Security" dated November 2020, the P&P indicated, "Storage 1. [hospital] will maintain proper environmental control (i.e. [for example] proper temperature) wherever drugs and supplies are stored. . . 9. Medications that require storage at controlled room temperature will be maintained with temperatures between 20° C [Celsius- unit of measure] (68°F) and 25° C (77°F)."

During a review of the hospitals's P&P titled, "Repairs and Maintenance" dated October 2020, the P&P indicated, "It is the policy of [hospital] to ensure the maintaining of the facilities in general and keep the facility structurally sound, according to all health care and fire codes and stay in compliance with all federal, state and local regulations."

Based on observation, interview, and record review, the hospital failed to ensure responsibility and oversight of pharmacy staff's education by the Director of Pharmacy (DOP) when Pharmacy Technicians (PT) did not receive education on the process of completing and reporting unacceptable medication storage area temperatures on the "Ambient Room Temperature Log" (ARTL). This failure resulted in having unqualified staff not maintaining accurate and complete data in the ARTL, report out of range storage room temperature, and had the potential to result in medication ineffectiveness.

Findings:

During a concurrent interview and record review on 7/24/23 at 2:25 p.m. with PT and DOP, the "ARTL," dated July 2023, for ICC/fast track (area in the emergency department) medication storage room was reviewed. The "ARTL" indicated on 7/6/23 current temperature 81° F maximum temperature 82° F (PT initials) "If temperature is out of acceptable range indicate the name of the Engineer and Pharmacist notified." PT stated she was aware the ambient temperatures in the ICC/fast track medication storage room was out of range when she recorded the temperatures on 7/6/23. PT stated the ambient temperatures should be 68° F to 77° F and if the temperatures were out of range she should notify engineering and pharmacy by electronic mail. PT stated she did not notify engineering or the pharmacist regarding the out of range temperatures because someone else had reported the out of range temperatures on 7/4/23. PT stated she did not receive written training on how to take ambient temperatures in the medication storage areas, how to record the temperatures, or what to do if the temperatures were out of range. PT stated when she was on orientation, the form was explained to her. DOP was unable to provide documentation PT had been trained on how to take the ambient temperatures in the medication storage areas, what to do if the temperatures were out of range, or how to complete the "ARTL."

During a review of the hospital's P&P titled, "Repairs and Maintenance," dated October 2020, the P&P indicated, "It is the policy of [facility name] to ensure the maintaining of the facilities in general and keep the facility structurally sound, according to all health care and fire codes and stain compliance with all federal, state and local regulations. . .EDUCATION: A. [facility name] Staff: will receive education pertaining to this policy. . .staff's knowledge, skills and abilities will be validated during unit-specific orientation.

The facility failed to meet the regulatory requirements for the Condition of Participation: CFR 482.41 Physical Environment as evidenced by:

1. Based on observation, interview, and record review, the facility failed to maintain a safe and comfortable temperature in the hospital environment for patients. This failure resulted in placing patients at risk for heat-related illnesses and mental distress. (Refer to A-0701, item 1)

2. Based on observation, interview, and record review, the facility failed to follow its policy and procedure on "Environmental Controls, Pressure Differentials, Temperature and Humidity Monitoring" for seven operating rooms (OR - room in hospital specially equipped for surgical operations) when the temperatures reached higher than acceptable ranges. This failure had the potential for operating rooms to be unsafe for patients' use. (Refer to A-0701, item 2)

3. Based on observation, interview, and record review, the facility failed to ensure room temperatures were monitored and maintained within acceptable range where six of nine Pyxis (medication dispensing system) and one code cart (cart containing medications used in emergencies and airway supplies) were located. This failure had the potential to affect the stability, potency, integrity, and efficacy of these medications and cause adverse health outcomes to patients. (Refer to A-0726)

The cumulative effect of these systemic problems resulted in the hospital's inablity to ensure quality health care in a safe and comfortable physical environment, in compliance with Condition of Particiation for Physical Environment.

Based on observation, interview, and record review, the hospital failed to:

1. Maintain a safe and comfortable temperature in the hospital environment for patients. This failure resulted in placing patients at risk for heat-related illnesses and mental distress.

2. Follow its policy and procedure on "Environmental Controls, Pressure Differentials, Temperature and Humidity Monitoring" for seven operating rooms (OR - room in hospital specially equipped for surgical operations) when the temperatures reached higher than required. This failure had the potential for operating rooms to be unsafe for patients' use.

Findings:

During a review of the facility's "Work Orders" (a document which provides all the information about a maintenance task and outlines a process for completing the task), the "Work Orders" indicated:

On 7/13/22 in Unit 2C (2 Center - Medical Surgical unit) - "to [sic] hot in the area"
On 8/21/22 in Unit 2C - "too hot"
On 11/12/22 in Unit 2C - "to [sic] hot"
On 2/2/23 in Unit 2C - "very hot"
On 3/14/23 in Unit 2C - "hot"
On 3/23/23 in Unit 2C - "too hot in this room"
On 3/30/23 in Unit 2C - "too hot"
On 5/17/23 in Unit 2C - "too hot in the room"
On 5/27/23 in Unit 2C - "too hot"
On 6/13/23 in Unit 2C - "too hot
On 6/16/23 in Unit 2C - "too hot in the room" "checked area. It's warm [staff] is going to check unit."
On 7/3/23 in Unit 2C - "VERY HOT ALL OVER 2C"
On 7/8/22 in Unit 3C (3 Center- Medical/Surgical unit) "too hot"
On 8/5/22 in Unit 3C "too hot"
On 8/24/22 in Unit 3C "too hot in the room"
On 11/3/22 in Unit 3C "the AC is off and staff are hot in there. . . placed an order for this a few weeks ago"
On 1/3/23 in Unit 3C - "too hot in 3C"
On 4/27/23 in Unit 3C - " 3C hot all over"
On 6/15/23 in Unit 3C - "too hot"
On 6/30/23 in Unit 3C - "too hot"
On 7/3/23 in Unit 3C - "Patients and family in room [patient room number] are complaining and very upset because it is so hot in the room and the fans are no longer helping.
On 7/5/23 in Unit 3C - "too hot"
On 7/10/23 in Unit 3C - "too hot in 3C patients are complaining"
On 7/10/23 in Unit 3C - "check the air conditioning, the patient is extrememly hot, agitated, and refusing to go back in the room until these things are fixed and we have no other room to put patients in as we are full."
On 7/13/22 in Unit 4C (4 Center, Pediatric unit - unit for sick children) "[room number] is hot. C-penthouse air handler responsible for this issue is under quote process for major component replacement."
On 8/8/22 in Unit 4C - "room is hot and sweltering like a suana. Can someone please evaluate the AC in this room? [Engineering stated] Main air handler controlling most of the rooms in C-wing is failing. The unit is in the bid process for having major components replaced, this should restore adequate cooling."
On 8/19/22 in Unit 4C - "too hot"
On 8/25/22 in Unit 4C - "too hot"
On 9/5/22 in Unit 4C - "very hot. [Engineering stated] CONTROLS SHOWING TEMP 77, ACTUAL TEMP [temperature] IS 82. C wing needs new cooling coil, awaiting approval by admin [administration]."
On 9/7/22 in Unit 4C - "too hot, temp is at 81 degrees"
On 1/13/23 in Unit 4C - "Pt's [patients] are very hot in [room number]
On 4/17/23 in Unit 4C - "too hot in the area of Peds (pediatrics)
On 6/2/23 in Unit 4C - "too hot"
On 7/7/23 in Unit 4C - "too hot"
On 7/8/23 in Unit 4C - "very hot in [room number]

During an interview on 7/14/23 at 2:18 p.m. with Engineering Staff Member (ESM) 1, ESM 1 stated the facility has known about the temperature complaints in the "center units" of the facility. ESM 1 stated the air handler [device used to regulate and circulate air/air conditioner (AC)] that controls the center units have not been working correctly for two years. ESM 1 stated the issue had been escalated to upper management but the repair project was never approved. ESM 1 stated engineering addressed the issue every three to four months and every summer when it gets hotter. ESM 1 stated the facility was looking at six to eight weeks to get the parts in to repair the air handler.

During an interview on 7/14/23 at 2:22 p.m. with Hospital Maintenance Manager (HMM), HMM stated, there has been an issue with the AC for a long time and hasn't been fixed due to prioritization and lack of funding.

During an interview on 7/14/23 at 2:45 p.m. with Director of Licensing, and Accredidation (DLA), DLA stated she knew about the AC not working properly. DLA stated, "We have safety huddles every Monday and this has been a known issue."

During a concurrent observation and interview on 7/14/23 at 3:40 p.m. in units 2C, 3C, and 4C, with ESM 1, the following temperatures were taken by ESM 1:

Unit 2C Hallway- 78° F (Fahrenheit-temperature measurement)
Patient room 2231-82.1° F
Patient room 2201 -78° F
Patient room 2217 - 84.9° F
Patient room 2231- 80° F
Patient room 2220- 82° F
Patient room 2217- 80° F
Patient room 2215 - 81° F
Patient room 2216- 82° F
Patient room 2218- 81° F
3C nursing station -81.4° F
3C Hallway - 79° F
Patient room 3236-81.1° F
Patient room 3201 -78.2° F
Patient room 3227 -83.5° F
Patient room 3234- 80° F
Patient room 3228- 81° F

ESM 1 stated the hospital uses the American Society of Heating, Refrigerating, and Air-Conditioning Engineers (ASHRAE) guidelines for temperature controls. ESM 1 stated, "Their guidelines state 78 degrees is the upper guidelines."

During an interview on 7/14/23 at 4:44 p.m. with DLA, DLA stated every patient on the center units were supposed to have their own fans but that did not happen.

During a concurrent observation and interview on 7/18/23 at 3:06 p.m. with Charge Nurse (CN) 1 and ESM 1, in 3C nursing station, the temperature taken by ESM 1 was 83.5 degrees (F). CN 1 stated, "It is still hot up here. It gets hot every year and I have never seen anything done by the facility."

During an interview on 7/20/23 at 11:20 a.m. with Senior Director of Engineering (SDE), SDE stated the center section air handler project had been requested for two years now and kept getting denied in favor of other projects.

During an interview on 7/20/23 at 11:30 a.m. with Construction Manager (CM), CM stated the hospital had been working on the center section for nine months. CM stated the AC unit had been part of the capital budget a few times and kept getting denied.

