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Based on observation, interview, and record review, the governing body failed to make sure staff was completing and maintaining the Daily Blanket Warmer (warm linens, blankets) temperature logs (temperature readings taken at set intervals over a given period of time) on a daily and consistent basis and monitoring if staff is properly trained on how to complete the temperature logs accurately. This failed practice has the potential to increase the risk of injury to all patients and staff by not tracking the temperature of the blanket warmer which can lead to igniting (catch on fire).

The findings are:

A. On 05/24/2021 at 10:40 am during tour of Floor 7B Unit (stroke and progressive care) the following was observed in the Clean Equipment room (name of room, used for storage):

B. The Daily Blanket Warmer (warm linens, blankets) temperature logs (used by staff to monitor if the blanket warmer is within the ranges of 100 to 120F or 38 to 49C), was last completed in March 2021.

C. On 05/24/2021 at 10:45 am during interview, S33 (Assistant Nurse Manager Unit 7B) confirmed the last completed Daily Blanket Warmer temperature log was in March 2021.

D. On 05/24/2021 at 10:50 am during interview, S22 (Chief Operations Officer) confirmed there is no policy on how facility ensures nurses or other staff are documenting temperature checks and keeping those logs up to date, only the written information in the middle of the page on the temperature log for the blanket warming cabinet.

E. On 05/25/2021 at 8:30 am during interview, S6 (Chief Nursing Officer) provided a copy of [Initials of the facility] Temperature Log Blanket Warming Cabinets dated April 2021 and May 2021. S6 confirmed the charge nurse in Unit 7B on the night shift is responsible to make sure the temperature logs are completed daily. S6 confirmed Unit 7B evening staff was instructed and re-trained on 05/24/2021 on how to properly complete the temperature logs each night going forward. S6 confirmed a policy for completing daily blanket warming temperature logs is in draft (process of generating preliminary versions of a written work) and submitted to the facility policy committee.

F. Record review of a blank copy of [Initials of the facility] Temperature Log Blanket Warming Cabinets, undated, in the middle of the page above the daily temperature check section revealed, "if the temperature in the Blanket Warmer Cabinet does not fall within this range, please notify the charge nurse and maintenance (ext.XXXX) and document action taken on the back of this form."

G. Record review of [Initials of the facility] Temperature Log Blanket Warming Cabinets, dated March, Year: 2021, Unit: 7B, Location: Hall revealed, temperature checked on the 14th, 19th, and the 27th.

H. Record review of [Initials of the facility] Temperature Log Blanket Warming Cabinets, dated April, Year: 2021, Unit: 7B, Location: Round revealed, no temperatures checks completed for the month.

I. Record review of [Initials of the facility] Temperature Log Blanket Warming Cabinets, dated May, Year: 2021, Unit: 7B, Location: 7th floor revealed, a temperature check was done on May 24th.

Based on record reviews and interviews, the facility failed to ensure the active participation (Being part of the decision process) of the patients in the care planning for 2 patients (P) (P26 & P34) out of 10 (P26- P36) patients sampled. This failed practice is likely to lead to inaccurate care and misunderstandings regarding goals of treatment.

The findings are:

Findings for P26:
A. Record review of P26's Medical Record from 10/09/2019-10/12/2019 revealed:

1. On 10/09/2019 Internal Medicine Progress Note indicated that P26 was evaluated for a left leg wound with a lot of bleeding. P26 was noted to have a decrease hemoglobin (cells that transport oxygen through the human body) from 11 to 7.6 gm/dL (Grams per deciliter) prompting the administration of blood. Documentation of Orthopedic service plan to do surgical evacuation (removal of fluid in a sterile environment) of a P26's hematoma (an abnormal collection of blood outside of a blood vessel) today.

2. On 10/09/2019 Orthopedic Consult Note indicated that P26 was made aware of plan to have surgical evacuation done today and informed consent obtained. No addendum to documentation indicating delay in the procedure or that P26 was informed of the delay.

