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Based on interview and record review, the hospital did not protect and promote each patient's rights and did not ensure that the patient's representative was informed in advance of discontinuing patient care (A-0117). This resulted in the hospital's failure to provide Patient 40 with continuing care and life sustaining treatment.

The effect of this practice resulted in the hospital's failure to comply with the statutorily mandated regulations under Patient Rights.

Based on record review and interview, the hospital did not inform the patient's representative in advance of discontinuing patient care. This resulted in the hospital's failure to provide resuscitative care which was against Patient 40's preferred intensity of care directive.

Finding includes:

Patient 40 was admitted to the facility on 3/08/22 with several diagnoses including altered mental status, cerebral infarction due to thrombosis of the left carotid artery, acute respiratory failure with hypoxia, compression of the brain, and kidney failure.

Review of the medical record dated 3/09/22 revealed that Patient 40 experienced "decrease responsiveness" following a flight from Hawaii to Guam. The patient, accordingly, was transferred via EMS from the airport to the hospital for management and evaluation which included mechanical ventilation and life sustaining interventions.

On 3/11/22, a physician's consult notes revealed a discussion between the physician and the "patient's sister" regarding the patient's condition, and the "likelihood of poor prognosis to include progression to brain death." The note added that the "sister made it clear to me (the physician) and the patient's primary nurse that the family has discussed goals of care and wish to continue all current interventions and have no intent at this time to transition to end-of-life or comfort measures."

According to the note, the physician also informed the family that the patient "will not have a meaningful recovery and will almost certainly require life sustaining support."

Review of the medical record revealed that Patient 40 had undergone apnea testing on 3/10/22 and 3/11/22. A consultation note dated 3/10/22 revealed that the patient did not have spontaneous breathing during the test. Another test conducted on 3/11/22 revealed that 20 minutes after the apnea test was completed, the patient had "an abrupt bradycardia event" (slower-than-expected heart rate) and "lost pulses."

There was no indication that the patient's representative was informed of the tests to determine brain death and involved disconnection of mechanical ventilation for the patient.

On 3/11/22, a nurse's notes revealed that at 8:56 a.m., during the apnea test, providers MDA and MDB were "called to bedside immediately for initiation of a code (any patient with an unexpected cardiac or respiratory arrest requiring resuscitation and activation of a hospital wide-alert). According to the nurse's notes, the "patient (was) pulseless" with a heart rate in the "30s." The nurse's note added that MDA assessed the patient at the beside and confirmed that the patient had no pulse or heart tones. At 8:58 a.m., MDB was noted as saying, "At this time I feel it is appropriate to not move forward with code and to make him DNR (do not resuscitate)." MDA was noted to agree with MDB and ordered staff to not proceed with the cardiopulmonary resuscitation.

Patient 40 was noted to have expired shortly thereafter.

There was no indication that the patient's representative was informed about the providers' decision not to initiate cardiopulmonary resuscitation contrary to the patient's representative's directive. According to the nurse's note, the "Pt (patient) was Full Code made DNR."

Review of the hospital's policy regarding Patient Self-Determination (Policy A-RI400) revealed that the hospital will "act affirmatively with respect to every patient's right to make decisions regarding their choices of medical treatment."

The hospital's policy on Do Not Resuscitate (DNR Policy A-RI500) defines "Full Code" to mean that the patient "will receive full resuscitative efforts including life sustaining procedures."

Review of the same policy under Unresolved Issues and Other Guidelines (page 3) revealed that "In situations where the patient or surrogate decision maker disagrees with the Attending Physician regarding the decision for a DNR order, the physician must honor the wishes of the patient or surrogate decision maker and may choose to make arrangements to transfer patient care to another physician, resolve the conflict through a multidisciplinary family/patient conference, or refer the issue to the Ethics committee."

There was no documentation that these were followed or discussed with the patient's representative.

Further review of the policy regarding Withdrawal of Life Support (A-RI600) noted that "Decisions concerning the issue of withdrawal of care are made in the same fashion as all other medical judgment," and that "decisions require informed consent of the patient or an appropriate surrogate decision maker."

During an interview at 11:15 a.m. on 9/23/22 about the incident, a member of the medical executive committee (MD11) stated that the "code should have continued."

Based on observations, interviews and record review, the facility's Outpatient Clinics failed to ensure care was provided in a safe setting, as evidenced by:

1. An initial tour of the Specialty Care Clinic on the first floor was done on 9/19/22 at approximately 10:17 a.m. with Clinic Nurse (CN) 1. During the tour, CN 1 stated that the clinic provided care to adult and pediatric patents. At approximately 10:23 a.m. on 9/19/22, an emergency crash cart was observed in of the exam/treatment room that also contained a treadmill used for cardiac (heart) testing. CN1 was asked to open the crash cart that revealed various adult and pediatric emergency medical supplies and medications in the cart. Additionally, there were two separate plastic 'toolbox' containers containing adult and pediatric emergency supplies, respectively, that CN1 opened. The crash cart and two plastic 'toolboxes' did not have evidence of having a Broselow Pediatric Emergency Tape (a color-coded tape measure that is used as a quick reference for pediatric emergencies). When CN1 was asked if the crash cart or patient care unit had a Broselow tape, she indicated she didn't know what that was, and responded "I don't know what that is?".

2. An initial tour of the Outpatient Rehab Clinic was done on 9/19/2022 at approximately 10:47 a.m. with CN1. During the tour, CN 1 stated that the clinic provided care to adult and pediatric patents. At approximately 10:53 a.m. on 9/19/22, an emergency crash cart was observed in a hallway near the staff breakroom. CN1 was asked to open the crash cart that revealed various adult and pediatric emergency medical supplies and medications in the cart. Additionally, there were two separate plastic 'toolbox' containers containing adult and pediatric emergency supplies, respectively, that CN1 opened. The crash cart and two plastic 'toolboxes' did not have evidence of having a Broselow Pediatric Emergency Tape (a color-coded tape measure that is used as a quick reference for pediatric emergencies). When CN1 was asked if the crash cart or patient care unit had a Broselow tape, she indicated she didn't know what that was, and responded "I don't know, I don't think I've seen one of those before."

Based on record review and interview, the hospital did not measure, analyze, and track quality indicators and other aspects of performance that assessed processes of care, and hospital services and operations. This resulted in the failure by medical staff members to attend mandatory hospital training and in-services resulting in low compliance rate.

Finding includes:

During an interview at 11:00 a.m. on 9/22/22, MS1 stated that the hospital credentialing office keeps track of medical staff members' attendance in mandatory training and in-services.

In a separate interview on 9/22/22, a member of the credentialing unit (CS1) verified that the hospital requires members of the medical staff to complete the required training every year. CS1 added that for 2022, for example, the hospital required several training/courses which included Covid-19 Self-Reporting Acknowledgment, 2022 Patient Safety Awareness Training, Violence in the Workplace, CMS Expectations for Protocols and Standing Orders, Interim Life Safety Measures, Infant and Pediatrics Security, Medication Administration from a CMS Point of View, and Basic Patient/Resident Rights.

When asked if data was being collected periodically to determine actual participation, and whether an analysis of the data was being conducted, CS1 had no comment but stated that a "Medical Staff Training % Completion Report" could be generated. CS1 added that the report measured compliance by the various departments.

Following an anonymous complaint alleging low participation by members of the medical staff in mandatory hospital training, review of the data compiled by CS1 on 9/22/22 (for 2022) to revealed an overall compliance rate of 48% (and 53% if telemedicine providers were included).

In addition, there was no indication that the low compliance rates were tracked and analyzed periodically so that appropriate interventions could be implemented.

Based on observation, interview and record review, the facility failed to implement, for 2 nurses (Staff 6 and Staff 100), their procedures to ensure that hospital nursing personnel had a valid and current license.
This failure increased risk for patients to be cared for by unlicensed and unqualified nurses.

Findings include:

Facility policy Documentation of Licenses and Certifications, dated 2/18, documented "All RNs (Registered Nurses) ....employed ....will maintain a current license/certification at all times. The Nursing Services Office will be responsible for maintaining copies of all licenses and certifications of RNs ....The Unit Supervisor will be responsible for updating the Nursing Office with these records. It is the ultimate responsibility of the staff to provide an updated copy of their license/certification to their Unit Supervisor in a timely manner in compliance with deadlines indicated in this policy. Expiration date of all license for RNs ...is September 30th of each odd-numbered year. All licensed nurses must submit a current license before October 1 of every odd-numbered year ....Staff who do not submit a copy of their license/certification before October 1 shall be subject to the following ...a) they will not be allowed to return to work until such time he/she presents a valid Guam license/certification ...."

