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Based on interview and record review, it was determined the hospital failed to have an effective governing body responsible for the hospital's conduct. Specifically, the governing body failed to provide surveyors with requested information in a timely manner. Additionally, the governing body failed to ensure the infection prevention and antibiotic stewardship programs were maintained.

Findings include:

1. On 10/14/2020, at approximately 3:00 PM., four patient medical records were requested to be sent in electronic format to the survey team. The hospital's administration told the survey team this was possible but would be time-consuming because the hospital currently used paper charts.

On 10/15/2020 at approximately 10:30 AM, two additional patient medical records were requested. The survey team had not received any patient medical records at this time. The hospital's administrative staff stated they were working on getting the requested medical records to the survey team.

On 10/16/2020 at 9:02 AM, the first of the requested records were received by the survey team. This was approximately 42 hours after the surveyor's initial request.

Failure to provide requested information in a timely manner impeded the survey process and made a review of some compliance areas challenging to complete.

2. The hospital failed to maintain active hospital-wide programs for the surveillance, prevention, and control of HAIs (Healthcare Associated Infections) and other infectious diseases, and for the optimization of antibiotic use through stewardship. (Refer to tag 747)

Based on observation, interview, and record review, it was determined that the hospital failed to maintain active hospital-wide programs for the surveillance, prevention, and control of Healthcare Aquired Infections (HAIs) and other infectious diseases, and for the optimization of antibiotic use through stewardship

Findings include:

1. The hospital failed to ensure that individuals were qualified through education, training, experience, or certification, in infection prevention and control, before they were appointed by the governing body as infection preventionists. (Refer to tag 748.)

2. The hospital failed to ensure systems were in place and operational for the tracking of all infection surveillance, prevention, and control, and antibiotic use activities, in order to demonstrate the implementation, success, and sustainability of such activities. (Refer to tag 770.)

3. The hospital failed to ensure personnel had competency-based training and education on the practical applications of infection prevention and control guidelines, policies, and procedures. (Refer to tag 775.)

4. The hospital failed to ensure the antibiotic stewardship program was fully functional. (Refer to tag 778.)

Based on observation, interview and record review, it was determined the hospital did not provide adequate numbers of licensed registered nurses and other personnel to provide nursing care to all patients as needed for 7 of 13 sample patients. Specifically, medications including insulin, blood thinners, and intravenous antibiotics were not administered as ordered; wound treatments and dressing changes were not completed as ordered; catheter care and peripherally inserted central catheter (PICC) dressing changes were not completed as ordered; and a high vancomycin level was not acted on resulting in a critically high value.

Additionally, staff stated that incontinence care was not being provided and patient's were "often" found in urine soaked linens; call lights were not answered for more than an hour; and patient's with complex wound care were not being turned and repositioned every two hours. (Patient identifiers: 1, 2, 5, 6, 9, 10 and 12)

Findings include:

1. Patient 1 was admitted to the hospital on 9/18/2020 with diagnoses which included right chest wall empyema necessitans with necrotizing fasciitis of the overlying tissue and rib osteomyelitis, recent septic shock, acute respiratory failure and methicillin-susceptible staphylococcus areus urinary tract infection.

Patient 1's medical record was reviewed on 10/22/2020.

a. Review of the Admission Nursing Assessment revealed that patient 1 had a peripherally inserted central catheter (PICC) in the left upper extremity.

On 10/6/2020 at 9:00 PM, a registered nurse documented in a progress note, "...PICC dressing is almost 2 weeks old, passed along to next shift since I wasn't able to change dressing tonight. ..."

A telephone interview was conducted with the Nurse Manager (NM) on 10/21/2020 at 3:04 PM related to the hospital policy regarding PICC line dressing changes. The NM stated PICC line dressing changes were to be completed every Saturday night.

Review of the nursing documentation, including medication administration records (MARs), critical care daily flowsheets and nursing progress notes revealed that patient 1's PICC line was not changed until 10/12/2020; six days after a nurse documented the dressing had not been changed in almost two weeks and 24 days after admission to the hospital, according to documentation.

A copy of the hospital "CENTRAL LINE PROTOCOL/ORDERS" was obtained. It was documented the central line dressing change was to be completed on Saturday nights and as needed.

