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Based on review of policy, observation, clinical record review, and interview it was determined the facility failed to protect patient rights by providing personal privacy in 35 of 35 patient bathrooms observed and failed to provide safe and timely care to one #17 of 32 (#1-#32) patients reviewed. Failure to protect the patient's rights did not allow for personal/physical privacy or early detection and recognition of clinical deterioration. Further the facility did provide clinical criteria to guide staff in determining appropriate activation of emergency response systems within the facility or the need for timely transfer to a higher level of care. The failed practice had the likelihood of affecting all in-patients outside of the critical care areas. See A-0143 & A-0144 for details.

Based on review of policy and procedure and interview, it was determined the Governing Body failed to ensure that Medical Staff were informed of the accountability for the quality of care provided to patients by adopting policies and procedures for rapid response, code blue, patient falls, physical assessment and reassessment, high risk patients (e.g. suicidal), and monitoring and/or observation of patients in the psychiatric setting. The failed practice did not give guidance to Medical Staff on the expected policy and procedures to be followed to ensure high quality care. The failed practice had the likelihood of affecting all patients receiving care within the facility. Findings follow:

A. Policies for rapid response, code blue, patient falls, physical assessment and reassessment, high risk patients (e.g. suicidal), and monitoring and/or observation of patients in the psychiatric setting were requested on 02/24/25, 02/25/25, and again on 02/26/25. No policies were provided.
B. During an interview with the Director of Quality and Director of Compliance and Risk they confirmed the facility did not have policies for the topics requested.
C. For each topic requested an online procedure was provided from EBSCO Information Services, an outside vendor, and included a comment titled "A Note From Your Workplace" in which comments were made on what staff may or should do. None of the documents provided showed approval or adoption by any Governing Body within the facility.

Based on review of policy, observation, and interview, it was determined the facility failed to provide doors and/or breakaway door coverings for 35 of 35 patient bathrooms observed on Adult Psychiatric Unit 3 South (3S) and Geriatric Psychiatric Unit 6 South (6S). Failure to provide door coverings did not allow for patient privacy while toileting and/or showering. The failed practice had the likelihood of affecting all patients admitted to Units 3S and 6S. Findings follow:

A. A review of "Behavioral Health Unit: Patient Statement of Rights and Responsibilities", no date, showed "the patient has the right to be treated with respect, dignity, and consideration of personal privacy at all times."
B. During a tour of Psychiatric Units 3S and 6S on 02/24/25 between 9:00 AM and 10:30 AM, 35 patient bathrooms observed did not have doors or breakaway door coverings allowing for physical privacy while toileting or showering.
C. During an interview with the Director of 3S and 6S on 02/24/25 at 10:30 AM, she confirmed there were no door covering for patient bathroom on either unit and confirmed that patients receive a copy of the patient rights during the intake process. She further confirmed that all patients admitted to the psychiatric units were monitored every 15 minutes or more often if ordered to ensure their safety, including when they were in the patient bathroom.

Based on review of policy and procedure, clinical record review, observation, and interview it was determined the facility failed to provide reassessment and timely care to 1 (#17) of 32 (#1-#32) patients reviewed. The failed practice did not allow for recognition and early intervention of live saving measures. The failed practice had the likelihood of affecting all patients admitted to the facility. Findings follow:

A. A policy for rapid response and/or code blue was requested on 02/25/25 and again on 02/26/25. No policy was provided.
B. Review of "Nursing Skill: Recognizing and Responding to Deteriorating Conditions in Adults in Acute Care" dated 05/31/23 and "Nursing Skill: Managing the Emergency Response (Code Blue) Team" dated 02/08/23, showed that Psychiatric Units 3S (Adults) and 6S (Geriatrics) may call the Rapid Response Team (RRT) for a change in patient condition and that the Code Blue Team will respond when activated. A request was made for clinical criteria or any other triggering criteria staff would use to guide and determine when to appropriately activate RRT and/or Code Team, none was provided.
C. A policy for falls was requested on 02/24/25 and again on 02/25/25. No policy was provided.
D. Review of "Nursing Skill: Using a Fall Risk Assessment Tool" dated 04/19/23 showed that post fall assessment should include notification to the primary physician, completion of the "Post Fall Form" was encouraged, and a post fall huddle should be performed and include nursing leadership.
E. A review of "Behavioral Health Unit: Patient Statement of Rights and Responsibilities", no date, showed the patient has the right to expect safe care related to hospital practices and environment.
F. Review of Patient #17's clinical record showed the following:
1) A Nurse progress note dated 03/16/24 at 5:21 PM, showed the patient had fallen to the floor hitting forehead. No evidence was provided which showed the physician was notified, if a post fall physical assessment had been completed, or if a post fall huddle had occurred.
2) Serology results dated 03/19/24 at 12:09 PM showed Patient #17 tested positive for Flu A. A Physician progress note dated 03/21/25 at 5:14 PM, stated the Physician had received a text at 9:00 AM stating that Patient #17 had "deteriorated significantly" and was noted with ashen color, generally not as active or alert, more labored breathing and requiring more assistance. Further noted, Patient #17 had a syncopal episode "shortly after the x-ray while being assisted in the bathroom and became poorly responsive"; Physician then received a phone call at 11:39 AM, that the staff feels the patient should be seen in the Emergency Room (ER) and the Physician agreed.
3) The clinical record showed on 03/21/24 between 9:00 AM and 11:39 AM one set of vital signs was recorded at 9:00 AM, a nebulizer treatment was administered at 9:38 AM and patient was placed on 2 liters of oxygen. A portable chest x-ray obtained at 9:42 AM showed "increased interstitial and parenchymal markings are chronically accentuated by expiratory chest." No evidence was provided which showed Patient #17 received further intervention, laboratory studies, or diagnostic treatment between 9:38 AM and 11:39 AM or that the Rapid Response or Code Blue teams were activated to provide further assessment.
4) A Nurse Triage note dated 03/21/24 at 11:58 AM, showed Patient #17 was triaged in the Emergency Room (ER). Labs were collected at 11:59 AM and an electrocardiogram (EKG) was obtained at 11:55 AM which showed a heart rate of 155 beat per minute (BPM) and Supraventricular Tachycardia rhythm.
5) An ER Physician note dated 03/21/24 at 3:29 PM, states Patient #17 was brought to ER for altered mental status which had been reported to have declined over the last day or so... and shortness of breath. Also it was noted the patient was in "Septic Shock" as "evident by lactic acid 8.0, white blood cell count 1.5, creatinine 2.12, systolic blood pressure 85 at time of visit, HR 140-160s, respiratory rate 22-50. Patient also requiring Bipap (Bilevel Positive Airway Pressure) due to Po2 of 49."
5) A Nurses Note dated 03/21/24 at 3:50 PM showed Patient #17 experienced cardiac arrest and Cardiopulmonary Resuscitation (CPR) was initiated. Patient #17 expired at 4:11 PM.
G. During an interview with the Director of 6S, a Geriatric Psychiatric Unit, she stated that patients who require a higher level of care were discharged from the unit and admitted to the ER. When asked if 6S was able to utilize the Rapid Response and/or Code Blue team, she stated they were able to call if the nurses feel there was a need, however, no clinical criteria had been provided by the hospital to help guide staff on when to activate either team.
H. During an interview with the Director of Intensive Care Unit (ICU), he confirmed he is over the RRT and Code Blue teams and that no clinical criteria or other triggering criteria have been provided to facility staff to help serve as a guide for staff in the activation of RRT or Code Blue Teams.
I. During an interview with Registered Nurses (RN) #1-#4 and the Clinical Nursing Directors of Units 5S and 3W, they all confirmed they had not been provided with clinical criteria or other triggering criteria to help direct when to call the RRT or Code Blue Team, however, each RN expressed confidence in their ability to recognize when to activate either team.


