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Based on record review and interview, the hospital failed to ensure that a medical history and physical examination was completed and documented for each patient no more than 30 days before or 24 hours after admission or registration for 1 (Patient #1) of 25 records reviewed for completeness in a total sample of 30.
Findings:

Review of the hospital's policy Health Information Management (HIM) 1003 titled, "Designated Record Set" revealed in part: History and Physical (H&P) and or H&P update (Completed within 24 hours of admission).

Review of Patient #1's medical record revealed an admit date of 08/24/2022 and an H&P dated 08/26/2022.

In an interview on 09/21/2022 at 10:00 a.m., S4RN confirmed the H&P for Patient #1 was not completed within 24 hours after admission.

Based on observations and interviews, the hospital failed to ensure that outdated, mislabeled or otherwise unusable drugs and biologicals were not available for patient use as evidenced by having opened undated medications available for patient use.
Findings:

Observations of the Emergency Department on 09/20/2022 at 12:55 p.m. accompanied by S3RN Emergency Department Manager revealed the following open and undated medication available for patient use: Trauma Room 1 - two tubes of lubricating jelly; Trauma Room 2 - one tube of lubricating jelly, one spray bottle of Woundclens, one liter of normal saline irrigation solution and one liter of sterile water used with the ventilator.

In an interview on 09/20/2022 at 1:15 p.m., S3RN Emergency Department Manager acknowledged the items should have been dated when opened or discarded.

In an interview on 09/20/22 at 3:40 p.m., S1CNO stated the opened medications should be for single use only and should have been discarded and not available for use.

Based on policy review, observation and interview, the hospital failed to develop and implement an effective system in controlling infections and communicable diseases of patients as evidenced by failing to maintain a sanitary environment.
Findings:

Review of the hospital's policy HSK 2004 titled, Discharge Room Cleaning revealed in part: Terminal Check-Out Supplemental Procedures (Isolation Check-Out) - 5. Throw away unused toilet paper, disposable utensils and any other items that cannot be disinfected.

Review of the hospital's policy IP-1019 titled, "Infection Prevention Plan" revealed in part: Decontamination of all reusable surfaces and equipment will be provided by the appropriated department immediately after patient use is completed, according to individual manufacture's recommendation. After decontamination practice is performed the reusable equipment will be bagged and placed in the clean equipment room.


Observation of the Isolation Rooms 122 and 124 on 09/20/2022 at 10:35 a.m., which were designated as clean, revealed the anteroom with 4 used disposable gowns, 1 used disposable face shield and 1 pair of used disposable goggles stored in an area designated as clean. Items should have been discarded.

In an interview on 09/20/2022 at 10:40 a.m., S6RN confirmed the findings.

Observation of Room 128 used as Clean Equipment Room on 09/20/2022 at 10:45 a.m. revealed 2 infusion pumps, 2 sequential compression pumps, 1 feeding pump uncovered and stored with equipment covered with plastic bags and designated as clean.

In an interview on 09/20/2022 at 10:50 a.m., S6RN confirmed the findings.

Observation of ICU Room 102 on 09/20/2022 at 11:10 a.m. revealed rips/tears to the vinyl covering on the armchair which prevents proper sanitizing.

In an interview on 09/20/2022 at 11:15 a.m., S2RN confirmed the findings.

Observation of the Laboratory on 09/21/2022 at 10:30 a.m. revealed dried reddish streaks and debris on the interior aspects of the Sero-Fuge centrifuge used to typing and matching of blood products.

In an interview on 09/21/2022 at 10:35 a.m. S5Lab Manager confirmed the finding and stated the equipment should be cleaned and sanitized whenever there is visible debris.

In an observation on 09/22/2022 at 9:27 a.m. of the kitchen with S7 DM revealed multiple flies flying in the kitchen where food was being prepared.

In an interview with S7DM during the observation verified there were multiple flies flying in the kitchen where food was being prepared.




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