An interview was conducted with the chief clinical officer (COO) on 10/26/2020 at 11:04 AM, related to patient 1 and his PICC line dressing changes. The COO stated the PICC line dressing was not changed until 10/12/2020. The COO stated she did not know why the agency nurse did not change PICC line dressing on 10/6/2020 when she identified that the dressing had not been completed in "almost 2 weeks". The COO stated that the PICC line dressing change was missed and it wasn't changed timely.

b. On 9/18/2020, an order was received to administer Enoxaparin Sodium 40 mg (milligrams)/0.4 ml (milliliters) subcutaneously every twelve hours. The Enoxaparin was scheduled to be administered at 9:00 AM and 9:00 PM. The Enoxaparin was not administered as ordered on 10/10/2020 at 9:00 PM (the 9:00 PM dose was not administered until 10/11/2020 at 1:45 AM) and 10/11/2020 at 9:00 AM (the 9:00 PM dose was not administered until 10/12/2020 at 1:45 AM), according to documentation.

c. On 9/28/2020, an order was received to administer Zosyn 3.375 g (grams) intravenously every six hours. The Zosyn was not administered on 10/10/2020 at 9:00 PM. The licensed nurse (LN) documented, "Missed." No further documentation was available for review to indicate why the Zosyn was not administered as ordered.

d. On 9/22/2020, an order was received to cleanse the wounds on the bilateral lower extremities (BLE) with hibiclens, cover the wounds with medihoney and apply a 6 X (by) 6 borderless optifoam and wrap the legs with kerlix. The nursing staff was to coordinate the dressing changes with the therapy department so compression wraps could then be applied to the BLE. The dressing changes were not completed on 10/8/2020, 10/12/2020 and 10/15/2020 as ordered, according to documentation.

e. On 9/22/2020, an order was received to cleanse the right lateral chest wound with hibiclens, apply medihoney to the chest tube sites and cover with 4 X 4 optifoam border twice a week. Additionally, negative pressure wound therapy (NPWT) was to occur twice a week on Monday and Thursdays. The dressing change was not completed on 10/8/2020 and the NPWT was not completed on 10/8/2020 and 10/12/2020 as ordered, according to documentation.

f. On 10/13/2020, an order was received to cleanse the right lateral chest wound with hibiclens, apply sureprep to the periwound, a Dakin's rolled gauze was to be placed on the wound base and covered with an ABD (abdominal) pad secured by tape. The dressing change was to be completed twice a day. The dressing was not changed on 10/14/2020 at 9:00 AM and 10/15/2020 at 9:00 AM as ordered, according to documentation.

An interview was conducted with the NM on 10/21/2020 at 3:04 PM, related to the medications not being administered and the wound care not being performed as ordered. The NM stated that she would research the concerns.

An interview was conducted with the CCO on 10/26/2020 at 11:04 AM related to the medications that were not administered and the wound care that was not completed. The CCO stated the Zosyn was not administered as ordered on 10/10/2020 and that the nurse would be educated. The CCO did not provide an explanation as to why the dressing changes were not completed as ordered.

2. Patient 2 was admitted to the hospital on 9/15/2020 with diagnoses which included MRSA (Methicillin-resistant Staphylococcus aureus) pneumonia, mild developmental delay, COVID-19 pneumonia and schizophrenia.

Patient 2's medical record was reviewed on 10/16/2020.

a. On 9/17/2020, an order was received to apply miconazole nitrate 2% topically twice a day. The miconazole was not applied as ordered on 9/26/2020 at 9:00 PM and 9/28/2020, according to documentation.

b. On 9/23/2020, an order was received to cleanse the left knee with hibiclens, apply medihoney to the wound base and cover with an optifoam 4 X 4 three times a week on Monday, Wednesday and Friday. The left knee dressing change was not completed as ordered on 9/25/2020, according to documentation.

c. On 9/28/2020, an order was received to cleanse the left knee with hibiclens, apply medihoney to the wound base and cover with an optifoam 4 X 4 three times a week on Monday, Wednesday and Friday. The left knee dressing change was not completed as ordered on 9/28/2020; 10/5/2020; 10/7/2020; 10/12/2020; and 10/14/2020, according to documentation.

d. On 10/8/2020, an order was received to cleanse the groin, buttocks, and scrotal area with a no rinse soap and water. Miconazole powder was to be applied to the yeasty areas of the skin and sensi care was to be applied to the open areas on the buttocks for barrier protection and healing twice a day. The miconazole powder was not applied as ordered on 10/9/2020 at 9:00 PM; 10/10/2020 at 9:00 PM; 10/11/2020 at 9:00 PM; 10/12/2020 at 9:00 AM and 9:00 PM; 10/13/2020 at 9:00 AM and 9:00 PM; 10/14/2020 at 9:00 AM; 10/15/2020 at 9:00 AM; and 10/16/2020 at 9:00 PM, according to documentation.