3. On 10/10/2019 Internal Medicine Progress Note indicated that surgery was not able to take place on 10/09/19 or that P26 was involved in the planning of the procedure. Documentation that procedure is to take place at 1:00 pm today 10/10/2019.

4. No Surgical Note on 10/10/19 identified in the medical record indicating a delay in procedure or explanation of the delay to P26.

5. On 10/11/2019 Internal Medicine Progress Note indicates that P26 did not have the evacuation procedure on 10/10/19 but was sent to the Operating Room (OR) and had it done this morning 10/11/2019.

6. On 10/11/2019 Orthopedic Surgical Report Note indicates that P26 was upset over the delays for his procedure.

B. Record Review of P34's Medical Record from 11/11/2019-11/13/2019 revealed:

1. Inpatient Code Status History from 11/11/2019-11/19/2019 indicated that P34 was ordered as a Do Not Resuscitate/ Do Not Intubate (DNR/DNI).

2. On 11/11/2019 Admission Internal Medicine Progress Note indicates that P34 was admitted for a wound infection of the toe. Note also documents that P34 wishes to be a DNR/DNI during the course of the hospitalization.

3. On 11/11/2019, Podiatry Consult Note indicates that P34 needed an amputation of the hallux (great toe) due to a significant wound infection. No mention of discussion of advanced directives during the procedure.

4. On 11/13/2019 Podiatry Consult Note indicates that P34 needed a subsequent procedure for their infection. Indicates that P34 consents to the procedure.

C. Record Review of P34's Consent Form from 11/12/2019-11/13/2019 revealed:

1. On 11/12/2019 procedural consent indicates under the "Regarding your resuscitation wishes during this procedure" that P34's advanced directive is to be a Full Code status.

2. On 11/12/2019 Permit for Anesthesia Consent, under "Patients with Do Not Resuscitate Orders" (Portion of the consent form that permits the expression of what is to be done regarding resuscitative measures as a consequence of anesthesia) is not filled out.

3. On 11/13/2019 procedural consent indicates under the "Regarding your resuscitation wishes during this procedure" that P34's advanced directive is to have their DNR/DNI stopped and permit full resuscitative efforts.

4. On 11/13/2019 Permit for Anesthesia Consent under "Patients with Do Not Resuscitate Orders" is not filled out.

D. Record Review of facility's "Do Not Resuscitate" policy, effective since 03/20/2017, revealed:

1. Management of DNR status during a procedure requiring anesthesia indicates: in this situation the patient or their personal representative shall be informed of the patient's options for care during the procedure.

2. The "Special Surgical Procedures Consent, For Patient with DNR Orders" is used for this documentation.

E. On 05/20/2021 at 11:45 am, interview with S6 (Director of Nursing) reported that the expectation for nursing in the event of a delay in a surgical procedure is that a note regarding the reason for the delay is to be inputted.

F. On 05/20/2021 at 1:21 pm, interview with S23 (Vice President of Medical Affairs) confirmed that the expectation for physicians in the event of a delay in a procedure they were going to perform is to explain the circumstance to the patient and document that they have acknowledged the change to the plan of care.


G. On 05/20/2021 at 1:35pm, interview with S28 (Registered Nurse) indicated that during the pre-operative phase, the nurse is expected to have the patient sign their consent for the procedure and the anesthesiologist will come and consent the patient separately for anesthesia. S28 indicates that when taking report from the sending unit, asking a patient's advanced directive is not always done as it can be verified in the electronic medical record. When a patient is identified as having a DNR/DNI, S28 would explain risks of the procedure to the patient and ask if they would either want to rescind their DNR/DNI status or remain a DNR/DNI. For the case of P34, S28 confirmed that there was no indication or charting to support a documentation of a Full Code Status on the procedural consent form from 11/11/19. Regarding delayed procedures, S28 stated that nursing is the primary source that tells patients their procedure is not going to be done at the expected time or date. S28 confirmed that it is frustrating to have to be the primary source of this and is unsure if the surgeon does update the delayed patients on the reasoning.