During a review of hospital's "24 hour temperature log for C-wing and Labor and Delivery" (TL), the "TL's" indicated:

On 7/17/23:
Patient Room 2231 reached 82° F
Patient Room 2216 reached 83° F
Patient Room 2217 reached 83° F
Patient Room 2218 reached 83° F
3C Nursing Station reached 83° F
Patient Room 3236 reached 83° F
Patient Room 3227 reached 82° F
Patient Room 3234 reached 81° F
Patient Room 3228 reached 82° F
Patient Room 4245 reached 83° F

On 7/18/23:
Patient Room 2201 reached 80° F
Patient Room 2217 reached 82° F
Patient Room 2231 reached 81° F
3C Nursing Station reached 83° F
Patient Room 3236 reached 83° F
Patient Room 3227 reached 81° F
Patient Room 3227 reached 80° F
Patient Room 4245 reached 85° F

On 7/19/23:
Patient Room 2231 reached 81° F
Patient Room 2217 reached 82° F
Patient Room 2218 reached 82° F
Patient Room 2216 reached 82° F
3C Nursing Station reached 82° F
Patient Room 3227 reached 80° F
Patient Room 3228 reached 83° F
Patient Room 3234 reached 82° F
Patient Room 3236 reached 80° F
Patient Room 4245 reached 83° F
Patient Room 3136 reached 80° F

On 7/20/23:
Patient Room 2231 reached 80° F
Patient Room 2217 reached 82° F
Patient Room 2218 reached 81° F
Patient Room 3228 reached 83° F
Patient Room 3234 reached 80° F
Patient Room 3236 reached 80° F
Patient Room 4245 reached 82° F

On 7/20/23:
Patient Room 2231 reached 82° F
Patient Room 2217 reached 82° F
Patient Room 2218 reached 82° F
Patient Room 2216 reached 81° F
Patient Room 3228 reached 81° F
4C Nursing Station reached 80° F
Patient Room 4245 reached 80° F

On 7/22/23:
Patient Room 2217 reached 80° F
Patient Room 2218 reached 80° F
Patient Room 3134 reached 80° F

On 7/23/23:
Patient Room 2231 reached 80° F
Patient Room 2217 reached 81° F
Patient Room 2216 reached 80° F

During a review of "ASHRAE Design Parameters-Inpatient Spaces (ADPIS)," the ADPIS indicated, "Nursing units and other patient care areas: All room Design Temperature °F/°C 70-75/21/24."

During a review of the hospital's policy and procedure (P&P) titled, "Utility Management," dated October 2020, the P&P indicated, "Purpose: to establish, maintain, and continually provide a reliable Utility Management Program to ensure operational reliability of utility systems. Address the reliability and minimize potential risks of utility systems failures to promote a safe, controlled, and comfortable environment of care for patients, visitors, and staff of the facility. . . V. A. The Utilities Management Program will include complying with all relevant safety standards and regulations for equipment that includes the following criteria: 1. Equipment maintains the climatic environment in patient care areas."

During a review of hospital's "Standard operating procedures Utilities Management Plan" (UMP), dated 4/4/23, the "UMP" indicated, "The Utilities Management Plan of [hospital] serves to provide a framework to promote the safe, controlled and comfortable environment of care (EOC). The Engineering Management is also responsible for reporting utility systems issues to the Safety Officer and the EOC/Safety Committee. . . The Engineering Management is responsible for coordinating maintenance, repair, and inspection of all utilities within the hospital campus. . . Objectives: 1. Provide for a safe, controlled, and comfortable environment for patients, staff and others, who use the facilities. . . 4. Provide an appropriate and timely response to utility systems failures. . . Any utility system problems and failures will be reported initially to the engineering department and to the engineering management. Investigation and corrective action will be conducted by the engineering department or the appropriate contractor under the direction of the engineering management team. The engineering Management team will report any utility failure, planned or unplanned, to the safety officer."


40516

2. During an interview on 7/17/23 at 12:36 p.m. with Staff Development Supervisor (SDS) and Hospital Maintenance Manager (HMM), temperature and humidity monitoring logs for the surgery department operating rooms were requested.

During a concurrent interview and record review on 7/17/23 at 1:35 p.m. with Charge Nurse (CN) 2 and Director of Operating Room (DOR), The July 2023 "Temperature and Humidity Log" for OR 1, OR 2, OR 3, OR 4, OR 5, OR 6, OR 7, and OR 8 were reviewed. CN 2 stated the logs are completed at night by a registered nurse or a scrub tech (person trained to pass instruments during surgery). DOR stated there is an acceptable variance of two degrees higher or lower than the acceptable temperature range. DOR stated if the temperature or humidity is out of range engineering is called, but if engineering is not on-campus report is given to day shift. The "Temperature and Humidity Log" indicated, "Temperature and Humidity will be recorded per policy. . . *contact Facilities/engineering to adjust temperature and/or humidity as needed per policy. Record action taken on back of form. . . Risk Assessments will be completed on any HVAC [heating, ventilation, air conditioning] parameter +/- 2 degrees of % of acceptable ranges. Operating rooms Temp[erature] 68-75 F Humidity 20% - 60%.

The "Temperature and Humidity Log" indicated:

OR 1 log dated July 2023:
7/1/23 Temp (temperature) 64 Action Req (Required) Y[es] N[o]. N was circled but no documentation of engineering notification.
7/2/23 Temp 65 Action Req N was circled but no documentation of engineering notification.
7/16/23 Temp 62 Action Req N was circled but no documentation of engineering notification.

OR 2 log dated July 2023:
7/1/23 Temp 55 Action Req N was circled but no documentation of engineering notification.
7/2/23 Temp 65 Action Req N was circled but no documentation of engineering notification.
7/3/23 Temp 65 Action Req N was circled but no documentation of engineering notification.
7/8/23 Temp 65 Action Req N was circled but no documentation of engineering notification.
7/10/23 Temp 64 Action Req N was circled but no documentation of engineering notification.
7/15/23 Temp 65 Action Req N was circled but no documentation of engineering notification.