An interview was conducted with the NM on 10/21/2020 at 3:04 PM' related to the dressing changes not being completed. The NM stated that she would research the concerns.

An interview was conducted with the CCO on 10/26/2020 at 11:04 AM, related to the treatments and wound care that was not completed. The CCO did not provide an explanation as to why the treatments and dressing changes were not performed as ordered.

3. Patient 5 was readmitted to the hospital on 9/8/2020, with diagnoses which included recent Coronavirus disease, hypoxic respiratory failure requiring tracheostomy and mechanical ventilation; pericardial effusion with tamponade, anemia, and stage IV sacral decubitus ulcer.

Patient 5's medical record was reviewed on 10/16/2020.

a. On 9/9/2020, an order was received to change the colostomy wafer twice a week on Monday and Thursday. The colostomy wafer was not changed as ordered on 9/10/2020; 9/21/2020; 9/24/2020; 10/5/2020; 10/8/2020; and 10/12/2020, according to documentation.

b. On 9/9/2020, an order was received to apply NPWT to the sacrum twice a week on Wednesday and Friday. The NPWT was not completed as ordered on 9/16/2020, according to documentation.

c. On 9/23/2020, an order was received to cleanse with sacral wound with hibiclens, apply a no sting spray, pack with Dakin's rolled gauze, cover with an abdominal pad and secure with Medipore tape, twice a day. The wound care not completed as ordered on 9/25/2020 at 9:00 PM, according to documentation.

d. On 10/8/2020 an order was received to cleanse the sacral wound with hibiclens, apply sureprep to the periwound, loosely fill the wound with acetic acid gauze, apply an abdominal pad and secure the dressing with Medipore tape. The dressing change was not completed as ordered on 10/7/2020 at 9:00 AM; 10/8/2020 at 9:00 AM; 10/9/2020 at 9:00 PM; 10/10/2020 at 9:00 PM; 10/11/2020 at 9:00 PM; 10/12/2020 at 9:00 AM and 9 PM; and 10/13/2020 at 9:00 AM, according to documentation.

An interview was conducted with the NM on 10/21/2020 at 3:04 PM, related to the wound care not being performed as ordered. The NM stated that she would research the concerns.

An interview was conducted with the CCO on 10/26/2020 at 11:04 AM, related to the wound care not being completed as ordered. The CCO did not provide additional information as to why wound care was not completed as ordered.

4. Patient 6 was admitted to the hospital on 9/18/2020, with diagnoses which included spina bifida with lower extremity paraplegia, and a stage IV sacral pressure ulcer with underlying osteomyelitis.

Patient 6's medical record was reviewed on 10/16/2020.

a. On 9/22/2020, an order was received to cleanse the left ischium wound with hibiclens, apply sureprep to the periwound, pack with acetic acid, cover with an abdominal pad and secure with Medipore tape twice a day. The dressing change was not completed as ordered on 9/25/2020 at 9:00 AM and 9:00 PM, according to documentation.

b. On 9/30/2020, an order was received to apply NPWT to the sacrum twice a week on Monday and Thursday. The NPWT was not completed as ordered on 10/8/2020, according to documentation.

c. On 10/12/2020, an order was received to cleanse the left ischium with hibiclens, apply sureprep to the periwound, loosely fill with acetic acid gauze, apply an abdominal pain and secure with Medipore tape. The dressing change was not completed as ordered on 10/13/020 at 9:00 AM, according to documentation.

An interview was conducted with the NM on 10/21/2020 at 3:04 PM, related to the wound care not being performed as ordered. The NM stated that she would research the concerns.

An interview was conducted with the CCO on 10/26/2020 at 11:04 AM, related to the wound care not being completed as ordered. The CCO did not provide additional information as to why wound care was not completed as ordered.

5. Patient 10 was admitted to the hospital on 7/29/2020, with diagnoses which included acute on chronic hypoxic and hypercapnic respiratory failure tracheostomy, ventilator associated pneumonia and tracheostomy.