H. On 05/20/2021 at 1:45 interview with S 29 (Charge Registered Nurse) confirmed that nursing handles the signing of consent forms for a patient's procedure. S29 reinforced that pre-operative nurses do not always ask about a patient's advanced directive as they can verify in the electronic medical record. When a patient is identified as having a DNR/DNI, the nurse is expected to confirm their advanced directive and determine if they wish to rescind it for the duration of the procedure S29 reported that the Charge Registered Nurse does not engage in any chart audits regarding verifying of advanced directives. Regarding delays in procedures, S29 stated that nursing primarily relays that there will be a delay in the procedure and is unaware if the surgical service provider discusses with the patient about the delay and any updates to the plan of care.



I. On 05/20/2021 at 2:00pm, interview with S 30 (Registered Nurse Manager) confirmed the practice that nursing does not verify consent with the sending unit nurse during report as there is an internal "Pre-Op In-Patient Report Form" that should serve as a guide for important information needed. S 30 also reinforced the utilization of verifying in the medical record for a DNR/DNI advanced directive. If a patient has a DNR/DNI status, the expectation is to have the nurse verify their advance directives and document accordingly in the medical record and appropriate consent form. Regarding delays in procedures, S30 stated that the expectation for nursing is to document a delay in the treatment and the reasoning prior to sending them back to the inpatient unit. S30 was unsure if the surgical providers do update the patients on the reasoning for the delay.

J. Record Review of facility's "Pre-Op In-Patient Report Form", utilized since 06/24/2019, revealed:

1. No prompting on form of the patient's advance directive or code status.

Based on record review and interview the facility failed to communicate with the patient's representative the patients' status so the patient representative be able to make an informed decision on 1 patient (P51) out of 10 (P51-P60) patients sampled. This failed practice is likely to not provide information to the patient representative to make an informed decision for the patient.

Findings are:

A. Record review of P51's medical chart revealed, no documentation that the patient's POA (Power of Attorney- legal document giving another person the authority to make decision for another person) was contacted to inform them that P51 was being transferred to another facility due to the need for a surgical procedure (leg amputation).

B. On 05/25/2021 at 8:30 am during interview with S4 (Compliance Manager) confirmed, P51's medical chart did not have any documentation that the patient's representative was contacted to inform them that the patient was being transferred to another facility for a surgical procedure.

Based on observation, interviews, and record reviews, the facility failed to ensure safety by failing to ensure the oversight of assuring food placed in refrigerated designated for patients within the unit is removed after the expired date which affects all patients and by failing to ensure safety by not attempting to locate or follow-up for 3 (P6, P16, & P24) out of 25 (P1-P25) vulnerable (newborn and pediatric) patients selected that were designated as Left Without Being Seen (Left the facility without being seen by a provider or given any treatment). This failed practice is likely to cause harm from food borne illness (disease caused by consuming contaminated food or drink) and to lead to worsening condition of the patients reliant on the decision-making of a parent or guardian.


The findings are:

A. On 05/24/2021 at 11:00 am during tour of Floor 7B Unit (stroke and progressive care) the following was observed:

1. In the Nourishment room (name of room, food storage for patients) the refrigerator designated for patient snacks contained two red jello (gelatin desserts (fruit-flavored gels) cups with a sticker dated 05/22/2021 (labeled by dietary staff.)

B. On 05/24/2021 at 11:05 am during interview, S33 (Assistant Nurse Manager Unit 7B) and S22 (Chief Operations Officer) could not confirm if the date is when the jello cups are available in the refrigerator or the use by date. S33 confirmed dietary staff should check the refrigerator daily to remove expired items.