Concurrent observation and interview on 9/19/22 about 2:00 pm showed Registered Nurse (Staff 6) entering and exiting multiple patient rooms. When asked, Staff 6 stated that she worked full time for about the past two years at the facility.

Review of Staff 6 ' s personnel file showed hire date of 12/11/20 as a staff nurse. File showed Staff 6 completed NCLEX (National Council Licensure Examination, nationwide examination for the licensing of nurses) and received a provisional nursing license. Email from Guam Board of Nurse Examiners to facility representative, dated 11/24/20, documented "This is to confirm the following are all active RNs expiring on 9/30/21". Four names were listed which included Staff 6. Staff 6 ' s personnel file did not contain evidence Staff 6 had an active current registered nurse license.

During concurrent interview and record review on 9/23/22 about 3:45 pm Compliance (Staff 99) reviewed Staff 6 ' s personnel file and confirmed there was no evidence of an active current registered nurse license, but this should have been present in the file.

Review of Staff 100 ' s personnel file did not contain evidence of active current registered nurse license. Staff 100 was working and shown on the facility ' s schedule.

During concurrent interview and record review on 9/23/22 about 3:59 pm Compliance Officer (CO) provided two separate Nursys quick confirm license verification reports, both dated 9/23/22, which documented Staff 6 and Staff 100 had active current RN licenses. CO confirmed the reports was completed today to demonstrate primary source verification but should have been completed before today and was absent in the individual staff personnel files.

Based on observation, interview and record review the facility failed to ensure nursing care for Patient 17 was supervised and evaluated by a registered nurse to ensure continuing monitoring, accuracy of assessments, and compliance with physician's orders when:
1. Two inhalers were not secured and accessible to confused patient who was not assessed or approved for self-administration of medications;
2. Did not ensure two inhalers had drug labels containing key information such as patient ' s name (who medication was prescribed for), information about the drug such as generic/brand name, directions for use (dose, frequency, indications for use such as needed for shortness of breath), expiration date or physician ' s name;
3. Atrovent inhaler did not match the physician order;
4. Albuterol inhaler did not include the frequency of administration and therefore, was not a complete order;
5. Nurse administered aforementioned Atrovent and Albuterol inhalers despite discrepancies with orders;
6. Physician orders to maintain 1:1 feeder/supervision during meals and strict aspiration precautions was not carried out;
7. Physician orders for sequential compression device for DVT (deep vein thrombus, blood clot in leg that could be life threatening) was not carried out;
8. Assessment risks for pressure injury was not accurate.

These failures increased risk for unmet care needs, medication errors, aspiration pneumonia, deep vein thrombus and pressure injuries.

Findings include:

Record review showed Patient 17 was admitted on 9/11/22 with diagnosis including acute stroke, acute heart attack, and active covid infection. Patient 17 was over 75 years old and was confused.

Record review showed Patient 17 had a physician order, start date 9/17/22, which documented Atrovent 14g 1 puff IH (inhalation) prn (pro re nata, as needed) every six hours for shortness of breath and Albuterol 90 mcg 1 puff IH prn shortness of breath. The order for Albuterol did not include the frequency (how often medication could be given). Patient 17 was not assessed or approved to self-administer medications. Record review documented on 9/13/22 at 6:05 am Albuterol lH and Atrovent IH 1 puff each was given.

Concurrent observation and interview on 9/19/22 at about 2:00 pm showed Patient 17 ' s room included an anteroom (small room with outer and inner door separating and leading to patient ' s room). Registered Nurse (RN)5 was in Patient 17 ' s room setting up and assisting patient with meal tray. Patient was confused and coughing; surveyor opened night stand drawer in patient ' s room looking for a tissue. In the drawer, two boxes containing inhalers, Albuterol sulfate 90 mcg with dose indictor and Atrovent HFA17 mcg/actuation with dose indicator (medications for shortness of breath) was observed. RN5 confirmed the inhalers were used for Patient 17 and should not have been left in the patient ' s room. RN5 stated that since patient had covid, they could not keep patient ' s multi-dose medication in the shared medication cart but acknowledged it would have been safer to keep inhalers in the anteroom of patient ' s room.

During an interview on 9/21/22 at 10:49 am Pharmacy Director (PD) stated that medications should not have been at patient ' s bedside and instead secured at the nurses ' station or medication cart, or in Patient 17 ' s individual case, anteroom would have been a good alternative. PD stated that inhalers are not dispensed from pharmacy but nurses remove directly from the Pyxis system (automated medication dispensing cabinet) and the nurse is supposed to print and affix label onto drug container. PD reviewed Atrovent order which showed 14 grams which was different than 17 mcg shown on the inhaler in the patient ' s room. PD stated the physician order and dispensed medication should match. In addition, PD reviewed the Albuterol order and confirmed the frequency was not defined and therefore, it was not a complete order and should have been clarified before administering medication.

During an interview on 9/23/22 at 8:38 am nursing unit supervisor (NUS)5 stated that medications should not left at patient ' s bedside. When informed Atrovent inhaler did not match the physician order, Albuterol inhaler did not include the frequency of administration, and patient received both medications, NUS stated that nursing should have clarified orders with physician before administering medication and this would be considered a medication error.

During an interview on 9/23/22 about 9:00 am Pharmacist 5, nursing unit clinical pharmacist for Patient 17, stated that Patient 17 ' s Atrovent and Albuterol was ordered and dispensed from the unit Pyxis and not the emergency department and the unit nurse should have printed and affixed label on drug containers.

During an interview on 9/23/22 at 11:16 am Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed medications should not be left at patient ' s bedside and physician should be contacted with medication orders clarified if they are unclear or different than medication available. Expectation is nursing staff will follow the five rights (right patient, right drug, right dose, right route and right time) when administering medications and this was not done but should have been.

Review of facility policy Medication Administration and Documentation, dated 9/18, documented "Before administration, the individual administering the medication does the following: A. Verifies that the medication selected matches the medication order and product label ....All medications shall be administered using the six (6) rights of medication and administration: A. The right dose, B. The right time, C. The right method/route, D. The right patient, E. The right medication, F. The right documentation. Before administration, the individual administering the medication discusses any unresolved concerns about the medication with the patient's licensed independent practitioner, prescriber (if different from the licensed independent practitioner), and/or staff involved with the patient's care, treatment, and services. This discussion is documented in the patient's medical records by the individual administering the medication."

Review of facility policy Labeling Standard for Medications, dated 3/23/18, documented "All drug containers shall be labeled and drug labels must be clear, consistent, legible and in compliance with state and federal requirements." Medication label shall include at a minimum ...."Generic and brand name; dose form (if other than oral), dose, manufacturer ' s name, drug ' s lot number and expiration; and/or internal-assigned lot number ....appropriate auxiliary labels."

Review of facility policy Medication Orders, dated 3/23/18, documented "Complete medication orders reduce the likelihood of errors ....to be considered complete, all medication orders shall include .....frequency of administration ....Nursing staff shall check the completeness and clarify any ambiguous order before sending the order to the pharmacy. The approving pharmacist may directly contact the prescriber for any clarifications."

Record review of Patient 17 ' s physician orders, start date 9/12/22, documented "Recommend 1:1 feeder/supervision during meals/snacks. Recommend strict aspiration precautions. Recommend that patient may need crushed medications if resistant to po (oral) medications whole, one at a time. Diet order was ground (level 2) consistency."

Record review of Speech Language Pathologist (SLP)1 bedside swallow assessment, completed and dated 9/12/22, documented "patient was alert but not oriented", "Pt (patient) was fairly calm during the evaluation, however, when SLP left the room, and observed pt through the window, pt appeared agitated, was pulling her gown off, was pulling her diaper off and was pulling all of her (telemetry, heart rhythm monitoring wires) off and was wrapping cords around her neck. SLP entered

the room again, assisted the pt and removed cords from around her neck area. SLP immediately notified CN [charge nurse name] of pt's agitated condition. RN was not available for SBAR (situation background assessment recommendation, communication tool) after the evaluation due to pt care, therefore recommendations were given to CN. Pt appears to possibly have some degree of dementia as observed by pt's behavior during this swallow evaluation. Evaluation documented possible mild dysphagia (swallowing difficulty) .....Modified diet is recommended. Recommend 1:1 feeder/supervision during meals/snacks. Recommend strict aspiration precautions. Recommend that patient may need crushed medications if resistant to po (oral) medications whole, one at a time. Diet order was ground solids, thin liquids."

Record review of Swallow Evaluation, dated 9/12/22, documented Physician notified and SBAR with RN was completed on 9/12/22.