Patient 10's medical record was reviewed on 10/22/2020.

a. On 8/16/2020, a LN documented in a progress note, "a PICC line was placed in the right arm". The PICC line dressing change was not completed every Saturday per the PICC line protocol on 8/22/2020 and 8/29/2020. The PICC line dressing was changed on 8/30/2020, fourteen days after the PICC dressing was placed, according to documentation.

b. On 7/29/2020, an order was received to check patient 10's blood sugar every six hours and to administer insulin according to a sliding scale. Patient 10's blood sugar was not checked and insulin was not administered on 7/31/2020 at 6:00 AM; and 9/10/2020 at 3:00 PM, according to documentation.

c. On 7/31/2020, an order was received cleanse patient 10's breast, groin and under the arms with hibiclens, apply miconazole powder and place soft white wicking cloths twice a day. The miconazole powder was not completed as ordered on 9/3/2020 at 9:00 PM, according to documentation.

An interview was conducted with the CCO on 10/26/2020 at 11:04 AM related to the PICC line dressing change, blood sugar and insulin not being administered and the wound treatment. The CCO stated that the CNAs (certified nursing assistants) were probably applying the miconazole to patient 10's breasts, groin and under the arms, but that the licensed nurse did not confirm and document that the treatment was completed. The CCO did not provide an explanation as to why insulin was not administered as ordered and the PICC line dressing change was not completed.

6. Patient 12 was admitted to the hospital on 9/17/2020, with diagnoses which included COVID and acute respiratory failure, acute kidney injury secondary to ischemic acute tubular necrosis, toxic metabolic encephalopathy, pneumonia and acute blood loss anemia presumed secondary to a gastrointestinal bleed.

Patient 12's medical record was reviewed on 10/26/2020.

a. On 9/17/2020, an order was received to check patient 12's glucose every 4 hours and to administer insulin per the sliding scale. Patient 12's glucose was not checked on 9/20/2020 at 5:00 AM; 10/3/2020 at 9:00 AM; 10/14/2020 at 5:00 AM; and 10/15/2020 at 5:00 AM, according to documentation.

b. On 9/17/2020, an order was received to administer Metoclopramide HCL (hydrochloride) 5 mg ½ tablet every six hours per the feeding tube. The metoclopramide was not administered as ordered on 9/22/2020 at 3:00 AM and 9/23/2020 at 3:00 AM, according to documentation.

c. On 9/18/2020, an order was written cleanse the sacrum wound with hibiclens, apply sureprep to the periwound, pack with Dakin's soaked gauze, apply an abdominal pad and secure with Medipore tape. The treatment was not completed as ordered on 9/23/2020 at 9:00 PM; 9/26/2020 at 9:00 AM; and 9/27/2020 at 9:00 AM and 9:00 PM, according to documentation.

d. On 9/19/2020, an order was received to apply bacitracin with zinc according to the wound care orders twice a day. The bacitracin was not applied as ordered on 9/20/2020 at 9:00 AM; 9/24/2020 at 9:00 PM; 9/27/2020 at 9:00 PM; 9/28/2020 at 9:00 PM; 10/3/2020 at 9:00 PM; 10/12/2020 at 9:090 PM; and 10/14/2020 at 9:00 PM, according to documentation.

e. On 9/22/2020, an order was received to clean the right groin area, pat dry and apply stoma powder twice a day. The treatment was not completed as ordered on 9/23/2020 at 9:00 PM; 9/26/2020 at 9:00 AM; 9/27/2020 at 9:00 AM and 9:00 PM; 10/2/2020 at 9:00 PM; 10/3/2020 at 9:00 AM; 10/7/2020 at 9:00 AM and 9:00 PM; 10/12/2020 at 9:00 AM and 9:00 PM; 10/13/2020 at 9:00 AM and 9:00 PM; 10/14/2020 at 9:00 PM; and 10/15/2020 at 9:00 PM, according to documentation.

f. On 9/22/2020, an order was received to apply bacitracin to the left ear wound daily. The bacitracin was not applied as ordered on 9/24/2020 and 9/26/2020, according to documentation.

g. On 10/6/2020, an order was receive to cleanse the sacrum with hibiclens, apply sureprep to the periwound, place Dakin's soaked gauze to the wound base, cover with an abdominal pad and secure with Medipore tape twice a day. The treatment was not completed as ordered on 10/11/2020 at 9:00 PM; 10/12/2020 at 9:00 AM; 10/14/2020 at 9:00 PM; and 10/15/2020 at 9:00 PM, according to documentation.

h. The LN staff documented on 9/17/2020 that patient 12 had a right midline catheter in place. The midline catheter dressing change was completed on 9/19/2020 per the hospital central line protocol. The dressing change was not completed again until 10/3/2020 when a new midline catheter was ordered. Patient 12's catheter dressing change was not completed for fourteen days. A PICC line was placed on 10/4/2020 in the left brachial vessel. The next PICC line dressing change was completed on 10/13/2020, nine days after the dressing was last changed, according to documentation.

i. On, 9/28/2020 an order was written for the pharmacy to dose the vancomycin that patient 12 was receiving. A vancomycin trough was checked on 9/29/2020 at 4:10 AM. The trough returned high at 21.7 micrograms (mcg)/milliliter (mL). The lab documented a normal range of 5.0 to 10.0 mcg/mL.