Based on policy and procedure review, observation and interview, it was determined the facility failed to follow the policy titled "Warming Cabinets for Blankets and Fluids" in that two of two (Adult Psychiatric Unit 3S and Emergency Department) blanket warmers observed were outside of the posted temperature and no evidence was provided which showed the warming cabinets were monitored on a daily basis as indicated in the policy to ensure safe use in patient care areas. The failed practice had the likelihood of causing harm to any patients who were provided blankets from the warmers. Findings follow:

A. Review of policy "Warming Cabinets for Blankets and Fluids, last revised 03/2021, showed blanket warming compartments within the warming cabinet will not exceed a temperature of 130 degrees Fahrenheit and that ongoing temperature monitoring of fluid and blanket warmers will be performed by staff working in the vicinity by visual observation of the posted maximum temperature and the temperature gauges on the equipment. Additionally, the policy states "do not place blankets on the bottom self of the blanket warmer."
B. Observation on 02/24/25 at 9:30 AM on Adult Psychiatric Unit 3S showed blanket a warmer with two compartments, both containing blankets, the top cabinet was 132 degrees Fahrenheit, and the bottom cabinet was 133 degrees Fahrenheit, both outside the maximum posted temperature of 130 degrees Fahrenheit. During an interview with the Director of 3S on 02/24/25 at 9:30 AM, she confirmed that the warmer was out of range. She further confirmed that the department does not keep a daily monitoring log of warmer temperatures or action taken when warmer was out of range.
C. Observation on 02/27/25 at 1:40 PM in the Emergency Department, showed the bottom cabinet with blankets on the bottom shelf of the warmer and a temperature of 135 degrees Fahrenheit. The posted maximum temperature was 130 degrees Fahrenheit. During an interview with the Director of the Emergency Department on 02/27/25 at 1:40 PM, she confirmed the warmer was out of range and that the blankets were improperly stored on the bottom shelf. She further confirmed that the department does not keep a daily monitoring log of warmer temperatures or action taken when warmer was out of range.

Based on review of United States Pharmacopeia (USP), observation and interview, it was determined the facility failed to follow accepted standards of practice in two of two (Room #3 and Room #4) Procedure Rooms observed in that they were using longer then accepted Beyond Use Dates (BUDs) when labeling syringes. By not providing correct BUDs on syringes that contained intravenous medication in them, the facility could not assure the product they administered was safe and free from microbial growth. The failed practice had the likelihood to affect all patients that had procedures at the hospital. Findings follow:

A. Record review of key changes to the United States Pharmacopeia (USP) (November 1, 2023) showed administration must be started within 4 hours following the start of preparation (drawing up of syringes).
B. During a tour of the Procedure Rooms on 02/25/25 from 10:10 AM to 11:00 AM, observation showed the following:
1) Procedure Room #3:
a) #2 drawn-up Propofol syringes that were drawn up at 7:07 AM and had a BUD of 6 hours (instead of 4);
b) #1 drawn-up Propofol syringe that was drawn up at 8:55 AM and had a BUD of 6 hours (instead of 4); and
c) #2 drawn-up Lidocaine syringes that were drawn up at 7:09 AM and had a BUD of 12 hours (instead of 4 hours).
2) Procedure Room #4 had #1 drawn-up Lidocaine syringes that was drawn up at 7:02 AM and had a BUD of 12 hours (instead of 4 hours).
C. During an interview on 02/25/25 at 10:29 AM, the Director of Pharmacy verified the BUD for intravenous medications pulled up and stored in the procedure rooms was longer than the accepted Standard of Practice of 4 hours.

Based on observation of the Emergency Department, Cardiac Pulmonary Rehab, Gastroenterology Department, Surgery Department, Post Anesthesia Care Unit, Geriatric Psychiatric unit, and Adult Psychiatric Unit, 5th floor Surgery and Orthopedics, and interview, it was determined the facility failed to maintain the building physical structure, safety, environment, and equipment in a state of good repair. The failed practice promoted the spread of infection and/or placed the patients at risk of fire. The failed practice had the likelihood of affecting all patients, staff and visitors. Findings follow:

A. Observation of the Emergency Department on 02/24/2025 at 11:19 AM showed the following:
1) Multiple wall penetrations throughout the emergency department.
2) Nurses station had damaged Formica.

B. The findings in A were verified by the Director of Maintenance on 02/24/2025 at the time of observation.

C. Observation of the Cardiac Pulmonary Rehab Department at 11:40 AM showed the following:
1) Wall damaged in Magnetic Resonance Imaging (MRI) Zone 3.
2) Items stored under the sink in the pharmacy department.
3) Hydro Room 1 and 2 had items stored under the sinks.
4) There was exposed wood under the sinks in Hydro Rooms 1 and 2 that needed to be repaired or sealed.
5) The treatment room had wall damage.