Concurrent observation and interview on 9/19/22 at about 2:00 pm showed Registered Nurse (RN)5 bringing lunch meal tray into Patient 17 ' s room, placed tray on overbed table, repositioned overbed table in front of patient in bed, opened Styrofoam container which showed ground meat, removed lids on beverage cups, and placed utensils in front of patient. RN5 then exited room with water pitcher and walked about 30 feet down hallway where another staff poured two cups of water into pitcher. While RN5 was out of the room, resident took a few bites from tray left in front of her. RN5 re-entered Patient ' s 17 ' s room and assisted patient with eating. Patient 17 started coughing. White board in room showed "1:1 feeder" written. When asked what 1:1 feeder meant, RN5 stated that it was old and no longer applicable. When asked, RN5 nodded head and stated that meal tray can be left with patient while staff is out of the room.

During an interview on 9/23/22 at 1:19 pm SLP1 stated that there was no change in diet, 1:1 feeder/supervision or strict aspiration precautions orders for Patient 17. When asked, SLP1 stated that 1:1 feeder/supervision and strict aspiration precautions means that someone needs to be at the bedside while patient is eating to prevent aspiration or choking as sometimes patients in these conditions can be impulsive or take too large sips or bites. SLP1 further stated that she intentionally recommended supervision so staff know they can't leave tray at the bedside and then leave the room. When asked, SLP1 stated that communication hand-off of these recommendations was given to nursing staff via SBAR communications and spoke with charge nurse because nurse assigned was providing cares. SLP1 stated that she was particularly concerned for Patient 17 ' s safety and risk for choking given patient ' s confused state, wrapping cords around neck and isolation given covid diagnosis and need for isolation precautions and putting on personal protective equipment to enter patient ' s rom.

During an interview on 9/23/22 at 8:38 am nursing unit supervisor (NUS)5 stated that 1:1 feeder/supervision with meals and snacks means patient needs to be observed when eating and staff should be in the room or supervise them to make sure patient is not coughing when eating, tolerating diet and can intervene if needed. When informed of observation, NUS5 shook her head and stated that staff should not be leaving tray with Patient 17 given her orders and will remind nurses.

During an interview on 9/23/22 at 11:16 am Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed patients should not be left alone with meal trays if there are orders for 1:1 feeder/supervision and strict aspiration precautions.

Facility policy Nursing Scope of Practice, dated 7/17, documented "The scope of practice for a Registered Nurse means ....3). Implementing nursing care through the execution of .... prescribed medical regimen."

Record review of Patient 17 ' s physician orders, start date 9/12/22, documented "Recommend 1:1 feeder/supervision during meals/snacks. Recommend strict aspiration precautions. Recommend that patient may need crushed medications if resistant to po (oral) medications whole, one at a time. Diet order was ground (level 2) consistency."

Record review of Patient 17 ' s physician orders, start date 9/11/22, documented "SCDs (sequential compression device) for DVT (deep vein thrombus) prophylaxis."

Record review of Patient 17 ' s physician progress note, dated 9/14/22, documented SCDs for DVT prophylaxis.

Record review of Patient 17 ' s cardiologist consultation note, dated 9/20/22, documented patient had a stroke due to atrial fibrillation (abnormal heart rhythm) and was not anticoagulated before the stroke event.

Observation on 9/19/22 about 1:30 pm showed Certified Nursing Assistant (CNA)10 providing bed bath to Patient 17. Patient was confused and at times agitated. Patient 17 ' s legs were bare without SCD or compression hose on the patient or in patient ' s room.

During an interview on 9/19/22 about 2:30 pm when asked about lack of SCD for Patient 17, Staff 93, who was unit charge nurse, stated that Rehabilitation has started seeing patient and physicians do not usually discontinue SCD orders.

During an interview on 9/23/22 at 8:38 am when asked, nursing unit supervisor (NUS)5 stated that sometimes the unit doesn ' t have enough SCDs so TED (compression) hose is provided instead. When informed that Patient 17 had neither SCD or compression hose, NUS5 stated that she will follow-up.

During an interview on 9/23/22 at 11:16 am Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed hospital had SCDs and they should be used or an alternative and physicians should be informed so patient needs can be addressed.

Facility policy Nursing Scope of Practice, dated 7/17, documented "The scope of practice for a Registered Nurse means ....3). Implementing nursing care through the execution of .... prescribed medical regimen."

Observation on 9/19/22 about 1:30 pm showed Certified Nursing Assistant (CNA)10 providing bed bath to Patient 17. Patient was confused and at times agitated. Both of Patient 17 ' s heels had some blanchable redness and purple discoloration. Patient 17 ' s briefs was wet and changed. No observation of patient with heel protectors or heels floating on pillow, and moisture barrier or skin protectant was not applied to bony prominences after bathing.

Facility policy Pressure Injury Management for Adults, dated 5/18, documented the purpose of the policy was "to provide a standard of care in the identification, prevention and treatment of pressure injuries. Assess the patient ' s risk level for pressure injury using the Braden Scale." The Braden Scale assigned risk factors for sensory perception, exposure to moisture (urinary/fecal incontinence), physical activity, mobility, nutrition and friction and shear. Treatment of moisture barrier (e.g. Cavilon cream) to bony prominence was indicated for patients at high risk indicated by braden score less than 12 and treatment of skin protectant (e.g. A&D ointment) to bony prominences after bathing or changing of soiled clothing was indicated for patients at moderate risk indicated by braden score of 13-14. Detailed descriptions were outlined for each risk factor. The details for Sensory Perception and Moisture risk factors included the following:

*Sensory Perception defined as ability to respond meaningfully to pressure related discomfort:
Score of 1: Completely Limited-unresponsive
Score of 2: Very Limited-
Score of 3: Slightly Limited-responds to verbal commands but cannot always communicate discomfort or need to be turned or has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities.
Score of 4: No impairment-responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort.
*Moisture define as the degree to which skin is exposed to moisture
Score of 1: Constantly moist-skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned.
Score of 2: Often moist-skin is often but not always moist. Linen must be changed at least once a shift.
Score of 3: Occasionally moist-skin is occasionally moist, required an extra linen change approximately once a day.
Score of 4: Rarely moist-skin is usually dry; linen only requires changing at routine intervals

Record review of Braden sensory perception risk factor from 9/12/22 to 9/19/22 documented "No Impairment: responsive, no sensory deficit"

Record review of CNA flow sheet for orientation status documented "Confused" on 9/15/22, 9/16/22, and 9/19/22.

Record review of nursing care plan showed care plan initiated for confusion with patient alert to self only on 9/12/22; this care plan was still ongoing as of 9/19/22.
Record review of nurse ' s progress notes documented patient was confused on several occasions including on 9/13/22 and 9/15/22. Assessment of Braden sensory impairment risk factor was not congruent with CNA and nursing care plan and progress note documentation.

Record review of Braden moisture risk factor from 9/12/22 to 9/19/22 documented "Rarely moist: skin is usually dry. Routine linen changes"

Record review of CNA flow sheet for urinary status from 9/12/22 to 9/19/22 documented "Incontinent" except for 9/13/22 when "foley (tube in bladder to drain urine) was used. Assessment of Braden moisture risk factor was not congruent with CNA flow sheet documentation. Patient could not be "Rarely moist" defined as skin is usually dry with routine linen changes if there were multiple occurrences in a single day of urinary incontinence and instead "Occasionally moist" or "Often moist" were more congruent with CNA flow sheet.

There was no care plan for reduction of pressure injury or risk for skin or tissue injury.

During concurrent interview and record review on 9/23/22 at 8:38 am nursing unit supervisor (NUS)5 reviewed Patient 17 ' s braden scale assessment and CNA flow sheets and concurred scoring of "Rarely moist" was not congruent with patient with urinary incontinence and "No impairment" for sensory deficit was not congruent for patient that was mostly confused.

During an interview on 9/23/22 at 11:16 am when informed of observations and incongruent documentation with braden scale risk factors, Director of Nursing (DON) and Assistant Director of Nursing (ADON) stated that additional training may be needed on the Braden scale pressure injury assessment.

Facility policy Nursing Standards of Clinical Practice, dated 6/11, documented "The registered nurse collects comprehensive data pertinent to the patient ' s health or the situation, then registered analyzes the assessment data to determine the diagnosis or issues ...The registered nurse develops a plan that prescribes strategies and alternatives to attain expected outcomes. Includes strategies within the plan that address each of the identified diagnoses or issues, which may include strategies for promotion and restoration of health and prevention of illness, injury and disease."

Based on observation, interview and record review the facility failed to ensure that the nursing staff developed and kept current, a nursing care plan for Patient 17 who was at high risk for aspiration.
This failure increased risk for patient to develop aspiration pneumonia.