The hospital Vancomycin dosing and monitoring protocol was reviewed. According to the protocol, a trough between 20-25 mcg/mL was to be decreased. An order to decrease the Vancomycin was not given and patient 12 continued to receive Vancomycin 1.5 grams every 12 hours.

A vancomycin trough was rechecked on 10/2/2020 and returned critically high at 36.8 mcg/mL. The lab documented that a hospital staff member was notified of the critical results at 6:33 AM at which time a new order was received to decrease the vancomycin dose to 1.5 grams daily.

An interview was conducted with the CCO on 10/28/2020 at 10:00 AM related to blood sugars not being checked and insulin administered; metoclopramide not being administered, PICC line dressing changes not being completed; and wound treatment and dressing changes not being completed. No additional information was provided.

An interview was conducted with the pharmacy director (PD) on 10/29/2020 at 10:20 AM related to the vancomycin levels. The PD stated that vancomycin troughs were to be drawn one hour before the dose was administered. The PD stated that based on his clinical judgement, the vancomycin dose was not decreased 9/29/2020 because the trough was drawn too soon. The PD stated that the vancomycin dosage was changed after the critical high vancomycin trough was received on 10/2/2020.




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7. Patient 9 was admitted to the hospital on 9/10/2020, with diagnoses including respiratory failure, heart failure, extensive wounds, diabetes, asthma, sleep apnea, and end-stage renal disease requiring dialysis.

A review of patient 9's medical record was completed on 10/27/2020.

a. On 9/10/2020, an order was received to apply triamcinolone cream topically twice a day. There was no documented evidence that the triamcinolone was applied on 9/16/2020 at 9:00 PM, 9/17/2020 at 9:00 AM, 9/20/2020 at 9:00 AM, 9/24/2020 at 9:00 PM, or 10/6/2020 at 9:00 AM.

b. On 9/11/2020, an order was received to apply miconazole nitrate 2% topically twice a day. There was no documented evidence that the triamcinolone was applied on 9/16/2020 at 9:00 PM, 9/17/2020 at 9:00 AM, 9/20/2020 at 9:00 AM, 9/24/2020 at 9:00 PM, and 10/6/2020 at 9:00 AM.

On 10/26/2020 at 12:05 PM, the CCO was asked to provide evidence the triamcinolone and miconazole creams were applied on the dates listed above. The CCO did not provide the survey team with any evidence.

8. On 10/15/2020 at 1:47 PM, an interview was conducted with the wound care nurse (WCN) and wound care technician (WCT). The WCN stated the hospital nurses and CNAs were "overloaded," and patient care was suffering. The WCN stated they often find patients "soaked" in urine. The WCN stated when this happened, an incident report was completed. The WCN stated the wound care team had "done probably 20" incidents over the last month due to patients being found in this state. Both the WCN and WCT indicated nursing staff needed more education in general. The WCT stated that in the last couple of days, they had a nurse come running out indicating a patient was bleeding from a wound, and she did not know what to do when she should have applied direct pressure. At 2:36 PM, the wound care manager (WCM) joined the interview. After the WCN and WCT finished discussing the patient care issues they had seen, the WCM stated, "We have not been able to have our skills day this year, so the little things get laxed on." The WCM further stated, "I feel like the CNAs have had one too many patients lately; they are at the limit."

On 10/16/2020 at 2:38 PM, a telephone interview was conducted with CNA 5. CNA 5 stated, "We are short-staffed all of the time." CNA 5 stated patients sometimes had to wait an hour or longer for their call lights to be answered.

On 10/19/2020 at 10:15 AM, a telephone interview was conducted with agency nurse (AN) 1. AN 1 was asked he was able to complete tasks as assigned. AN 1 stated that the staffing ratio was changed two months ago and that employees had a higher employee to patient ratio. AN 1 stated that the wound care team waw down several staff members and that the floor nurses were struggling to keep up with the dressing changes that were not being completed by the wound care team.