C. Record review of [name of facility] Title: Stock Distribution, Current Effective Date: 11/19/19, page 1 of 2, under Procedure section, revealed, "The Food and Nutrition Services Department staff stock pantries: d. Label and date all perishable items for appropriate disposal. And e. Discard expired products from assigned unit refrigerators."



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D. Record review of the facility's policy for Patients Leaving Against Medical Advice, dated 01/10/21 revealed that the process for documenting a patient who has left against medical advice must include documenting a 'Risk Event' in their internal web-based tracking system. The policy further states the following:

1. "When a staff member discovers that a patient cannot be located on the unit or in the department, the patient will be paged overhead and asked to return the unit or department.
2. "If the patient does not respond to the overhead page, notify Security if available, and the Supervisor/Administrator on Call will be notified, and they will initiate a search of the facility."
3. "The patient's physician/provider and nursing supervisor will be notified that the patient is missing."
4. "The patient's next of kin or legally authorized representative will be notified in accordance with the facility's HIPAA policy."
5. "Document as follows":
a. Time patient's absence was discovered
b. Time patient was last seen
c. Time of physician notification
d. Time of other notifications (security, Administrator on Call, Department Director, Supervisor/Charge Nurse, patient's family, etc.)
e. Document as a "Risk Event" using the link on the facility's intranet homepage

E. On 05/17/2021 at 9:45am, interview with S6, (Chief Nursing Officer) confirmed that the procedure for patients who leave without being seen is to notify the charge nurse and provider, attempt to locate the patient, document the attempts, and discharge the patient from the system as Left Without Being Seen.

F. Record Review of P6's Emergency Department Narrator from 07/21/20 revealed:
1. P6 is a 9-year-old who presented to the emergency department at 1:24 pm with the complaint of a seizure.
2. At 4:34 pm P6 was discharged from the ED after treatment for a potential seizure.
3. At 4:56 pm P6 represented to the Emergency Department with the chief complaint of seizure-like activity.
4. At 5:10 pm documentation of P6 being dismissed from the Emergency Department.
5. No documentation of attempts to triage P6 or documentation of discovery.

G. Record Review of P16's Emergency Department Narrator from 01/09/21 revealed:
1. P16 is a 8 year old who presented to the emergency department at 9:51pm with the complaint of vomiting
2. At 10:44pm documentation of P16 being dismissed from the Emergency Department. No documentation of triage or assessment.

H. Record Review of P24's Emergency Department Narrator from 02/27/21 revealed:
1. P24 is a 2-year-old who presented to the emergency department at 9:30 pm 02/27/21, the date listed above, with the complaint of leg pain.
2. At 10:05 pm documentation of P24 being dismissed from the Emergency Department as Left without being seen. Pt was initially triaged and documentation stops there. There is no additional documentation until it is charted that the patient left without being seen.

I. On 05/18/21 at 1:30pm during an interview with S47 (Emergency Room Registered Nurse - ER RN) revealed that this nurse is not fully aware of the process for Left Without Being Seen patients and protocols. Nurse admitted that when faced with this issue, they did not know the exact steps to follow.

J. At 05/18/21 at 1:45pm, interview with S48 (ER Charge Nurse) revealed that the process for patients w wanting to leave without being seen are to explain any potential risks to leaving abruptly with no instructions, or if patient has already left then attempt to locate the patient and notify security. Call the numbers on file for the patient and check on their well-being, especially pediatric patients.

Based on record review and interviews, the facility failed to ensure that nursing care plans meet the needs of the patients based on changes in care and conducting re-assessments for 4 patients (P33, P37, P39, & P40) out of 20 (P26-P46) patients reviewed. This failed practice is likely to lead to inconsistent care for the patient and disconnection between the transfering facility.

The findings are:

A. Record Review of facility's "Hand-off and Patient Transfer Communication" policy, effective since 01/17/2020, revealed:

1. Hand-off communication will occur whenever transferring a patient to another clinician or setting, including from one care facility to another.