OR 3 log on July 2023:
7/1/23 Temp 62 Action Req N was circled but no documentation of engineering notification.
7/2/23 Temp 63 Action Req N was circled but no documentation of engineering notification.
7/3/23 Temp 64 Action Req N was circled but no documentation of engineering notification.
7/8/23 Temp 62 Action Req N was circled but no documentation of engineering notification.
7/10/23 Temp 62 Action Req N was circled but no documentation of engineering notification.
7/11/23 Temp 62 Action Req N was circled but no documentation of engineering notification.
7/12/23 Temp 62 Action Req N was circled but no documentation of engineering notification.
7/13/23 Temp 64 Action Req N was circled but no documentation of engineering notification.
7/14/23 Temp 64 Action Req N was circled but no documentation of engineering notification.
7/15/23 Temp 64 Action Req N was circled but no documentation of engineering notification.
7/16/23 Temp 64 Action Req N was circled but no documentation of engineering notification.

OR 4 log dated July 2023:
7/1/23 Temp 64 Action Req N was circled but no documentation of engineering notification.
7/2/23 Temp 65 Action Req N was circled but no documentation of engineering notification.
7/3/23 Temp 65 Action Req N was circled but no documentation of engineering notification.

OR 5 log dated July 2023:
7/1/23 Temp 63 Action Req N was circled but no documentation of engineering notification.
7/2/23 Temp 64 Action Req N was circled but no documentation of engineering notification.
7/3/23 Temp 63 Action Req N was circled but no documentation of engineering notification.
7/8/23 Temp 64 Action Req N was circled but no documentation of engineering notification.
7/10/23 Temp 64 Action Req N was circled but no documentation of engineering notification.
7/17/23 Temp 64 Action Req N was circled but no documentation of engineering notification.

OR 6 log dated July 2023:
7/1/23 Temp 65 Action Req N was circled but no documentation of engineering notification.

OR 7 log dated July 2023:
7/8/23 Temp 63 Action Req N was circled but no documentation of engineering notification.
7/9/23 Temp 62 Action Req N was circled but no documentation of engineering notification.
7/10/23 Temp 63 Action Req N was circled but no documentation of engineering notification.
7/11/23 Temp 65 Action Req N was circled but no documentation of engineering notification.
7/12/23 Temp 64 Action Req N was circled but no documentation of engineering notification.
7/13/23 Temp 65 Action Req N was circled but no documentation of engineering notification.
7/14/23 Temp 65 Action Req N was circled but no documentation of engineering notification.
7/15/23 Temp 62 Action Req N was circled but no documentation of engineering notification.
7/16/23 Temp 63 Action Req N was circled but no documentation of engineering notification.
7/17/23 Temp 63 Action Req N was circled but no documentation of engineering notification.

DOR stated her expectation was if the temperature or humidity was out of range, the staff who completed the log should have circled Y and notified engineering.

During an interview on 7/17/23 at 1:38 p.m. with Supervisor of Peri-Operative Assistants (SPOA), SPOA stated nurses and scrub techs (technicians) complete the temperature and humidity logs, not his staff.

During an interview on 7/17/23 at 1:53 p.m. with Peri-Operative Staff Educator (POSE), POSE stated she thought peri-operative assistants completed the temperature and humidity logs.

During a review of the hospital's P&P titled, "Environmental Controls, Pressure Differentials, Temperature and Humidity Monitoring", dated November 2020, the P&P indicated, "Purpose: To maintain a safe, comfortable, and therapeutic environment for patients and personnel. . . It is the policy of [hospital] to follow the standards set by the American Society of Healthcare Engineering (ASHE) and the Association of Perioperative Registered Nurses (AORN) to effectively monitor and maintain an effective and safe heating, ventilation, and air conditioning system (HVAC) to decrease the risk of infection to patients and employees ... Temperature and humidity will be maintained in each designated procedural area . . . 1. The Department Manager/Supervisor is responsible for ensuring that the temperature and humidity readings for areas within the department of perioperative services and other invasive procedure departments . . . are monitored and recorded daily when areas of the department are being utilized. 2. Any ranges/readings unintentionally out of range will be reported to the Manager/Supervisor and documented on the Temperature and Humidity Log, interventions implemented, as needed and one-hour reassessments documented on the department's Temperature and Humidity Log . . . Educations: A. [Hospital] Staff: Will receive education pertaining to this policy, as appropriate, at time of general orientation and/or unit-specific orientation and as changes in legislation, quality or regulatory requirements. Staff's knowledge, skills and abilities will be validated during unit-specific orientation. B. Patient Care Staff: Applicable staff will be trained to perform monitoring and notify Engineering when appropriate during orientation and as changes occur . . . Documentation . . . B. Temperature and humidity logs will be maintained in the area where monitoring occurs."

Based on observation, interview, and record review, the hospital failed to ensure room temperatures were monitored and maintained within acceptable range where six of nine Pyxis' (medication dispensing system) and one code cart (cart containing medications used in emergencies and airway supplies) were located. This failure had the potential to affect the stability, potency, integrity, and efficacy of these medications and cause adverse health outcomes to patients.

Findings:

During a concurrent observation and interview on 7/18/23 at 3:15p.m. with Charge Nurse (CN) 1 and Engineering Staff Member (ESM) 1, in 3C (3 Center) hallway where the Pyxis and code cart were located, ESM 1 checked the room temperature and it read 82° Fahrenheit (F-unit of measurement). CN 1 stated the ambient temperature log for the Pyxis had been out of range for the entire month of July and engineering had been notified and nothing had been done. CN 1 stated she did not know if the pharmacy had been notified of the issue. CN 1 stated the temperature range should be between 68° F and 77° F.