On 10/19/2020 at 11:32 AM, a telephone interview was conducted with CNA 4. When asked if she felt there were enough staff to meet the patients' needs, CNA 4 stated, "No we don't have enough staff." CNA 4 stated she could not complete all required patient care because of the lack of staff. CNA 4 stated she was supposed to be rounding on each of her patients every two hours but that she can only complete this every "three to four hours," and, "as far as people being turned every two hours that is not happening." CNA 4 stated she had informed her manager of her concerns. CNA 4 further stated, "Lots of staff have talked to management and admin (administration), and they say we don't have the budget for more CNAs on the floor."

On 10/19/2020 at 12:41 PM, a telephone interview was conducted with registered nurse (RN) 3. RN 3 stated she felt recently that staffing ratios were changed due to budget cuts and, "Now things are not getting done." RN 3 stated wound care specifically was not happening as ordered. RN 3 further stated she felt catheter-associated urinary tract infections and PICC line infections had also increased because "I truly do not feel there is enough staff." RN 3 then stated, "The patients aren't getting turned or cleaned as often." RN 3 stated CNAs try to ensure patients are turned and cleaned but do not have a chance because they are understaffed. RN 3 further stated that the infection control and education departments had been "eliminated." RN 3 stated, "They did not even teach us how to do a COVID test. We had to look it up on YouTube to figure it out." RN 3 then stated when the hospital had its COVID unit staff showed up to work, was handed a "little" packet, and told, "we have this COVID unit, and you need to work over there." RN 3 stated, "You are responsible for your own education." RN 3 stated the hospital had been relying heavily on agency staff and that they get almost no training, "they pretty much show up and do not even get a tour from the charge nurse because they are so busy. So they show up and are thrown on the floor." RN 3 stated the agency staff often have no acute care experience and do not even know how to mix antibiotics or straight catheterize patients.

9. A review of the hospital's incident log was completed on 10/22/2020. Seven incidents in the month of September 2020 were found relating to concerns with patient care.

On 9/14/2020, the WCM documented the following regarding patient 5, "Brief soaked. Bed soaked. Mattress soaked. CAN (sic) does not check patient or offer to help patient with urinal. Room was disgusting."

On 9/15/2020, the WCM documented the following, "Pt. (patient) is a para (paraplegic) sitting in soaked through urine 3 pads. Patient states only sees CAN's (sic) when they bring tray. He has a suprapubic catheter. No one had been in since last night when were there at 1300 (1:00 PM)."

On 9/15/2020, a hospital staff member documented, "Patients PD (peritoneal dialysis) was alarming. Nurse (name of nurse) silenced it all night. Charge nurse note notified. Treatment had to be finished on day shift."

On 9/17/2020, the WCM documented that she and a physician evaluated the wounds of patient 3. The WCM documented that the patient was "in a puddle of urine soaked through layers of chucks including dry flows ...Skin was macerated. Patient had not been moved or repositioned all day by nurse or CNA's."

On 9/17/2020, the WCM documented the following, "5 layers of green chucks and a dry flow sheet under patient."

On 9/24/2020, the WCN documented the following, "Patient reports she only saw nurse one time yesterday during the day shif (sic) on 9/23/20- when she took BG (blood glucose) in AM. Patient reports she was not given any insulin at all during the day shift. Went back to patient room at lunch time-pt. sitting in a chair at bedside table- call light attached to bed side opposite of patient that she could not reach. 2 insulin syringes and 1 10 ml (milliliter) syringe with 18 gauge needle on bedside table next to lunch tray. All with fluid in syringes unmarked. Took to charge nurse and reported."

On 9/24/2020, the WCN documented the following, "Wound care visit: patient reports that he just had a shower this am. He was lying in bed with no sheet or blanket, cold to the touch, no linen in room either. Patient has suprapubic wound with specific orders to clean peri area BID (twice daily) with dressing changes on the MAR (medication administration record) This nurse and tech cleaned peri area cutting an inch size hard piece of crusty drainage out of pubic hair. Several smaller pieces of crusty drainagestuck (sic) and tangles, sides of groin and under scrotum cleaned out thick moist yelloow (sic) stuff, probably old powders and sttol (sic)- had been there (sic) way more than a day. Pulled back foreskin and oh my!! enough said. Peri care needs to be done and improved the way it is done."