2. The use of the Situation, Background, Assessment, Recommendation (SBAR) Communication Model will be used whenever care is transferred.

B. Record Review of the facility's "Interprofessional Care Plan" policy, effective since 08/24/2020, revealed:

1. All direct caregivers evaluate the patient's progress at the following intervals: changes in patient condition and upon patient discharge.

2. Documentation of assessments, interventions, and the patient's response to treatment are completed in discipline-specific policies, guidelines, rules, and regulations.

C. Record Review of facility's "Nursing Documentation" policy, effective since 03/01/2019, revealed:

1. Changes in the physical/ psychological (Mental change) status of the patient are documented depending upon the severity of the change; either a full or partial reassessment must be documented.

Findings P(37):
D. Record Review of P37's Medical Record from F2 (Acute Care Hospital) dated 01/21/2021 revealed:

1. On 01/21/2021, Inpatient Discharge Summary indicates that P37 was to be transferred to F3 (Group Home).

2. On 01/21/2021, the Nursing Assessment (Section were the nurse documents their assessment of the patient) section of the record revealed no documentation of intravenous line (IV) assessment or documentation of its removal from P37. There is no documentation of hand-off report given to nursing staff at F3.


E. Record Review of P37's Medical Record from F2 (Acute Care Hospital) from 01/22/2021 revealed:

1. Nursing Emergency Department Narrator revealed that P37 presented to F2's Emergency Department for the chief complaint of right arm swelling with the notation "noted [swelling] by caregiver when patient was discharged yesterday 01/21/2021".

2. Emergency Department Provider note documents "[caregiver] reports patient was discharged yesterday 01/21/2021, and new symptoms were not reported in discharge paperwork. Nurse [from F3] reports noticing large bruise and swelling on right hand and forearm with redness and heat." Discharge diagnosis for P37 was "superficial thrombophlebitis (condition where an inflammation in a vein is caused by a blood clot, affecting normal blood flow), likely from recent IV placement."


Findings P(40):
F. Record Review of P40's Medical Record from F2 (Acute Care Hospital) from 02/08/2021 revealed:

1. Provider Inpatient Discharge Summary dated 02/08/2021 indicates that P40 is to be transferred to F4 (Skilled Nursing Facility).

2. Nursing note dated 02/08/2021 from 8:14 pm indicates that P40 fell at 5:20 pm and was assessed by medical staff. The note then indicated that at 8:00 pm P40 was discharged to F4. No documentation of hand-off report being given to staff at F4 per hospital policy.

Findings P(39):
G. Record Review of P39's Medical Record from F2 (Acute Care Hospital) from 01/03/2021 revealed:

1. At 7:17 am on 01/03/2021, P39 had a hypoglycemic (Low blood sugar) event with a blood sugar of 37 (low blood sugar, reference range 70-100).

2. At 7:28 am on 01/03/2021, P39 was given Dextrose 50% (IV medication, concentration of sugar to rescue one from a hypoglycemic event.)

3. No documentation of provider notification or reassessment after the low blood sugar event.

4. At 2:36 pm on 01/03/2021, Inpatient Provider note mentions hypoglycemic event.

Findings P(33):
H. Record Review of P33's Medical Record from F2 (Acute Care Hospital) dated 09/27/2019 revealed:

1. At 5:28 am on 09/27/2019, P33 had a hypoglycemic event (Low blood sugar) with a blood sugar of 36.

2. At 5:29 am 09/27/2019, P33 was given Dextrose 50% (IV medication, concentration of sugar to rescue one from a hypoglycemic event.).