During a concurrent interview and record review on 7/18/23 at 3:48 p.m. with Director of Pharmacy (DOP), the "Ambient Room Temperature Log [ARTL]," dated July 2023 was reviewed. The ARTL indicated, "Acceptable range 68-77 degrees F":

On 7/1/23 CT (Current Temperature) 77° F, MT - (Maximum Temperature) 79° F
On 7/2/23 CT 79° F, MT 79° F
On 7/3/23 CT 79° F, MT 81° F
On 7/4/23 CT 79° F, MT 81° F
On 7/5/23 CT 77° F, MT 81° F
On 7/6/23 CT 79° F, MT 81° F - "Engineering Notified"
On 7/7/23 CT 77° F, MT 81° F
On 7/8/23 CT 79° F, MT 81° F - "Engineering Notified"
On 7/9/23 CT 79° F, MT 79° F - "Engineering Notified"
On 7/10/23 CT 77° F MT 79° F
On 7/11/23 CT 77° F, MT 79° F
On 7/12/23 CT 77° F, MT 79° F
On 7/13/23 CT 79° F, MT 81° F - "Engineering Aware"
On 7/14/23 CT 79° F, MT 81° F - "Engineering notified"
On 7/15/23 CT 79° F, MT 81° F
On 7/16/23 CT 79° F, MT 81° F
On 7/17/23 CT 81° F, MT 81° F - "will follow up with engineering"
On 7/18/23 CT 81°F, MT 82° F - "Engineering called, no answer"

DOP stated, "This is unacceptable. I am going to have to close this Pyxis and figure out how to destroy the medications that are in there." DOP stated to staff , "How long has it been hot up here?" DOP stated the pharmacy staff will have to call the pharmaceutical companies for guidance regarding medication storage temperatures. DOP stated the nursing staff completes the "ARTL" and is suppose to notify pharmacy when temperatures on the "ARTL" are out of range. DOP stated the medications in the crash cart in the hallway of this unit will have to be destroyed as well.

During an interview on 7/18/23 at 2:50 p.m. with ESM 1, ESM 1 stated the engineering department was not aware of any work orders regarding the room temperatures around the Pyxis being out of range.

During an interview on 7/18/23 at 3 p.m. with CN 1, CN 1 stated Pyxis 2 has liquid antibiotics, vials of medications, tablets, and aerosol medications and serves as the backup to Pyxis 1. CN 1 stated patients receive medications from Pyxis 2 throughout the day.

During a review of the facility's "Device Inventory" (list of medications in the Pyxis), dated 7/18/23, the "Device Inventory" indicated, the following medications were in the Pyxis 2 at the time the room temperatures were out of range:

Miralax 17 grams (G-unit of measurement) Powder (treats constipation) quantity- 9
Zofran 2mg(milligrams-unit of measurement/1ml (milliliters-unit of volume measurement) (2ml) vial (treats nausea) quantity- 35
Romazicon 0.1mg/1ml (5ml) injection (reverses the affects of sedation) quantity- 1
hydralazine 25mg tablet (treats high blood pressure) quantity- 4
Seroquel 25mg tablet (treats mental disorders) quantity- 15
Zyprexa 10mg tablet (treats mental disorders) quantity- 8
Tapazole 10mg tablet (treats thyroid disease) quantity- 6
Entresto 49mg-51mg tablet (treats chronic heart failure) quantity- 12
Milk of Magnesia 30ml liquid (treats indigestion) quantity- 9
Motrin 100mg (5ml suspension) (treats pain) quantity- 22
Colace 100mg capsule (Stool softener) quantity- 27
Hexavitamin tablets (multivitamin) quantity- 15
Bentyl 10mg capsule (treats irritable bowel syndrome) quantity- 6
Nitrostat 0.4mg tablets (treats chest pain) quantity- 4
Lipitor 40mg tablets (treats high cholestrol) quantity- 48
Protonix 40mg tablets (treats indigestion) quantity- 25
Folic Acid 1mg tablet (treats low blood count) quantity- 11
Metoprolol 25mg tablet (treats high blood pressure) quantity- 29
Lasix 10mg/1ml (4ml) vial (treats heart failure) quantity- 23
Ativan 2mg tablets (treats anxiety and seizures) quantity- 11
Hydrocodone 10/325mg tablets (narcotic pain medication) quantity- 14
oxycodone IR 5 mg tablets (narcotic pain medication) quantity- 20
Rocaltrol 0.25mcg (microgram-unit of measurement) (treats low calcium) quantity- 13
Robaxin 100mg/1ml (10ml) vial (muscle relaxer) quantity- 5
Motrin 400mg tablets (treats minor pain) quantity- 27
Baclofen 10mg tablets (muscle relaxer) quantity- 16
Brilinta 90mg tablets (blood thinner) quantity- 9
Depakote 500mg tablets (prevents seizures) quantity- 15
Nicotine Patch 21mg (nicotine replacement therapy) quantity -7
Tylenol 325mg tablets (treats fever/minor pain) quantity- 36
Neurontin 300mg tablets (treats nerve pain) quantity- 17
Keppra 500mg tablets (prevents seizures) quantity- 43
Potassium Chloride 10MEq tablets (Vitamin) quantity-28
Carvedilol 12.5mg tablet (treats heart disease) quantity- 35
Benadryl 50mg tablets (antihistamine) quantity- 11
Aricept 5mg tablets (treats Alzheimers) quantity-16
hydrochlorothiazide 25mg tablets (treats high blood pressure) quantity- 19
Tramadol 50mg tablets (treats moderate pain) quantity-13
Synthroid 0.1mg tablet (treats low thyroid levels) quantity- 28
Perforomist 20mcg inhalation solution (treats lung problems) quantity- 6
Methocarbamol 500mg tablet (muscle relaxer) quantity- 20
Lopressor 25mg tablet (treats high blood pressure) quantity- 20
Zyprexa 5mg tablet (treats mental disorders) quantity- 9
Flagyl 500mg tablets (antibiotic) quantity- 27
Morphine 2mg (1ml) injection (treats severe pain) quantity- 31
Calcium Carbonate 1250mg (5ml) suspension (treats abnormal calcium levels) quantity- 6
Percocet 5/325mg tablets (treats moderate pain) quantity- 44
Dilaudid 2mg (1ml) injection (treats severe pain) quantity- 16
Dilaudid 1mg (1ml) injection quantity- 44
Robitussin 200mg (10ml) liquid (treats cough) quantity- 13
Prazosin 1mg capsule (treats high blood pressure) quantity- 9
Albuterol 2.5mg (0.5ml) inhalation solution (treats lung issues) quantity- 20
Pulmicort 0.5mg (2ml) inhalation solutions (treats lung issues) quantity- 13
Mucomyst 20% (4ml) vial (treats tylenol overdose) quantity- 18
Duoneb 0.5mg (3ml) inhalation solution (treats lung issues) quantity- 113
Albumin 5% (250ml) (increases volume of blood plasma) quantity- 4
Dextrose 10% (250ml) bag- (treats low blood sugar) quantity- 6
Zithromax 500mg (250ml) bag (antibiotic) quantity- 2
Heparin Flush 100unit/1ml (5ml) syringe (blood thinner) quantity- 10
Ciprofloxacin400mg (200ml) bag (antibiotic) quantity- 4
Lovenox 100mg syringe (blood thinner) quantity- 9
Lovenox 40mg syringe quantity- 11
Vancomycin 1g (200ml) bag (antibiotic) quantity- 5
Lovenox 30mg syringe quantity- 15
Amiodarone 360mg (200ml) bag (treats heart rhythm problems) quantity- 4
Tylenol 10mg/1ml (100ml) bag- (treats fever/pain) quantity- 4
Lactulose 20g (30ml) (treats high ammonia levels) quantity- 15
Zyvox 600mg (300ml) bag (antibiotic) quantity- 6
Flagyl 500mg (100ml) bag (antibiotic) quantity- 9
Vancomycin 750mg (150ml) bag (antibiotic) quantity- 7
Colace 100mg (10ml) liquid (stool softener) quantity- 22
KCL 20 meq 15ml Liquid (vitamin) quantity- 6
Ancef 2g (50ml) bag (antibiotic) - quantity- 9
Albumin 25g (100ml) injection (increase volume of blood plasma) quantity- 6
Go-lytely (4000ml) powder (laxative) quantity-2
D5W/0.45&NS W/ 40meq KCL (1000ml) bag (electrolyte replacement) quantity-3
Magnesium Sulfate 1G (100ml) bag (treats low magnesium) quantity- 8
Ancef 2G (50ml) bag (antibiotic) quantity- 1
Oxycodone 5mg tablet (treats moderate pain) quantity- 2
Lidocaine 4% patch (treats muscle pain) quantity- 1
Docusate 8.6mg tablet (laxative) quantity- 1
Neurontin 300mg capsule (treats nerve pain) quantity- 1