Findings include:

Record review showed Patient 17 was admitted on 9/11/22 with diagnosis including acute stroke, acute heart attack, and active covid infection. Patient 17 was over 75 years old and was confused. Patient 17 ' s physician orders, start date 9/12/22, documented "Recommend 1:1 feeder/supervision during meals/snacks. Recommend strict aspiration precautions. Recommend that patient may need crushed medications if resistant to po (oral) medications whole, one at a time. Diet order was ground (level 2) consistency."

Record review of Speech Language Pathologist (SLP)1 bedside swallow assessment, completed and dated 9/12/22, documented "patient was alert but not oriented", "Pt (patient) was fairly calm during the evaluation, however, when SLP left the room, and observed pt through the window, pt appeared agitated, was pulling her gown off, was pulling her diaper off and was pulling all of her (telemetry, heart rhythm monitoring wires) off and was wrapping cords around her neck. SLP entered

the room again, assisted the pt and removed cords from around her neck area. SLP immediately notified CN [charge nurse name] of pt's agitated condition. RN was not available for SBAR (situation background assessment recommendation, communication tool) after the evaluation due to pt care, therefore recommendations were given to CN. Pt appears to possibly have some degree of dementia as observed by pt's behavior during this swallow evaluation. Evaluation documented possible mild dysphagia (swallowing difficulty) .....Modified diet is recommended. Recommend 1:1 feeder/supervision during meals/snacks. Recommend strict aspiration precautions. Recommend that patient may need crushed medications if resistant to po (oral) medications whole, one at a time. Diet order was ground solids, thin liquids."

Concurrent observation and interview on 9/19/22 at about 2:00 pm showed Registered Nurse (RN)5 bringing lunch meal tray into Patient 17 ' s room, placed tray on overbed table, repositioned overbed table in front of patient in bed, opened Styrofoam container which showed ground meat, removed lids on beverage cups, and placed utensils in front of patient. RN5 then exited room with water pitcher and walked about 30 feet down hallway where another staff poured two cups of water into pitcher. While RN5 was out of the room, resident took a few bites of food in front of her. RN5 re-entered Patient ' s 17 ' s room and assisted patient with eating. Patient 17 started coughing. White board in room showed "1:1 feeder" written.

During an interview on 9/23/22 at 1:19 pm SLP1 stated that there was no change in diet, 1:1 feeder/supervision or strict aspiration precautions orders for Patient 17. When asked, SLP1 stated that 1:1 feeder/supervision and strict aspiration precautions means that someone needs to be at the bedside while patient is eating to prevent aspiration or choking as sometimes patients in these conditions can be impulsive or take too large sips or bites. SLP1 further stated that she intentionally recommended supervision so staff know they can't leave tray at the bedside and then leave the room. When asked, SLP1 stated that communication hand-off of these recommendations was given to nursing staff via SBAR communications and spoke with charge nurse because nurse assigned was providing cares. SLP1 stated that she was particularly concerned for Patient 17 ' s safety and risk for choking given patient ' s confused state, wrapping cords around neck and isolation given covid diagnosis and need for isolation precautions and putting on personal protective equipment to enter patient ' s rom.

During concurrent interview and record review on 9/23/22 at 8:38 am nursing unit supervisor (NUS)5 stated that 1:1 feeder/supervision with meals and snacks means patient needs to be observed when eating and staff should be in the room or supervise them to make sure patient is not coughing when eating and tolerating diet and can intervene if needed. When informed of observation, NUS5 shook her head and stated that staff should not be leaving tray with Patient 17 given her orders and will remind nurses. When asked, NUS5 stated that nursing care plan for aspiration precautions should have been initiated, but wasn ' t. NUS5 stated that she reviewed records and confirmed aspiration care plan was never initiated and checked to see if perhaps care plan was resolved or discontinued but that was not the case and would remind staff to initiate aspiration precautions care plans when appropriate.

Facility policy Nursing Standards of Clinical Practice, dated 6/11, documented "The registered nurse collects comprehensive data pertinent to the patient ' s health or the situation, then registered analyzes the assessment data to determine the diagnosis or issues ...The registered nurse develops a plan that prescribes strategies and alternatives to attain expected outcomes. Includes strategies within the plan that address each of the identified diagnoses or issues, which may include strategies for promotion and restoration of health and prevention of illness, injury and disease."

Based on observations, interviews, and record review the facility failed to ensure that medical records were stored in a secure manner. Medical records were found in areas where unauthorized personal could easily review the documents.

Finding include

1. An initial tour of the Specialty Care Clinic on the first floor was done on 9/19/22 at approximately 10:17 a.m. with CN1. In the open and unattended patient exam room was observed a 3-drawer cabinet. Upon opening the unlocked storage cabinet, drawers 1,2 and 3 each contained approximately 25 medical records that contained Protected Health Information (PHI) and Personally Identifiable Information (PII). CN1 stated the records were stored in the cabinet for patients to be seen in the clinic. "The top drawer are records of the patients we will be seeing this week". She added that the middle drawer "is for patients we will be seeing next week." Finally, she stated the bottom drawer was for patients to be seen in the clinic "next month." Some of the records in the cabinet were hospital records with the hospital letterhead on the documents, and other records had the letterhead of other physicians from the community that contained PHI and PII.

An interview with CN2 was done on 9/19/22 at approximately 10:41 a.m.. CN2 indicated that he was involved in the scheduling of patients to be seen in the clinic. CN2 added that part of the process is collecting and storing medical records in the unlocked cabinet ahead of the actual appointment dates of the patients. "We will get the records of patients that will be seen in advance." CN1 confirmed that the records in the cabinet containing PHI and PII were for patients to be seen the current and following weeks, and also next month."

An interview with Medical Records Director (MRD) was done on 9/22/22 at approximately 11:13 a.m. The MRD stated they were unaware that medical records containing PHI and PII were being stored in the clinic exam room. The MRD agreed that the records should be stored in a secured manner at al times when not in use to protect patients PHI and PII. "That should not be happening. I was not aware they were storing records in the clinic as I have not been over there yet."

2. On 9/23/22 at approximately 1:43 p.m., there were approximately 300 boxes (each containing 40-50 file jacket/records) that contained radiology images with associated medical records in the respective jacket/records that contained PHI and PII. These boxes were located on the second-floor, at the end of an unattended hallway stairwell, accessible by an unsecured 'push-bar' type door that had a window that made the boxes of records viewable from the common hallway.

During an interview with Radiology Manager (RM) on 9/23/22 at approximately 1:59 p.m., they stated that the boxes of records had been stored there for approximately 2-months. "We stored them there after the annex demolition where they were previously stored." When asked about any concerns related to the current storage location, the RM acknowledged that they did not consider the presence of PHI and PII being accessible and not stored in a secure manner.

An interview with the MRD was done on 9/23/22 at approximately 2:27 p.m.. The MRD stated they were unaware that the boxes of radiology record containing PII and PHI were being stored at the end of the second-floor hallway stairwell. The MRD was not certain if these records were directly or indirectly under the management of the Medical Records Department, but said they were going to follow-up.

Review of the hospital policy titled Health Data Integrity (Policy 6433-85) states "It is the policy of Guam Memorial Hospital to protect the privacy of individual identifiable health information." Further, the Policy states "The Health Information Management Committee is responsible for the development of organizational standards, policies, and procedures concerning timeliness, accuracy, security, privacy and confidentiality, access, integrity, and uniformity of data both of paper and electronic records consistent with law or regulation."

Based on record review and interview, the hospital did not ensure that all physician orders including verbal orders, must be dated, timed, and authenticated promptly by the ordering practitioner. This failure resulted in incomplete documentation of patient care rendered.

Findings include:

1. Patient 40 was admitted to the facility on 3/08/22 with several diagnoses including altered mental status, cerebral infarction due to thrombosis of the left carotid artery, acute respiratory failure with hypoxia, compression of the brain, and kidney failure.

On 3/11/22, a nurse's notes revealed that at 8:56 a.m. during an apnea test, providers MDA and MDB were "called to bedside immediately for initiation of a code" (any patient with an unexpected cardiac or respiratory arrest requiring resuscitation and activation of a hospital wide-alert). According to the nurse's notes, the "patient (was) pulseless" with a heart rate in the "30s." The nurse's notes added that MDA assessed the patient at the beside and confirmed that the patient had no pulse or heart tones. At 8:58 a.m., MDB was noted as saying, "At this time I feel it is appropriate to not move forward with code and to make him (Patient 40) DNR (do not resuscitate)." MDA, accordingly, agreed with MDB and ordered staff not to proceed with the cardiopulmonary resuscitation.