Based on interview and record review, it was determined the hospital did not ensure that all nursing personnel had required training and orientation to provide care to the patients. Specifically, skills and competencies were not evaluated prior to independently caring for patients. (Employee identifiers: 1, 2, 3, 4, 6, 7, 8, 9 and 10. Contracted Employee (CE) 14.)

Findings include:

On 10/19/2020, the orientation and competencies for employees (1,2,3,4,5,6,7,8,9 and 10) and contracted employees(11,12,13 and 14) was requested.

1. Initial orientation and training was not available for review for employees 1, 2, 6, and 7. Additionally, orientation and training was not available for contracted employees 12 and 13.

2. Employee skills and competencies had not been checked for employees 3, 4, 8, 9, and 10.

a. Employee 3 was hired by the hospital on 10/5/2020 as a certified nurse assistant (CNA). The chief clinical officer (CCO) documented that employee 3's skills and competencies were not due to be checked until 1/5/2021.

b. Employee 4 was hired by the hospital on 8/20/2020 as a CNA . The CCO documented that employee 4's skills and competencies were not due to be checked until 11/20/2020.

c. Employee 8 was hired by the hospital on 9/15/2020 as a registered nurse (RN). The CCO documented that employee 8's skills and competencies were not due to be checked until 12/11/2020.

d. Employee 9 was hired by the hospital on 9/8/2020 as a RN. The CCO documented that employees 9's skills and competencies were not due to be checked until 12/7/2020.

e. Employee 10 was hired by the hospital on 8/11/2020 as a RN. The CCO documented that employee 10's skills and competencies were not due to be checked until 12/11/2020.

3. CE 14 (a CNA) had not had skills and competencies checked. The CCO documented, "provided by agency awaiting receipt (sic)."

Note: The hospital relied on the agency to evaluate the skills and competencies of this employee. However, documented evidence of the evaluation was not readily available for review.

4. An interview was conducted with the chief clinical officer (CCO) on 10/15/2020 related to orientation documentation for employees 1, 2, 6, and 7 as well as CE 12 and 13. The COO stated, "all continuing education documentation including, education, competencies and skills day trainings were unavailable because when we moved the movers lost the file cabinet." The file cabinet was lost in May 2019.


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5. On 10/20/2020 at 3:31 PM, a telephone interview was completed with the CCO and nurse manager (NM). The CCO stated that several nursing staff whose records the survey team chose to review had not been working at the hospital for 90 days, so there would be no competency form for them. When asked if any documentation indicating the nursing staff's skills or competency were evaluated before the nursing staff provided patient care independently, the CCO stated, "No." The CCO stated that depending on the employee's experience level they received anywhere from two to six weeks of orientation. The NM stated, if needed, employees were given additional training shifts.

Based on interview and record review, it was determined that the hospital did not ensure individuals were qualified through education, training, experience, or certification in infection prevention and control, prior to being appointed by the governing body as infection preventionists. Specifically, the qualified and appointed infection preventionist was laid off approximately 12 weeks prior to the survey and those who took over the responsibilities were not qualified or appointed by the governing body. Additionally, there was not a current infection preventionist appointed.

Findings include:

On 10/14/2020 at 8:58 AM, during the entrance conference, the chief clinical officer (CCO) stated, "We do not have an official infection preventionist." The CCO stated that the duties of an infection preventionist had been split between herself, the infectious disease physician, and registered nurse (RN) 1.

On 10/15/2020 at 9:25 AM, an interview was conducted with the chief executive officer (CEO), the CCO, and the director of quality/risk, and RN 1. RN 1 stated she had been the hospital's infection preventionist, but that the hospital's corporate office had revamped the budget and determined a full-time infection preventionist was not needed, and she was laid off at the beginning of June. RN 1 stated she had been brought back to the hospital eight hours a week approximately six weeks prior to the survey to "help with HAI (Hospital Associated Infection) investigation." The CCO stated that the charge nurses, the medical team, herself, and the director of quality/risk reviewed patient medical records to identify HAI's. The CCO further stated those she stated were "screening but not logging" the information, and that was why RN 1 was called back. The CCO stated that while RN 1 was not working at the hospital, she and the director of quality/risk had been collecting data for reportable HAI's. The director of quality/risk confirmed HAI's that were not reportable, like a urinary tract infection in a patient without a catheter was not currently being tracked.

Note: The hospital had been without staff with appropriate education, training, experience, or certification for approximately 12 weeks prior to the survey.