3. No documentation of provider notification or reassessment after the low blood sugar event.

G. On 05/24/2021 at 2:30 pm, interview with S41 (Registered Nurse) indicated the process of discharging a patient to either a group home or a skilled nursing facility includes the following: the nurse and provider will evaluate the patient for their discharge readiness, education on any new diagnoses, reporting follow up care, and education on new medications prescribed. S41 confirmed that this information is not only given to the patient or family member, but also that the process is to call the receiving facility and speak to the attending nurse that will be taking care of the patient to ensure all questions are answered. Regarding IV assessments, S41 highlighted that assessments are done every shift and should be documented. This documentation should also include documenting the removal of the IV at discharge and S41 reinforced that patients do not go home with an IV.

H. On 05/24/2021 at 2:15 pm, interview with S40 (Charge Registered Nurse) explained that the process for discharging a patient to a skilled nursing facility or a group home involves the bedside nurse going over follow up care, appointments, any needed education, and medications to the patient or family member. This is also explained to the receiving facility's staff, as well. Regarding IV assessments, S40 confirmed that the expectation is that IV assessments are done at the beginning and end of the nurse's shift and are also assessed when there is a noted complication such as pain, swelling, or redness. S40 confirmed that patients are never discharged from the facility with an IV. If there is a change in status, S40 explained that the expectation for bedside nurses is to follow the notification chain of command and report the findings to both the Charge Registered Nurse and the patient's medical provider.

Based on record review and interviews, the facility failed to ensure the adherence of policies and procedures by licensed nursing staff for 3 (P6, P16, & P24) out of 25 (P1-P25) patients selected. This failed practice is likely to lead to worsening condition of patients and an increased risk of adverse events.

A. Record review of the facility's policy dated 07/20/2020 for "Patients Leaving Against Medical Advice " revealed that the process for documenting a patient who has left against medical advice must include documenting a 'Risk Event' (an event outside the normal that places a patient or staff at risk within the facility's care) in their internal web-based tracking system. The policy further states the following:

1. "When a staff member discovers that a patient cannot be located on the unit or in the department, the patient will be paged overhead and asked to return the unit or department.
2. "If the patient does not respond to the overhead page, notify Security if available, and the Supervisor/Administrator on Call will be notified, and they will initiate a search of the facility."
3. "The patient's physician/provider and nursing supervisor will be notified that the patient is missing."
4. "The patient's next of kin or legally authorized representative will be notified in accordance with the facility's HIPAA policy, dated 1/10/2021."
5. "Document as follows":
a. Time patient's absence was discovered
b. Time patient was last seen
c. Time of physician notification
d. Time of other notifications (security, Administrator on Call, Department Director, Supervisor/Charge Nurse, patient's family, etc.)
e. Document as a "Risk Event" using the link on the facility's intranet homepage

B. Interview with S6, (Chief Nursing Officer) confirmed that the procedure for patients who leave without being seen is to notify the charge nurse and provider, attempt to locate the patient, document the attempts, and discharge the patient from the system as Left Without Being Seen.

Finding P6:
C. Record Review of Patient 6's (P6) Emergency Department Narrator from 07/21/20 revealed:
1. P6 is a 9-year-old who presented to the emergency department at 1:24 pm 07/21/20 with the complaint of a seizure (sudden, uncontrolled electrical disturbance in the brain).
2. At 4:34 pm 07/21/20 P6 was discharged from the ED after treatment for a suspected seizure.
3. At 4:56 pm 7/21/20 P6 represented to the Emergency Department with the chief complaint of seizure-like activity.
4. At 5:10 pm 7/21/20 documentation of P6 being dismissed (discharge from waiting room with uncertainty of patient's disposition) from the Emergency Department.
5. No documentation of attempts to triage P6 or documentation of discovery.

Finding P16:
D. Record Review of P16's Emergency Department Narrator from 01/09/21 revealed:
1. On 01/09/21 at 9:51 pm P16 is a 8 year old who presented to the emergency department with the complaint of vomiting.
2. At 10:44 pm 01/09/21 documentation of P16 being dismissed from the Emergency Department. No documentation of any attempts to locate the patient or follow up on his condition

Finding P24:
E. Record Review of P24's Emergency Department Narrator from 02/27/21revealed:
1. P24 is a 2-year-old who presented to the emergency department at 9:30 pm 02/27/21 with the complaint of leg pain
2. At 10:05pm documentation of P24? being dismissed from the Emergency Department. No documentation of attempts to locate or follow-up on patient's well-being.