Review of the medical record revealed the lack of evidence that a physician's order was written to discontinue the patient's full code status (implementation of full resuscitative efforts including life sustaining procedures). Review of the hospital's policy on Do Not Resuscitate Orders (A-RI500) revealed that DNR "means there will be no initiation of CPR (cardiopulmonary resuscitation), Defibrillation and/or Mechanical Ventilation." The policy further clarified that DNR "must be documented in the Physician's orders."

2. Further record review revealed that Patient 40 had undergone apnea testing on 3/10/22 and again on 3/11/22. There was no indication that a physician's order was written for the procedures which involved disconnection of mechanical ventilation from the patient to determine brain death.

During an interview at 1:35 p.m. on 9/23/22, a respiratory therapy staff (RT1) explained that apnea testing determines brain death or whether the patient could breathe on his/her own. RT1 added that a physician's order is required to conduct the test.

This was verified by RT2, a supervising respiratory staff during the same interview.

Based on observation, interview and record review the facility failed to ensure pharmacy services was administered in accordance with accepted professional principles and standards when:
1. Two drug containers (inhalers) was not dispensed by the pharmacy;
2. Atrovent inhaler did not match the physician order;
3. Albuterol inhaler order did not include the frequency of administration and therefore, was not a complete order;
4. Both inhalers did not have pharmacy drug labels; drug containers did not specify the patient ' s name (who the medication was prescribed for), information about the drug such as generic/brand name, directions for use (dose, frequency, indications for use such as needed for shortness of breath), expiration date or physician ' s name.

These failures put patients at risk for medication errors.

Findings include:

Concurrent observation and interview on 9/19/22 at about 2:00 PM showed Patient 17 ' s room included an anteroom (small room with outer and inner door separating and leading to patient ' s room). Registered Nurse (RN)5 was in Patient 17 ' s room setting up and assisting patient with meal tray. Patient was confused and coughing; surveyor opened night stand drawer in patient ' s room looking for a tissue. In the drawer, two boxes containing inhalers, Albuterol sulfate 90 mcg with dose indictor and Atrovent HFA17 mcg/actuation with dose indicator (medications for shortness of breath) was observed. RN5 confirmed the inhalers were used for Patient 17 and should not have been left in the patient ' s room. RN5 stated that since patient had covid, they could not keep patient ' s multi-dose medication in the shared medication cart but acknowledged it would have been safer to keep inhalers in the anteroom of patient ' s room.

Record review showed Patient 17 was admitted on 9/11/22 with diagnosis including acute stroke, acute heart attack, and active covid infection. Patient 17 was confused and was not assessed or approved to self-administer medications. Physician order, start date 9/17/22, documented Atrovent 14g 1 puff IH (inhalation) prn (pro re nata, as needed) every six hours for shortness of breath and Albuterol 90 mcg 1 puff IH prn shortness of breath. The order for Albuterol did not include the frequency (how often medication could be given).

During an interview on 9/21/22 at 10:49 am Pharmacy Director (PD) stated that medications should not have been at patient ' s bedside and instead secured at the nurses ' station or medication cart, or in Patient 17 ' s individual case, anteroom would have been a good alternative. PD stated that inhalers are not dispensed from pharmacy but nurses remove directly from the Pyxis system (automated medication dispensing cabinet) and the nurse is supposed to print and affix label onto drug container. PD reviewed Atrovent order which showed 14 grams which was different than 17 mcg shown on the inhaler in the patient ' s room. PD stated the physician order and dispensed medication should match and changed the physician order in the pharmacy system. PD stated that discrepancy was related to formulary change. In addition, PD reviewed the Albuterol order and confirmed the frequency was not defined and therefore, it was not a complete order and should have been clarified before administering medication.

During an interview on 9/23/22 at 8:38 am nursing unit supervisor (NUS)5 stated that medications should not left at patient ' s bedside.

During an interview on 9/23/22 about 9:00 am Pharmacist 5, nursing unit clinical pharmacist for Patient 17, stated that Patient 17 ' s Atrovent and Albuterol was ordered and dispensed from the unit Pyxis and not the emergency department and the unit nurse should have printed and affixed label on drug containers.

During an interview on 9/23/22 at 11:16 am Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed medications should not be left at patient ' s bedside and physician should be contacted with medication orders clarified if they are unclear or different than medication available.

Review of facility policy In-patient Dispensing, dated 3/23/18, documented "All medication for in-patients will be dispensed by a licensed pharmacist from the pharmacy .....in the most ready to administer commercial preparation ....Multiple Usage Preparations: Upon receiving the order for ....MDI (metered dose inhalers) inhalers .....pharmacy will issue to individual patient once and place the order at "on call" status ....."

Review of facility policy Labeling Standard for Medications, dated 3/23/18, documented "All drug containers shall be labeled and drug labels must be clear, consistent, legible and in compliance with state and federal requirements." Medication label shall include at a minimum ...."Generic and brand name; dose form (if other than oral), dose, manufacturer ' s name, drug ' s lot number and expiration; and/or internal-assigned lot number ....appropriate auxiliary labels."

Review of facility policy Medication Orders, dated 3/23/18, documented "Complete medication orders reduce the likelihood of errors ....to be considered complete, all medication orders shall include .....frequency of administration ....Nursing staff shall check the completeness and clarify any ambiguous order before sending the order to the pharmacy. The approving pharmacist may directly contact the prescriber for any clarifications."

Based on observation, interview and record review the facility failed to ensure drugs were kept locked and secured when an unattended and unsecure medication cart was observed on the pediatric unit. In addition, two inhalers were observed in patient ' s room.
This failure increased risk of unmonitored access to drugs by unauthorized individuals.

Findings include:

Observation during initial tour of inpatient pediatric unit on 9/19/22 at 10:38 am showed medication cart located at the nurses ' station unattended and unlocked. All of the drawers of the cart could be opened. One of the drawers showed a bag of several syringes of Heparin 500 units per 5 milliliters. A "high alert medication" sticker was affixed to the bag. Heparin is a blood thinner that can cause severe bleeding. Another drawer contained a tube of Mupirciron (antibiotic) ointment. No staff member was seen at medication cart immediately before observation.

Observation on 9/19/22 at 10:41 am showed same medication cart locked but no staff member was seen at medication cart between 10:38 am and 10:41 am. A teenage male patient dressed in a hospital gown was observed walking pass the nursing station.

Review of facility provided census list, dated 9/19/22, showed ten patients on the pediatric/pediatric intensive care unit with six patients between the ages of 1 year to 3 years old. The facility was open to visitors.

During an interview on 9/19/22 about 11:15 am Registered nurse staff 58 stated that Pyxis (automated medication dispensing cabinet) was down so medication cart is in use. Staff 58 stated that medication cart automatically locks after awhile but wasn ' t sure on the time interval. Staff 58 stated that if she ' s passing medications and standing in front of the medication cart for a while, she hears the locks engage automatically, but she pushes the locking mechanism on the side of the cart to manually lock the cart before she walks away since the cart should not be unlocked when it is unattended. Curious children act fast so medications should not be left unattended.

During an interview on 9/21/22 at 9:54 am on pediatric unit in front of medication cart with Pharmacy Director (PD) and another surveyor, surveyor stated medication cart was timed and it locks automatically after 1 minute and 6 seconds after opening. PD confirmed medication cart should not be left unlocked and unattended.

During an interview on 9/21/22 at 9:56 am Pediatric charge nurse, Staff 59, stated that medication should not be left unlocked and unattended, especially on Pediatric unit.

Concurrent observation and interview on 9/19/22 at about 2:00 pm showed Patient 17 ' s room included an anteroom (small room with outer and inner door separating and leading to patient ' s room). Registered Nurse (RN)5 was in Patient 17 ' s room setting up and assisting patient with meal tray. Patient was confused and coughing; surveyor opened night stand drawer looking for a tissue. In the drawer, two boxes containing inhalers, Albuterol sulfate 90 mcg with dose indictor and Atrovent HFA17 mcg/actuation with dose indicator (medications for shortness of breath) were observed. RN5 confirmed the inhalers were used for Patient 17 and should not have been left in the patient ' s room. RN5 stated that since patient had covid, they could not keep patient ' s multi-dose medication in the shared medication cart but acknowledged it would have been safer to keep inhalers in the anteroom of patient ' s room.

Record review showed Patient 17 was admitted on 9/11/22 with diagnosis including acute stroke, acute heart attack, and active covid infection. Patient 17 was confused.

During an interview on 9/21/22 at 10:49 am PD stated that medications should not have been at patient ' s bedside and instead secured at the nurses ' station or medication cart.

During an interview on 9/23/22 at 8:38 am nursing unit supervisor (NUS)5 stated that medications should not left at patient ' s bedside.

During an interview on 9/23/22 at 11:16 am Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed medications should not be left at patient ' s bedside.