During a review of the hospital's "Adult Crash Cart: 1 Inventory" (CCI), dated 7/17/23, the "CCI" indicated the following medications were stored in the 3C code cart at the time room temperatures were out of range:

Adenosine (3mg/ml) 2ml Vial quantity- 5
Amiodarone (50mg/ml) 3ml Vial quantity- 3
Atropine (0.1mg/ml) 10ml syringe quantity- 3
Calcium Chloride 10% (100mg/ml) 10ml syringe quantity- 2
Dextrose 10% 250ml bag (raises blood sugar) quantity- 1
Dopamine in D5W 400mg/250ml bag quantity-1
Epinephrine HCL (0.1mg/1ml) 10ml Syringe quantity- 10
Lidocaine HCL 2% (20mg/ml) 5ml Injection quantity- 3
Lidocaine in D5W (4mg/ml) 500ml IV bag quantity- 1
Magnesium Sulfate 1g/100ml IV bag quantity- 2
Magnesium Sulfate 50% 2ml Vial quantity- 2
Metoprolol Tartrate (1mg/ml) 5ml Vial quantity- 3
Naloxone (1mg/ml) 2ml syringe quantity- 2
Sodium Bicarbonate 10ml Vial quantity- 2
Sodium Bicarbonate 50ml syringe quantity- 2
Sodium Chloride 10ml vial quantity- 3
Vasopressin (2ounits/ml) 1ml vial quantity- 2
Verapamil (2.5mg/ml) 2ml vial quantity- 2

All of these medication are given in sequence per Advanced Cardiac Life Support (ACLS) guidelines and are used in life saving measures.



39650

During a concurrent interview and record review on 7/24/23 at 1:42 p.m. with Emergency Department Clinical Director (EDD) and Emergency Department Supervisor (EDS), the ICC (Intermediate Care Center) fast track medication room (area in the emergency department) "ARTL," dated July 2023, was reviewed. EDS stated, the ICC/fast track medication storage room was closed on 7/20/23 due to the out of range temperatures documented on the "ARTL." EDD stated, the pharmacy staff recorded the ambient temperatures for the medication storage room on the ARTL and pharmacy staff were to request the work orders if the temperatures were out of range. EDS stated, the pharmacy staff were to report to the supervisor or engineering. EDS and EDD stated, nursing staff do not take the ambient temperatures for the medication storage room in the ICC. The "ARTL", dated July 2023 indicated, Date Current temperature (CT) Minimum Temperature (Min- T, lowest temperature in medication room in the past 24 hours) Maximum Temperature (MT-maximum highest temperature in medication room in past 24 hours) initials "If temperature is out of acceptable range, indicate the name of the Engineer and Pharmacist notified." The ARTL indicated:

On 7/1/23 CT 79° F, MT 81° F - "ticket in place" (engineer work order requesting repair was entered by staff member)
On 7/2/23 MT 79° F
On 7/3/23 MT 79° F
On 7/4/23 MT 79° F
On 7/5/23 CT 81° F, MT 82° F "PLACED TICKET"
On 7/6/23 CT 81° F, MT 82° F
On 7/7/23 CT 82° F, Min T 79° F MT 82° F "called"
On 7/8/23 CT 82° F, Min T 81° F MT 82° "ticket will be placed"
On 7/9/23 CT 82° F, Min T 81° MT 84° "ticket"
On 7/10/23 CT 79° F, Min T 79° MT 84°
On 7/11/23 CT 79° F, MT 82° F
On 7/12/23 MT, 81° F
On 7/13/23 CT 79° F, MT 79° F
On 7/14/23 MT F 82° F
On 7/15/23 MT 81° F
On 7/16/23 CT 79° F, MT 79° F
On 7/17/23 MT 79° F
On 7/19/12 MT 79° F
On 7/20/23 "No meds [medications] in room"

The ARTL dated July 2023 indcated, "Procedure: Temperature log is to be filled out daily. Temperature is to be recorded as current, as well as the 24hour [sic] minimum and maximum temperatures, initialed. Engineering is to document any corrective action on reverse side of this log."

During a concurrent observation and interview on 7/24/23 at 1:45 p.m. with Emergency Department Director (EDD), in the ICC/fast track medication storage area, a signage indicated, "Stop: Pyxis is down Use MAIN ED [Emergency Department] Pyxis" was posted on the Pyxis and the refrigerated medication storage units. EDD stated, she was notified by the DOP on 7/20/23, that the room temperatures in the ICC/fast track medication storage area were out of range, the room was to be closed and the medications to be removed.

During a concurrent interview and record review on 7/24/23 at 4:10 p.m. with Licensing and Accreditation Registered Nurse (LARN). LARN stated engineering department provided one work order for the ICC/fast track medication area dated 7/5/23 at 3:21 p.m. LARN stated no other work order for the ICC/Fast track department for July 2023 was found.

During a concurrent interview and record review on 7/24/23 at 2:50 p.m. with DOP, The hospital's "Device Inventory", dated 7/24/23, was reviewed. DOP stated the medications listed on the "Device Inventory" report were in the ICC/fast track pyxis 7/1/23-7/20/23. The "Device Inventory" indicated:

Acetaminophen 325 mg tablets, 650 mg (20.3 ml) liquid, 160 mg (5ml) liquid
Amoxicillin 125 mg tablets (antibiotic)
Haloperidol 5 mg tablets (treat certain mental/mood disorders)
Ciprofloxacin 500 mg tablets (antibiotic)
Naproxen 500 mg tablet (for pain)
Metronidazole 500 mg tablets (antibiotic)
Meclizine 25 mg tablets (for nausea)
Fluorescein 1 mg strips (checks for scratches in surface of eye)
Diphenhydramine 25 mg capsules/tablets and 50 mg (1 ml) injectable, 25 mg (10 ml) elixir (for itching and allergy)
Clindamycin 150 mg capsules (antibiotic)
Ibuprofen 400 mg, 600 mg tablets, 100 (5 ml) suspension (for pain and fever)
Dermabond topical solution (closes cuts in skin)
Ceftriaxone 500 mg vial, 1 g, 250 mg vials (antibiotic)
Methocarbamol 750 mg tablet (for painful muscles or bone conditions)
Metoclopramide 5 mg (2 ml) vial (treats nausea and vomiting)
Hydromorphone 1 mg (1 ml) injectable (for pain)
Ketorolac Tromethamine 60 mg vial (for pain)
Morphine 2 mg (1 ml) and 4 mg (1 ml) injectable (for pain)
Albuterol/Ipratropium 0.5 mg (3 ml) inhaled solution (for asthma, chronic lung conditions)
Lidocaine Viscous 2% (15 ml) oral solution (for numbing)
Lorazepam 2 mg (1 ml) vial (for anxiety)
HIV (human immunodeficiency virus -virus that attacks cells that help body fight infection) PEP Kit (employees only)
Trimeth 160 mg/Sulfameth 800 mg tablet (antibiotic)
Dexamethasone 4 mg (1 mg) vial, 6 mg tablet (steroid)
Albuterol 0.5% 2.5 mg (0.5) inhaled solution (for asthma, chronic lung conditions)
Morphine 15 mg tablet, 10 mg (1ml) vial (for pain)
Triple Antibiotic (0.5 g) ointment (antibiotic)
Hydrocodone/AC 5/325 mg tablet, 10/325 mg tablet (for pain)
Cefazolin 1 g vial (antibiotic)
Diazepam 5 mg tablet (for anxiety)
Aspirin 81 mg chewable tablet (reduce fever and relieve mild to moderate pain from conditions such as muscle aches, toothaches, common cold, and headaches)
Bupivacaine 0.5% (10 mg) vial, 0.25% (10 ml) vial (for numbing)
Oxycodone/APA 5-325 mg tablet (for pain)
Naloxone 0.4 mg (1ml) vial (used to reverse opiod [specific narcotic] overdose)
Azithromycin 250 mg tablet (antibiotic)
Ondansetron 4 mg tablet (for nausea and vomiting)
Ketorolac Tromethamine 1`5 mg (1 mg) vial, 30 mg (1 ml) vial (for pain)
Ceftriaxone 1 g (50 ml) bag, 2 gm (50 ml) bag (antibiotic)
Belladonna/phenobarbital liquid (10 ml) elixir (used to treat cramping and spasms in the stomach and intestines)
Lidocaine 2% (2ml) vial (for numbing)
Mag-Alum Hydrox-Simeth (30 ml) liquid (used for stomach upset, heartburn, and acid indigestion)
Water for injection (10 ml)
Proparacaine 0.5% (15 ml) ophthalmic (eye) solution (to numb the eye)
Vancomycin 1 g (200 ml) frozen (antibiotic)
Urinalysis control drops (checks for accuracy of urine test)
Penicillin G Benzathine 1200000 unit (2 ml) syringe (antibiotic)

During a review of the hospital's policy and procedure (P&P) titled, "Medication Storage and Security," dated November 2020, the P&P indicated, "V.A.1. [hospital] will maintain proper environmental control (i.e. proper temperature, light humidity. . . wherever drugs and supplies are stored. 9. Medications that require storage at controlled room temperature will be maintained with temperatures between 68° F and 77° F."