F. On 5/18/21 at 1:45pm, interview with S48 ( ER Charge Nurse) staff are to explain any potential risks to leaving abruptly with no instructions, or if patient has already left then attempt to locate the patient and notify security. Call the numbers on file for the patient and check on their well-being, especially pediatric patients.

Based on observation and interview, the facility failed to maintain a safe physical environment by identifying and managing the integrity (condition) of patient recovery areas to minimize the spreading of infections or communicable diseases. This failed practice is likely to expose patients to infectious diseases.

The findings are:

A. On 05/19/21 at 10:45 am during observation of the Perioperative (pre-operation) area the following was revealed:

1. Patient room 1303, the plastic molding cover on the entrance to the restroom, there was a vertical crack about 5 inches long.

B. On 05/19/2021 at 11:15 am during observation of the recovery room area aka PACU (post-anesthesia care unit following surgery and anesthesia) revealed:

1. Recovery area #3 the linen door was loose and being held in place by a small red biohazard (biohazard a risk to human or the environment arising from biological work, especially with microorganism) can.

2. In the recovery area several corners on the floor, the linoleum (material consisting of canvas backing, used for floor coating made of natural materials that are much more susceptible to damage from water and cleaning products) had cracks.

3. In a storage bin near patient recovery area #4, the two bottom corners closer to the floor the laminate (to unite layers of material by an adhesive or other means) covering was loose.

C. On 05/19/2021 at 11:20 am, during interview Staff (S)22 (Chief Operations Officer) confirmed the cracked plastic corner molding covering in the patient room, the loose linen door, and the linoleum cracked on the corners in the recovery room. S22 confirmed will notify Facility Operations Manager to address the identified areas immediately.

Based on observation and interviews, the facility failed to provide and monitor a sanitary (clean and free from dirt, bacteria, or etc.) environment to minimize the transmission of communicable disease within the unit by ensuring proper housekeeping processes are being done daily and correctly. This failed practice can place patients at risk for infections while receiving medical treatment.

The findings are:

A. On 05/17/2021 at 10:25 am during a tour of the emergency department the following was revealed:

1. In Emergency Room 147- Treatment 1, open medical supplies packages on a stainless steel table and appeared to have been previously opened and used. There was a package of blood pressure cuffs (an inflatable rubber cuff that is fastened on the arm to read the patients' blood pressure) and open package of 4x4 gauze (a thin translucent fabric of silk, linen, or cotton.)

2. In the sink drainage there was a blue plastic (object in the form of a tip) and a piece of white plastic, sink appeared to not have been rinsed or wiped

3. The bedsheet on patient room bed had dust marks that appeared to be from shoes or dirty pant leg.

4. The floor was dirty (covered or marked with an unclean substance) and appeared to not have been swept or mopped.

B. On 05/17/2021 at 10:35 am during tour of the facility, observed in the unisex (gender-neutral) restroom located by 123 CT Scan room (CT scan or computed tomography scan is a medical imaging technique used in radiology to get detailed images of the body) available for patient use, the floor was dirty (covered or marked with an unclean substance) and appeared to not have been swept or mopped.

C. On 05/18/2021 at 9:45 am during tour of the soiled utility holding area, (storage for biohazard (a risk to human or the environment arising from biological work, especially with microorganism) materials for pickup), two sharps (needles, IV catheters and other sharp, disposable medical tools) containers on the floor out of the box, three boxes of sharps containers on the floor. One box of sharps container on top of a biohazard barrel.