Review of facility policy Storage and Security of Drugs, dated 3/23/18, documented "All medications at nursing stations shall be in lockable storage at all times. Medications are stored either in lockable medication carts or the medication room. When unattended the medication carts and medication room are to be locked."

Based on observation, interview and record review, the hospital failed to ensure only qualified staff used the radiologic equipment and performed radiological exams when there was no documented evidence demonstrating competency assessment and verifying qualifications for 1 of 2 staff (Staff 56) personnel files reviewed.

This failure to ensure that competency assessments/performance evaluations were completed increased risk that staff did not meet the qualifications to perform their role and specific job duties in accordance with the facility ' s policy with the potential to adversely affect the safety and quality of care of radiological services.

Findings include:

Observation on 9/19/22 at 3:09 pm showed two staff members, including Staff 56, performing portable chest x-rays on two patients on the telemetry unit.

Concurrent interview and record review on 9/20/22 at 8:47 am with Assistant Chief of Radiology (RM1) of Staff 56 ' s personnel file showed as of 11/18/20, Staff 56 position changed from Patient Courier to X-ray Technician I. Previously, to being a Patient Courier, Staff 56 was a cook at the facility. Staff 56 ' s file did not have any documented evidence that competency or performance evaluation as an X-ray Technician was assessed or demonstrated. RM1 stated that there had been several office moves and staff departures recently.

During an interview on 9/21/22 at 9:17 am Assistant Administrator Professional Support (AAPS) stated that Staff 56 ' s competency assessment was completed but it was misplaced.

During an interview on 9/23/22 at 8:31 am with RM1 and Radiology manager in charge of nurses (RM2) stated that documentation of Staff 56 ' s competency could not be located. Previous employed staff who managed competency was contacted but documented evidence of competency assessment for Staff 56 could not be located. The competency assessment that should have been performed and documented during the past 20 months that Staff 56 worked in Radiology included review of portable chest x-rays and other radiographic imaging procedures (such as ensuring written physician ' s orders before exam, appropriate parameters are selected, appropriate positioning, use of beam collimation, use of tube and tube column locks, as low as reasonably achievable radiation exposure demonstrated, as well as other radiation safety procedures such as shielding and holding and minimizing number of people in the room.

Review of facility policy Use of Imaging Equipment by Technologist/Technician, dated 10/19, documented "Presently, the US Territory of Guam does not require a license to operate imaging equipment. Until such time a license law is passed, the following are some of the provisions governing the use of x-rays on patients ....Radiology Technologists/Technicians must have annual competency certification in order to perform the duties of a diagnostic radiologic technologist/technician within their respective modalities."

3). Record review showed Patient 17 was admitted on 9/11/22 with diagnosis including acute stroke, acute heart attack, and active covid infection. Patient 17 was over 75 years old and was confused.

Observation on 9/19/22 about 1:30 pm showed Certified Nursing Assistant (CNA)10 providing bed bath to Patient 17. Patient was confused and at times agitated. Both side rails on hospital bed had about six-inch cracks in the center of the rail where patient would place her hands when turning on her side.

During an interview on 9/19/22 at about 2:00 pm Registered Nurse (RN)5 confirmed the rails on both sides of the bed were cracked.

Facility policy Electrical Patient Bed, dated 12/2017, documented "Preventive Maintenance Procedures ....inspect ...cleanliness of unit ....Inspect side rails for proper operation and strength.


13533

Based on observation, interview and record review the facility failed to ensure equipment were maintained at an acceptable level of safety and quality. This failure was evident when:
1). Serum Guardian Hisense test strip [Used to test chlorine in treated water used to prepare dialysate] were expired which can provide inaccurate test results.
2). The periodic maintenance of electrical equipment for patients were not maintained.
3). Patient 17 hospital bed rails had a six-inch crack on the right and left side.

Finding includes:

1). During the initial tour of the hemodialysis unit at 8:30 a.m. on 9/21/22, two opened vials of Serim Guardian Hisense test strips were observed in a tray with other unopened vials inside the supply room. The strips were used to test for low levels of total chlorine in treated water used to prepare dialysate. One opened vial was noted as having a first-opened date of 9/09/22 on the outside label. The other vial however, which contained 14 remaining strips (out of 20) did not have a first-opened date. While this vial had an expiration date of 9/30/23, the manufacturer's instruction on the label noted that the strips were to be used "within 3 months of opening."

When the observation was brought to the attention of RN7, the nurse manager stated that the vials containing the test strips should always be dated when they are first opened. When informed about the additional manufacturer's instruction, RN7 had no comment but added that the vial was to be discarded.



18960

2). An initial tour of the Specialty Care Clinic on the first floor was done on 9/19/22 at approximately 10:17 a.m. with CN1. In the exam room was observed a blue medical device with a label reading 'Medtronic.' CN1 sated the device was currently being used by cardiologists seeing patients in the clinic that had 'pacemakers.' The medical device also had an orange sticker that was labeled from the "Biomedical Engineering Department - Electrical Safety Test. Inspection Due AUG 31, 2022."

Review of the hospital policy titled "Equipment Management Program" (Policy AM6480-202) states that "all equipment will be tested initially and then periodically thereafter" under testing intervals.

During an interview on 9/22/22 at approximately 11:33 a.m. with Bio-Med Staff (BMS) 1, they stated that the Bio-Med Department was responsible for ensuring that all medical equipment used on patients of the hospital had to have routine maintenance and testing as evidenced by the stickers on the medical devices. "We have to conduct regular checks on all the (medical) equipment, and we keep track of that in our department." When asked about the blue Medtronic device located in the Specialty Clinic, BMS 1 stated they were unaware that the Electrical Safety Test was overdue. "We will be transitioning to a newer system that will help us to better keep track of that kind of stuff."

Based on observation, interview, and record review, the facility failed to ensure its infection prevention and control program included maintaining a clean and sanitary environment to avoid sources and transmission of infections, including food borne illness/infections. Specifically,
1.Registered nurse did not remove isolation gown upon exiting room with ante-room of patient with known COVID-19 infection on transmission-based precautions (TBP).
2.Housekeeping staff did not remove isolation gown upon exiting room of patient on droplet and contact transmission-based precautions.
3. Two registered nurses and radiology technician did not follow manufacturer ' s instructions for use when cleaning and disinfecting personal protective equipment face shields and reusable medical equipment.
4. Foam head holder used in Radiology for Computed Tomography (CT) Scan had a large tear exposing the foam, which was not a cleanable surface.
5. Raw chicken in refrigerator was uncovered and open to air.
6. Pots, pans and other food containers were stacked wet.
7. Scooper handle was stored in food storage bin touching food.
These failures had the potential to spread infection.

Findings include:

Observation on 9/19/22 about 2:00 pm showed Registered Nurse (RN)5 wearing N95 mask donning (putting on) gown and face shield and entering Patient 17 ' s room. Patient 17 ' s room included an anteroom (small room with outer and inner door separating and leading to patient ' s room). and sign on patient ' s door showed N95 mask, gown, gloves and face shield was needed. RN5 brought lunch meal tray into room, placed on overbed table, repositioned overbed table in front of patient in bed, opened Styrofoam container which showed ground meat, removed lids on beverage cups, and placed utensils in front of patient. RN5 then exited room with water pitcher wearing isolation gown and gloves and walked about 30 feet down hallway where another staff poured two cups of water into pitcher. Staff walked back to Patient ' s 17 ' s room walking past open patient room doors and equipment in hallway and entered Patient 17 ' s room wearing same isolation gown. After providing cares to patient, RN5 exited room and then doffed (removed) her isolation gown in the hallway. RN5 did not remove gown before exiting the patient ' s room or anteroom.

Record review showed Patient 17 was admitted on 9/11/22 with diagnosis including acute stroke, acute heart attack, and active covid infection.

During an interview on 9/19/22 at 3:04 pm RN5 acknowledged that she did not removed isolation gown upon exiting patient ' s room or anteroom and walked in the hallway to refill water pitcher. RN5 stated that this was allowed because she stayed within the yellow taped lines on the hallway floor that was closest to the patient rooms. When asked about doffing gown in the hallway and not in the anteroom, RN5 stated that was a good idea to doff in anteroom but she usually doffs in the hallway.

During interview on 9/22/22 at 2:03 pm with Infection Preventionist (IP), Employee Health Nurse (EHN)1, Clinical Pharmacist (CP2), and Infection Prevention nurse, IP stated that staff should be doffing gowns inside transmission-based isolation rooms and not in the hallways.