Based on interview and record review, the hospital failed to follow its policy and procedure on "Employee Performance Reviews" (EPR-a formal assessment in which a manager evaluates an employee's work performance, identifies strengths and weaknesses, offers feedback, sets goals for future performance) for five of nine sampled employees (Licensed Vocational Nurse [LVN] 1, Registered Nurse [RN] 20, RN 22, RN 23, and RN 27) when EPRs were not completed and/or delinquent. This failure had the potential for patient care to be negatively impacted if performance issues of staff were not identified.

Findings:

During a concurrent interview and record review on 7/20/23 at 10:12 a.m. with Human Resources Director (HRD), LVN 1's personnel file was reviewed. LVN 1's file indicated, LVN 1 was hired on 11/6/22 (over six months ago). HRD stated newly hired employees should receive an EPR at six months. LVN 1's personnel file did not contain an EPR. HRD stated the supervisor's have a 60-day grace period to complete an EPR. HRD stated the EPR should have been completed by 7/6/23.

During a concurrent interview and record review on 7/20/23 at 11:05 a.m. with HRD, RN 20's personnel file was reviewed. RN 20's file indicated, RN 20 was hired on 3/18/19 as a contracted travel nurse. RN 20's personnel file did not contain an EPR. HRD reviewed the EPR policy and stated contracted travel nurses are evaluated at the end of their contract, but if they are employed for a year or more the nurses must have a performance evaluation annually. HRD verified RN 20 did not have an EPR.


46958

During a concurrent interview and record review on 7/24/23 at 2:15 p.m. with HRD, RN 22's personnel file was reviewed. RN 22's personnel file indicated RN 22 was hired on 9/19/21 as a contracted travel nurse. RN 22's personnel file did not contain an EPR. HRD stated she did not have an EPR on file.

During a concurrent interview and record review on 7/24/23 at 2:20 p.m. with HRD, RN 23's personnel file was reviewed. RN 23's personnel file indicated RN 23 was hired on 1/20/18 as a contracted travel nurse. RN 23's personnel file did not contain an EPR. HRD stated she did not have an EPR on file.

During a concurrent interview and record review on 7/24/23 at 2:35 p.m. with HRD, RN 27's personnel file was reviewed. RN 27's personnel file indicated RN 27 was hired on 1/20/18 as a contracted travel nurse. RN 27's personnel file did not contain an EPR. HRD stated she did not have an EPR on file.

During a review of the hospital's policy and procedure (P&P) titled, "Employee Performance Reviews: Types and Purpose" dated September 2022, the P&P indicated, "The employee's immediate supervisor is responsible for ensuring that an Employee Performance Review (EPR) is completed for each eligible employee in a timely manner and in accordance with the following guidelines. . . Probationary Employee EPRs: Employees who are newly appointed to a position, whether through a new hire, transfer or promotion must receive an EPR six (6) months after their appointment and again at 12-months post-appointment, which coincides with the applicable probationary period. . . Regular Employee Annual EPRs: An EPR will be completed annually for each employee on their EPR due date. . . Contract Employee EPRs: Contracted and agency employees are required to meet agreed upon standards of performance during their assignment. These employees must receive an evaluation by the department manager or designee at the expiration of their contract or assignment. For contracts and assignments that extend beyond one (1) year, a performance evaluation will be required on an annual basis at the anniversary of their contract or assignment start date."

Based on interview and record review, the hospital failed to ensure one Licensed Vocational Nurse (LVN 1) who was assigned to care for newborn infants had Neonatal Resuscitation Program (NRP- steps used to determine how a newborn baby transitions to life outside the womb and implementing emergency interventions when needed) certification. This failure had the potential for poor staff performance and potential to result in adverse health outcome for patients due to delayed or improper emergency resuscitative interventions.

Findings:

During an interview on 7/19/23 at 4 p.m. with Director of Maternal/Child Services (DMCS) and Manager of Operations for Maternal/Child Services (MOMCS), DMCS stated LVNs in the Post Partum unit (area of hospital for women and their newborn babies) are given patient assignments, including newborn patients.

During an interview on 7/20/23 at 10:12 a.m. with Human Resources Director (HRD), LVN 1's personnel file was reviewed. LVN 1 did not have NRP certification.

During an interview on 7/24/23, at 2:16 p.m. with DMCS, DMCS stated, "Each staff member should be certified in BLS [Basic Life Support- providing chest compressions and artificial breathing], NRP, and PALS [Pediatric Advance Life Support- course for assessing injured and sick children and recognize and treat respiratory (breathing) distress/failure, shock (sudden drop in blood pressure), and cardiac arrest (unexpected loss of heart function)], because we move staff through the different areas of maternal child services."

During a review of "American Heart Association [www.aha.org] AHA," the AHA indicated, NRP guidelines apply to resuscitation efforts for newborns transitioning from intrauterine [within the uterus] to extrauterine [outside the uterus] life, transitioned neonates during the first weeks after birth, and infants during their initial hospitalization.