D. On 05/18/2021 at 10:00 am during tour of the decontamination room (the process of removing contaminants on an object or area, including chemicals, micro-organisms or radioactive substances), (persons suspected of being contaminated are usually led into a decontamination room, where the person sheds their potentially contaminated clothes in a strip-down room. Then enter a wash-down room where they are showered.) There were a few chairs, a cardboard box on top of the chairs, a workstation (portable computer) on wheels, crutches (a long stick with a crosspiece at the top, used as a support under the armpit by a person with an injury or disability), portable toilet (receptacle for waste can be removed and emptied), a wagon (used for transporting goods or another specified purpose), and a mobile room divider (cloth rack.)

E. On 05/24/2021 at 10:30 am during tour of Floor 7B Unit (stroke and progressive care) the following was observed in Clean Equipment room:

1. A white mid-size cloth towel against the wall on the floor near the towel holding rack

2. A white mid-size cloth in a plastic bag on the floor

3. A large empty plastic bag underneath a medical drip IV stand (device that keep intravenous (administered into, a vein or veins) bags full of medicine or fluid in place. The bags are hung from the hooks at the top of the pole.)

F. On 05/24/2021 at 11:05 am during tour of Floor 7B Unit observed in shower #2 used by patients, a bottle of Bleach Cleaner (solution used to disinfect) on a shelf near some towels. No sign the shower had just been used or disinfected.

G. On 05/25/2021 at 10:10 am during tour of the Emergency Department (ED) observed in Pod B (a unit within a unit) in the Utility room (used for storage) five cases of canned Gatorade (drink to help refuel and rehydrate) on the floor. Three (3) grey and one (1) blue storage bin on the floor not on a riser (a shelf to organize and store boxes off the floor to meet the 6" food storage requirements per HACCP (a food safety and a risk management tool that stands for Hazard Analysis and Critical Control Points.)

H. On 05/25/2021 at 10:20 am during tour of the Emergency Department (ED) observed in Pod D (a unit within a unit) room 42, a disposable (no sign if used or not) glidescope stylet (ease intubation (passing a tube into a person's airway) by helping overcome obstructions such as vocal cords) in the sink.

I. On 05/17/2021 at 10:35 am during interview, Staff (S)3 (Registered Nurse) confirmed the medical supplies on the stainless steel table in Room 147- Treatment 1 (and that the supplies should have not been there), items in the sink, dust marks on the bedsheet, and the floor needing to be swept and mopped. S3 confirmed the room was last used Sunday before midnight and had not been cleaned. S3 confirmed housekeeping is there once a day in the evenings. S3 confirmed the medical supplies should not have been on the table and that any available staff member can sweep and mop when necessary or call housekeeping to assist.

J. On 5/24/2021 at 10:45 am during interview, Staff (S)36 (Clinical Professional Development Specialist) confirmed the towels and the plastic bag on the floor. S36 confirmed any staff within Unit 7B can sweep and mop the Clean equipment room and housekeeping will clean as needed. It was noticeable the floor was not swept.

K. On 05/24/2021 at 10:55 am during interview, S33 (Assistant Nurse Manager Unit 7B) and S22 (Chief Operations Officer) could not confirm the consistency of how often housekeeping cleans the Clean Equipment room.

L. On 05/24/2021 at 11:10 am during interview, S33 (Assistant Nurse Manager Unit 7B) confirmed the bottle of bleach cleaner in shower #2 and understanding not having bleach cleaner in the shower when not being disinfected.

M. On 05/24/2021 at 11:20 am during interview, S33 (Assistant Nurse Manager Unit 7B) confirmed the patient care items cluttered in the storage cabinet.

N. On 05/25/2021 at 10:25 am during interview S34 (Nursing Manager ED) confirmed the disposable (no sign if used or not) glidescope stylet (ease intubation (passing a tube into a person's airway) by helping overcome obstructions such as vocal cords) in the sink and should not have been there. S34 confirmed in ED D pod, technicians and registered nurses are responsible to clean the rooms and make sure are fully supplied for patient treatment.