D. The findings of C were verified by the Director of Maintenance at the time of observations.

E. Observation of the Gastroenterology Department on 02/24/2025 at 10:50 AM showed paint damage throughout the department.

F. The findings in D were verified with the Director of Maintenance on 02/24/2025 at the time of observation.

G. Observation of the Geriatric Psychiatric Unit on 02/25/2025 at 9:45 AM showed the following:
1) Exit signs that were free hanging that posed ligature risks.
2) There were no Ligature Resistant doors on bathrooms to ensure patient privacy.
3) Leaking shower in room 6416.
4) Counter damage in room 6416.
5) Multiple cabinets missing handles throughout the unit.
6) Cabinets missing locks throughout the unit.
7) Ceiling tiles were not clipped in patient areas.

H. The findings in G were verified with the Director of Maintenance on 02/25/2025 at the time of observation

I. Observation of the Post Anesthesia Care Unit on 02/25/2025 at 2:15 PM showed there was a damaged and cracked floor in the PAC-U area that needed to be repaired.

J. The findings of I were verified with the Director of Maintenance on 02/25/2025 at the time of observation.

K. Observation of the Surgery Department on 02/25/2025 at 1:44 PM showed the following:
1) Wall penetrations in Operating Room 1.
2) Paint damaged in Operating Room 1.

L. The findings of K were verified with the Director of Maintenance on 02/25/2025 at the time of observation.

M. Observation of the Adult Psychiatric Unit on 02/25/2025 at 3:00 PM showed the following:
1) There was a used C-PAP machine left on a counter in room 3438.
2) There were wall penetrations in the dining room.
3) There were unlocked drawers/cabinets in the dining room.

N. The findings of M were verified with the Director of Maintenance on 02/25/2025 at the time of observation

O. Observation of the 5th Floor Surgery and Orthopedics Department on 02/25/2025 at 2:40 PM showed the following:
1) Paint damage on the medicine room door.
2) Wall damage beside equipment in the medicine room.

P. The findings of O were verified with the director of Maintenance on 02/25/2025 at the time of observation

Based on observation, review of National Fire Protection Association (NFPA) 101 standards and interview, it was determined the facility failed to ensure that the generator was maintained in that an emergency stop switch was not installed on the generator and there was no battery powered emergency light installed on the generator. The failed practice did not ensure the facility had the means of stopping the generator in the event of an emergency, the generator would be able to run in the event of an emergency and did not ensure the facility staff had the ability to view the generator in the event of an emergency. The failed practice had the likelihood to affect all patients, visitors and staff in the facility. Findings follow:

A. Review of NFPA 101, 2012 edition standards showed the facility was to provide battery-powered emergency lighting and a covered emergency stop switch installed 10 to 15 feet away from the generator for the generator used for the Surgery Department.

B. On 02/25/2025 at 4:15 PM observation of the emergency generator showed there was no covered emergency stop switch installed 10 to 15 feet away from the generator used for the Surgery Department.

C. On 02/25/2025 at 4:15 PM, observation of the emergency generator showed there was no battery powered emergency light installed on the generator used for the Surgery Department.

D. The findings in A through C were verified by the Director of Maintenance on 02/25/2025 at the time of the observations.

Based on observation and interview, the facility failed to have provisions for storing and processing of clean and soiled linen to maintain a clean and sanitary environment to avoid sources and transmission of infection in the clean side of the laundry area and the clean laundry storage area. These failed practices did not ensure that the clean laundry would not be contaminated by insects or vermin potentially transported via the cardboard boxes into the clean area and clean storage area of the laundry from outside of the facility or that staff would not cross contaminate clean and dirty laundry. These failed practices had to likelihood of affecting all areas of the facility that used linen processed in the facility. Findings follow:

A. During a tour of the Laundry Department on 2/27/25 at 9:35 AM, staff were observed going from the clean side of the laundry area over to the sorting/dirty and washing/processing side of the laundry area, retrieving clean laundry and taking it back to the clean side of the laundry area. The staff took empty carts from the clean side of the laundry back into the dirty processing side of the laundry. The carts were not sanitized before or after transportation between the clean and dirty areas.
B. During a tour of the Laundry Department on 2/27/25 at 9:40 AM, there were twenty-one unopened cardboard boxes that contained surgical scrub uniforms, on a concrete ledge above three large rolling canvas bins of clean laundry.
C. During a tour of the Laundry Department on 2/27/25 at 9:50 AM, there were four raw wood pallets of cardboard boxes that contained newly purchased linens and five raw wood pallets that contained mesh burlap bundles covered with plastic, stored in the same room as nine covered rolling carts of clean laundry ready to be transported throughout the facility. There was a 36-inch x 60-inch raw wood storage shelf that contained six cardboard boxes next to a cart of clean linen and one cardboard box on the floor next to the same cart of clean linen.
D. During an interview with the Laundry Coordinator and Director of Environmental Services at the time of the observations the surveyor requested the facility's policy and procedures for the processing and storage of laundry. They stated the facility did not have any laundry policies or procedures and confirmed the findings in A, B, and C.



Based on review of manufacturer's instructions for use, observation and interview, the facility failed to ensure that single use items (Plush Fetal Belts) were not laundered and reused for multiple patients. This failed practice did not assure a clean and sanitary environment to avoid sources and transmission of infection and had the likelihood of affecting all patients in the Labor and Delivery Department who were not issued a new set of Plush Fetal Belts upon admission to Labor and Delivery. Findings follow:

A. Review of Documentation from EME (Electro Medical Equipment Company) dated February 24, 2025 showed, "To Whom it May Concern: Subject: Single Use Only
We would like to inform you that the 140PSB Plush Fetal Belts (EME 1.5' x 41" Plush Belt with Hook and Loop Closure, 2 per pack, 100 per case) manufactured by EME are intended for single use only. It is strongly advised not to wash or reuse these belts, as this is crucial for ensuring safety and maintaining hygiene standards."
B. During a tour of the Labor and Delivery Department Clean Supply Room on 2/24/25 at 12:35 PM, observation showed a navy-blue mesh bag full of approximately 100 sets of Plush Fetal Belts. The belts were not in any type of packaging and appeared to have been used.
C. During an interview with the Director of Endoscopy and Obstetrics Educator, while on the tour of Labor and Delivery, this surveyor asked if the belts were a single use item, and the staff stated they were not sure. They stated and confirmed that the belts were laundered after each use and not used as a single use item.




Based on review of Association of periOperative Registered Nurses (AORN) eGuidelines for Perioperative Practice (2012-2025), observation, and interview the facility failed to remove supplies from external shipping containers and open-edged corrugated cardboard boxes before transfer to the sterile storage area or point of use which did not maintain a clean and sanitary environment to avoid sources and transmission of infection. This failed practice did not ensure the integrity of sterile supplies was maintained in one of one Anesthesia Supply Room and had the likelihood of affecting all patients having endoscopy procedures in the facility. Findings follow:

A. Review of AORN eGuidelines for Perioperative Practice showed, "Remove supplies and equipment from external shipping containers and open-edged corrugated cardboard boxes before transfer to the sterile storage area or point of use." "External shipping containers and open-edged cardboard boxes can collect dust, debris, and insects during shipment and can carry contaminates into the surgical suite."
B. Review of documentation provided by the Infection Prevention Department showed the facility follows the following Nationally Recognized Guidelines: CDC (Centers for Disease Control), AORN, SGNA (Society of Gastroenterology Nurses and Associates), APIC (Association for Professionals in Infection Control and Epidemiology), AAMI (Association for the Advancement of Medical Instrumentation), and ASHE (American Society for Healthcare Engineering).
C. During a tour of the Endoscopy Department Anesthesia Supply Room on 2/27/25 at 3:35 PM, there was one cardboard box of Histoguide Wire Guided Forceps on the floor. There were two cardboard boxes of Ensure Nutrition Drinks, two cardboard boxes of 30 ml (milliliter) syringes, and four cardboard boxes of 20 ml syringes on a wire shelving unit with other sterile supplies.
D. In an interview with the Director of Endoscopy she confirmed the findings in A, B, and C at the time of the observation.