During an interview on 9/23/22 at 8:38 am nursing unit supervisor (NUS)5 stated that the unit used to be a covid unit (all patients on the unit had covid infection) and zones using different colored tapes on the floor were marked so staff could move within the zones as long as their hands were not visibly soiled. However, the unit was no longer a covid unit and instead had a few patients with covid infections isolated in their rooms and the unit had mostly non-covid patients. NUS5 stated that we need to change what we do now and staff should be doffing their gowns inside the patient ' s rooms before exiting the room.

During an interview on 9/23/22 at 11:16 am Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed there were no covid units in the facility and staff should be doffing gowns inside the patient ' s rooms and not in the hallways.

During Exit Conference on 9/23/22 about 4:15 pm Associate Administrator for Medical and Clinical Services stated that staff should be doffing gowns in anterooms for patients on transmission-based precautions for covid infections.

Review of Center for Disease Control and Prevention Transmission-Based Precautions, Contact Precautions, last review date 1/7/16, https://www.cdc.gov/infectioncontrol/basics/transmission-based-precautions.html, showed "Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient ' s environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens."

Review of facility policy Transmission Based Precautions (Contact Precautions, Droplet Precautions, Airborne Infection Isolation), dated 11/22/21, documented "Contact Precautions: These precautions are to be used to reduce the risk of transmission of resistant microorganisms by direct or indirect contact with a patient and/or patient's environment ... ... All Personal Protective Equipment (PPE) should be removed and discarded appropriately in the patient's room before exiting. Gloves, mask and gowns should not be worn outside the patient's room once care of the patient has been initiated ....Use Contact Precautions for diapered or incontinent children for duration of illness and to control institutional outbreaks for enteroviral infections .....Contact and Standard precautions indicted for Human metapneumovirus."

Observation on 9/19/22 at 10:26 am showed housekeeping staff (HK)1 enter Patient 18 ' s room wearing isolation gown, gloves, and mask. Signage on door instructed use of gown, gloves, and mask. After a few minutes, HK1 opened room door and exited room holding two red biohazard bags and wearing same isolation gown. HK1 walked a few feet down the hall and disposed bags, doffed (removed) gown in the hallway and applied alcohol-based hand rub on hands.

Record review showed Patient 18 was about a year old, admitted on 7/29/22 with diagnosis including cardiac arrest, hypoxic brain injury and positive rhinovirus-enterovirus (respiratory virus spread by droplet and contact especially for infants where close contact is likely) on 9/5/22. Covid test results on admission was negative.

During an interview on 9/19/22 about 10:30 am HK1 acknowledged she exited Patient 18 ' s room wearing isolation gown and doffed in the hallway. When asked, HK1 stated that she was told to take off gown and gloves outside the room and not inside the patient ' s room. HK1 also stated that she has to hold the trash bags, so is not able to remove the gown in the room.

Observation on 9/19/22 at 11:00 am showed housekeeping staff (HK)1 exiting from Patient 19 ' s room wearing isolation gown and gloves. Signage on Patient 19 ' s door instructed use of gown, gloves, and mask. HK1 placed broom and dustpan on cart and then doffed gown in hallway outside patient ' s room.

Record review showed Patient 19 was a month old, admitted on 9/15/22 with diagnosis including severe bronchiolitis and positive human metapneumovirus (respiratory virus spread by secretions from coughing, sneezing, or touching objects such as toys or doorknobs that have virus on them).

During an interview on 9/23/22 at 10:20 am with Environmental Services (EVS) Director (EVSD) and EVS Manager (EVSM), EVSD stated that HK staff attend yearly infection control trainings and were instructed to doff gown inside covid rooms before going into another covid room but for noncovid contact precautions, staff were instructed to doff outside the room. When asked about differences for gowns use related to contact precautions for covid different compared non-covid, EVSD stated that HK don ' t go inside covid rooms daily as nurses do some of the HK functions. EVSD further stated that you have to be really careful with covid because covid is contagious and you doff gowns inside the room to avoid aerosolization inside the room. "It is very tricky." When asked how HK staff adhered to contact transmission-based precautions, EVSD stated that HK don ' t touch the patient and don ' t touch the patient ' s belongings such as cell phones, wallets and purses but they do daily cleaning of bed controls built into bed rails, bed rails/cribs, light switches, hand rails, light fixtures in the room. When informed that HK ' s uniform could have been in contact with patient ' s room environment that patients, especially infants, could have touched or contaminated and the isolation gown is intended to protect HK ' s uniform and doffing inside room prevents spread in case something is on gown, EVSD nodded head and stated that she thought HK could doff outside room since HK didn ' t touch patient but did not consider that gown could have touched the patient ' s room environment.

Review of Center for Disease Control and Prevention Transmission-Based Precautions, Contact Precautions, last review date 1/7/16, https://www.cdc.gov/infectioncontrol/basics/transmission-based-precautions.html, with EVSD and EVSM showed "Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient ' s environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens."

Review of facility policy Transmission Based Precautions (Contact Precautions, Droplet Precautions, Airborne Infection Isolation), dated 11/22/21, documented "Contact Precautions: These precautions are to be used to reduce the risk of transmission of resistant microorganisms by direct or indirect contact with a patient and/or patient's environment ... ... All Personal Protective Equipment (PPE) should be removed and discarded appropriately in the patient's room before exiting. Gloves, mask and gowns should not be worn outside the patient's room once care of the patient has been initiated ....Use Contact Precautions for diapered or incontinent children for duration of illness and to control institutional outbreaks for enteroviral infections .....Contact and Standard precautions indicted for Human metapneumovirus."

During interview on 9/22/22 at 2:03 pm with Infection Preventionist (IP), Employee Health Nurse (EHN)1, Clinical Pharmacist (CP2), and Infection Prevention nurse, IP stated that staff, including HK staff, should be doffing gowns inside transmission-based isolation rooms and not in the hallways.

Not following manufacturer ' s instructions for disinfecting PPE (personal protective equipment) face shields and reusable medical equipment

Concurrent observation and interview on 9/19/22 about 2:00 pm showed Registered Nurse (RN)6 removing face shield and spraying TB quat disinfectant on shield and then hanging on wall hooks in hallway. When touched after 3 minutes and 4 seconds, face shield was dry to touch. When asked, RN6 confirmed face shield was dry to touch and stated it should remain wet for 5 minutes and should probably wipe it again. RN6 was not observed to wipe face shield again.

Observation on 9/19/22 at 3:04 pm showed after Registered Nurse (RN)5 exited Patient 17 ' s room, remove face shield and sprayed TB quat disinfectant on shield and then hung shield on wall hooks in hallway. When touched after 3 minutes, face shield was dry to touch.

Record review showed Patient 17 was admitted on 9/11/22 with diagnosis including acute stroke, acute heart attack, and active covid infection. Patient 17 ' s room included an anteroom (small room with outer and inner door separating and leading to patient ' s room).

Review of TB Quat disinfectant spray bottle showed to disinfect, treated surface must remain visibly wet for ten minutes.

Observation on 9/20/22 at 8:47 am showed patient from ICU (intensive care unit) being transferred using transfer slide board from hospital bed to Computed Tomography (CT) scan table, CT technician placed two foam wedges under patient ' s arms. After CT scan was completed, CT technician got a couple of wipes from red top Super Sani Cloth plus container and wiped all surfaces of three foam wedges (each about 8 inches x 8 inches x 18 inches), foam head holder and slide board (about 18 inches x 72 inches). When touched after 2 minutes 6 seconds, the slide board was dry to touch.

During interview on 9/20/22 about 8:55 am CT technician was asked about cleaning and disinfecting foam wedges, head holder and slide board. CT technician stated that there was a three-minute waiting time between when you wiped the equipment and when you could use the equipment again. CT technician acknowledged the sliding board was dry to touch within three minutes and said "it's fast this one. It ' s not even 3 minutes and its dry, its humid here."

Review of PDI red top Super Sani Cloth plus wipe container showed "To disinfect nonfood contact surfaces only, use a wipe to remove heavy soil. Unfold a clean wipe and thoroughly wet surface. Treated surface must remain visibly wet for a full three (3) minutes. Use additional wipe(s) if needed to assure continuous three (3) minute wet contact time. Let air dry."

Review of facility policy Guidelines for Cleaning, Disinfecting and Sterilization, dated 3/8/22, documented, "Manufacturer's instructions for recommended disinfection guidelines must be referenced and followed. Apply appropriate concentrations of disinfectant with the appropriate time frames based on manufacturer's recommendations."

During interview on 9/22/22 at 2:03 pm with Infection Preventionist (IP), Employee Health Nurse (EHN)1, Clinical Pharmacist (CP2), and Infection Prevention nurse, IP stated that staff should be following disinfecting manufacturer instructions to ensure surfaces are properly cleaned and disinfected.