47891

Based on observation, review of manufacturer's instructions for use, and interview it was determined the facility failed to maintain a clean and sanitary environment in the Nuclear Medicine and Endoscopy departments in that the departments were reusing oxygen extension tubing for multiple patients. By not following the manufacturer's instructions for use the facility could not ensure that the patients were not exposed to infectious material. The failed practice had the likelihood to affect all patients cared for in these departments. Findings follow:

A. Review of manufacturer's instructions for use showed that the extension tubing was to be for single patient use only.
B. During a tour of the Radiology Department on 2/24/2025 from 1:00 PM to 1:45 PM showed that in the Nuclear Medicine department there were two oxygen extension tubes connected to the oxygen delivery system.
C. Interview with Radiology Department Manager it was stated that the tubing was reused for patients. There was no indication of how long the tubing had been in place and no one in the department could state when the tubing was first put into use.
D. During an interview with the Radiology Department Manager at the time of the observation, the findings in A were confirmed.
E. During a tour of the Endoscopy Department on 2/25/2025 from 3:00 PM to 3:45 PM it was observed that in Endoscopic Suites #1, #2, #3, and #4 there was oxygen extension tubing in use.
F. Interview with Endoscopy Department Manager at the time of observation, it was stated that the tubing was being used for multiple patients.
G. Review of manufacturer's instructions for use showed that the extension tubing was to be for single patient use only.
H. Interview with Endoscopy Department Manager at the time of observation, the findings in E were confirmed.



50014

Based on policy and procedure review, observation, and interview, it was determined that the facility failed to provide a clean and sanitary environment in the Dietary Department in that there was dust and debris under an antifatigue mat stored under a metal shelf. The failed practice did not assure a clean and sanitary environment to avoid sources and transmission of infection. The failed practice had the likelihood of affecting all patients who received meals in the hospital. Findings follow:

A. On 02/24/25 a policy and procedure for cleaning the floors in the dietary department was requested. No policy was provided.
B. During a tour of the Dietary Department on 2/24/25 at 2:30 PM, the surveyor observed an antifatigue mat stored under a metal shelf with dust and debris under the mat.
C. In an interview with the Director of Dietary on 2/24/25 at 2:55 PM, she stated that "the Environmental Services (EVS) Department is responsible for maintaining the dietary floors."
D. In an interview with the Director of EVS on 2/24/25 at 4:05 PM, she confirmed that "they do not have a policy or a schedule for cleaning the dietary floors."

Based on review of United States Pharmacopeia (USP), observation and interview, it was determined anesthesia staff failed to follow accepted standards of practice in two of two (Room #3 and Room #4) Procedure Rooms observed in that they were using longer then accepted Beyond Use Dates (BUDs) when labeling syringes. By not using correct BUDs on syringes that contained intravenous medication in them, the facility could not assure the product they administered was safe and free from microbial growth. The failed practice had the likelihood to affect all patients that had procedures at the hospital. Findings follow:

A. Record review of key changes to the United States Pharmacopeia (USP) (November 1, 2023) showed administration must be started within 4 hours following the start of preparation (drawing up of syringes).
B. During a tour of the Procedure Rooms on 02/25/25 from 10:10 AM to 11:00 AM, observation showed the following:
1) Procedure Room #3
a) #2 drawn-up Propofol syringes that were drawn up at 7:07 AM and had a BUD of 6 hours (instead of 4);
b) #1 drawn-up Propofol syringe that was drawn up at 8:55 AM and had a BUD of 6 hours (instead of 4); and
c) #2 drawn-up Lidocaine syringes that were drawn up at 7:09 AM and had a BUD of 12 hours (instead of 4 hours).
2) Procedure Room #4 had #1 drawn-up Lidocaine syringes that were drawn up at 7:02 AM and had a BUD of 12 hours (instead of 4 hours).
C. During an interview on 02/25/25 at 10:29 AM the Director of Pharmacy verified the BUD for intravenous medications pulled up and stored in the Procedure Rooms was longer than the accepted Standard of Practice of 4 hours.