Foam head holder used in Radiology for Computed Tomography (CT) Scan had a large tear in the corner exposing the foam, which was not a cleanable surface.

Observation on 9/20/22 at 8:47 am showed CT room with head holder with about 2 cm tear in upper right corner exposing the foam, which is not a cleanable surface.

During interview on 9/22/22 at 2:03 pm with Infection Preventionist (IP), Employee Health Nurse (EHN)1, Clinical Pharmacist (CP2), and Infection Prevention nurse, IP confirmed exposed foam was not a cleanable surface.

Concurrent observation and interview on 9/19/22 at 11:53 am with Food Service Production manager (FSPM) showed a package of raw chicken in the reach-in refrigerator was uncovered and open to air, blood was observed pooled under the package and was dated 9/16/22 with use by date 9/21/22. FSPM stated that the chicken should be covered and not open to air.

During an interview on 9/21/22 at 12:39 pm Food Service Production supervisor (FSPS) stated that packages should be covered in the chiller (refrigerator).

Review of Guam Food Code: Regulations Governing Safe Food Handling and the Sanitary Operation of Food Establishments to Prevent Foodborne Illness, dated 2011, documented "Preventing food and ingredient contamination: Food shall be protected from cross contamination by: Storing the food in packages, covered containers or wrappings."

Review of facility provided ServSafe, Week 4: Preventing Cross-Contamination during storage, preparation, and cooking, dated 2012, documented "Wrap or cover food. Store raw meat, poultry, and seafood separately from ready-to-eat food."

Concurrent observation and interview on 9/19/22 at 9:52 am with Food Service Production manager (FSPM) showed pots, pans and dishware ready for use stacked wet; specifically, a stack of thirteen 2-inch half pans was inverted on a shelf with the first eight pans, three 2 inch 1/5 pans, eight 1/9 four inch, seven 4 inch full pans were stacked upside down on the shelves across the three sink washing area with large beads and droplets of water observed on the outside and inside surfaces of the pans. One stack of about four 6 inch 1/3 pans had a brownish yellow liquid in the channel of the inverted pan which was slimy to touch. Cook1 took one of the 6 inch 1/3 pans that was stacked wet and placed spaghetti noodles in it for the lunch meal. Observed multiple scoopers and serving utensils with pools of water on the utensils on the shelf below the pans; specifically, a scooper with blue handle was observed with about 2 teaspoon (tsp) of water pooled in the scooper, a scooper with a yellow handle was observed with about 1 tsp of water pooled in the scooper, a scooper with a grey handle had about 1 tsp water of water pooled in the scooper, and there was about 1 tsp of water pooled in the measuring cup. FSPM stated that the pans and dishes on the shelf should be dry, and not stacked wet, as the items on the shelves were ready for use.

During an interview on 9/21/22 at 12:39 pm Food Service Production supervisor (FSPS) stated that pans and other dishes should be dried and not stacked wet.

Review of United States Public Health Service Food Code, dated 2017, documented "Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow."

Review of facility policy Chipped or Cracked Items, dated 12/2020, documented "Chipped or damaged, china, glassware, trays, and other service ware can be both a sanitation and safety hazard, and must be removed from use."

Review of facility provided ServSafe NFSM (National Food Safety Month) 2021 Week 3-Cleaning and Sanitizing Dishes, dated 2021, documented "Make sure they are completely dry before stacking or storing them."

Observation during initial kitchen on 9/19/22 at 9:25 am showed bin filled with white rice contained a scooper with the scooper handle touching the rice.

During an interview on 9/19/22 at 9:52 am in front of rice bin Food Service Production manager (FSPM) confirmed scooper should not be in rice bin and removed it. FSPM stated that scoopers should be placed in dishwasher after use and not stored in bin.

During an interview on 9/21/22 at 12:39 pm Food Service Production supervisor (FSPS) stated that scoopers should not be let in food containers.

Review of United States Public Health Service Food Code, dated 2017, documented "In-Use Utensils, Between-Use Storage: Food preparation and dispensing utensils shall be stored ....in food ....with their handles above the top of the food within containers ....such as bins of sugar, flour, or cinnamon ...."

Review of facility provided ServSafe, chapter 4, Preventing Cross-Contamination, undated, documented "Store serving utensils in food with the handles extended above the rims of the containers."

Based on observation, interview and record review the facility failed to implement healthcare staff vaccination policy when additional precautions were not followed for 1 of 2 sampled unvaccinated staff (Staff 55) with non-medical exemptions. The additional precautions were intended to mitigate the transmission and spread of COVID-19 (an infectious disease capable of producing severe symptoms, and sometimes death). This failure increased the risk for COVID-19 infection for staff and patients.

Findings include:

During entrance interview on 9/19/22 at 8:48 am, Director of Nursing stated that the facility census was 143 including nine patients with covid infections.

Review of facility staff covid vaccination lists, dated 9/19/22, documented 100% of staff were either vaccinated (98%) or were granted an exemption (2%).

Review of facility's Mandatory COVID-19 Vaccination Protocol, dated 5/13/22, documented "[Name of facility] shall make a good faith effort to assure that by January 27, 2022 all applicable individuals have received ....COVID-19 vaccine ....Individuals may request an exemption from COVID-19 vaccination requirements ....Individuals who are either exempted or are not fully vaccinate at the time of the implementation shall undertake the measures below that are designed to mitigate the risk of getting/transmitting COVID-19." The mitigating measures included ...."Adhere to universal source control via use of any of the following source-control options upon entry and for the duration of time while physically present within the facility ....(NOTE: During times where it is necessary for the mask to be removed, the unvaccinated individual shall physically separate themselves from others (e.g. meal times)."

Review of Staff 55 ' s COVID-19 Vaccination Exemption-Individual Risk Mitigation Plan, signed and dated by staff, employee health and administrator on 9/7/22, documented "Based on an analysis of this individual ' s job function, the following risk mitigation strategies will be required for the duration that this individual remains unvaccinated .....Adhere to universal source control via use of any of the following source-control options upon entry and for the duration of time while physically present within the facility ....(NOTE: During times where it is necessary for the mask to be removed, the unvaccinated individual shall physically separate themselves from others (e.g. meal times)."

During an interview on 9/20/22 at 10:50 am Staff 55 stated that they worked full time providing radiological services to patients in the hospital and emergency department. Staff 55 stated that they were granted an exemption to covid vaccination, had covid multiple times and wore a surgical face mask while in the facility except when eating lunch in the break room in the department. Staff 55 stated the break room was limited to three persons and sometimes ate lunch with other staff in the break room. When asked, staff stated that they was not told they could not eat lunch with others or should be physically separate from other staff when unmasked, staff 55 frowned and questioned why should they be physically separate from others when unmasked in the hospital when this is done all the time when not in the hospital and out in public.

During an interview on 9/20/22 at 11:30 am Assistant Chief of Radiology (RM1) stated that he supervised Staff 55 and personally had a covid individual risk mitigation plan so was well aware of processes. RM1 stated that there were several mitigating actions including the need to be physically separate from others when eating and therefore he eats lunch in his office by himself. When asked, RM1 stated that he was unaware of any staff in the Radiology department that was unvaccinated that also needed to follow covid individual risk mitigation plan, otherwise he would be monitoring staff to ensure plans were followed.

Concurrent observation and interview with RM1 at radiology department breakroom where Staff 55 ate lunch on 9/21/22 at 8:54 am showed the room was about 12 feet x 7.5 feet. Upon entering the room, a small table with three chairs was observed against the left wall. A counter with sink was on the right wall and lockers were on the wall facing the door. RM1 confirmed the breakroom was small and therefore, limited to three staff at a time.

During an interview on 9/20/22 at 11:40 am Compliance Office (CO) stated that staff granted covid vaccination exemptions should be physically separate from others when unmasked and the staff ' s manager should be aware of their staff ' s covid unvaccinated mitigation risk plan and confirmed RM1 was Staff 55 ' s manager.

During an interview on 9/21/22 at 8:18 am Employee Health Nurse (EHN)1 stated that physically separate themselves from others means unvaccinated staff should be at least six feet away from others when unmasked and should not be eating in lunch unmasked with others especially if six feet distance cannot be maintained. EHN1 stated that Staff 55 signed covid individual risk mitigation plan and she recalled reading it out loud to Staff 55. When asked, EHN1 stated that she informed RM1 of Staff 55 ' s mitigation plan via whatsapp software on 9/7/22 and showed this to RM1 who responded that he forgot.

During an interview on 9/21/22 at 9:17 am Assistant Administrator Professional Support (AAPS) stated that Staff 55 should not be eating lunch with others unmasked and RM1 should have been aware so he could monitor Staff 55.