On 10/28/2020, when confirming the director of quality/risk's job title, it was noted that on the organizational chart provided to the survey team on 10/14/2020 at 12:09 PM, the director of quality and risk was also the director of infection prevention.

On 10/28/2020 at 9:50 AM, a telephone interview was conducted with the CCO. The CCO confirmed the director of quality and risk was also technically the director of the hospital's infection prevention program. The CCO stated this change was made in June 2020 when RN 1, the hospital's infection preventionist, was let go. The CCO said she and the director of quality, risk, and infection prevention did not have education, training, experience, or certification in infection prevention and control that qualified them to be an infection preventionist. The CCO confirmed there was not currently anyone appointed by the governing body as an infection preventionist.

Based on interview and record review, it was determined that the hospital did not ensure systems were in place and operational for the tracking of all infection surveillance, prevention, and control, and antibiotic use activities, in order to demonstrate the implementation, success, and sustainability of such activities. (Patient identifiers: 9.)

Findings include:

1. On 10/14/2020, at approximately 11:55 AM, an interview was conducted with the chief clinical officer (CCO). The CCO stated they had not been keeping a log of patients who had been tested for COVID-19. The CCO stated they were going to have to call the laboratory and find out who was tested and when. The CCO further stated she was "working" on the log of employees who had been tested for COVID-19.

On 10/14/2020 at 12:46 PM, the survey team received a form titled, "Infection Control and Prevention/Employee Health Dashboard 2020." The form had information listed from January 2020 through May 2020. No information was listed for June, July, August, September, or October 2020

On 10/14/2020 at 12:50 PM, a follow-up interview was conducted with the CCO. The CCO stated that they were going to go through the hospital's billing department to get a list of both patients and staff who had been tested for COVID-19.

On 10/14/2020 at 2:25 PM, when asked why the infection log given to the survey team had no information listed since May 2020, the CCO stated hospital staff regularly screened for and were "aware" of infections, but "the log is not up to date."

2. On 10/15/2020 at 3:21 PM, an interview was conducted with the housekeeping manager (HM). The HM stated that he had an employee, housekeeper 1, who tested positive for COVID-19 on 9/26/2020. The HM stated that she had been asymptomatic and was tested by her other employer. The HM stated he was notified on 9/28/2020 by housekeeper 1's other employer of her positive test result and that she had worked at the hospital on 9/25/2020, 9/26/2020, and 9/27/2020. The HM further stated that once he was notified, "I sent her straight home." The HM stated he informed the hospital's chief clinical officer (CCO) and chief executive officer (CEO) of housekeeper 1's positive COVID test. The HM then stated he was "not sure what they did as far as administration here."

3. On 10/20/2020 at 11:14 AM, a telephone interview was conducted with an Infection Preventionist (IP) 1. IP 1 was an employee of the state of Utah and had been working with the hospital. IP 1 stated the "biggest concern" with the hospital was that, "Initially when they had positive staff that it was not followed up on." IP 1 stated according to the information they had, housekeeper 1 tested positive for COVID-19 on 9/24/2020 and continued to work until 9/28/2020. IP 1 further stated CNA (certified nursing assistant) 3 tested positive for COVID-19 on 9/28/2020 and worked on 9/27/2020. IP 1 stated after patient 9 tested positive, they became involved with the hospital and recommended that all staff and patients be tested for COVID-19. IP 1 stated it was expected that at the "very least," the hospital should have notified each patient and staff that had come into contact with that employee of the possible exposure and "ideally testing."

A review of the employee COVID testing log provided to the survey team on 10/15/2020 at 9:24 AM was completed. Neither housekeeper 1 nor CNA 3 could be found on the log.

4. On 10/26/2020 at 11:03 AM, a telephone interview was conducted with the chief clinical officer (CCO) and nurse manager (NM). The CCO stated that if they were informed that a staff member tested positive for COVID-19, the employee would be pulled from the schedule and would not return to work until 10 to 14 days. The CCO stated that if an employee had worked in the three to five days prior to their positive test, contact tracing was done. The CCO stated she could not speak to the process after the housekeeper 1 tested positive because the hospital's housekeeping services were contracted. The CCO further stated she was under the impression "the state" was completing the contact tracing regarding housekeeper 1. The CCO confirmed she had not completed contact tracing or knew of any other hospital staff member that had completed the contact tracing regarding housekeeper 1. The CCO stated there was an "agency CNA" and "agency nurse" that had tested positive for COVID. The CCO stated they had looked back to see when the agency staff members last worked and what patients each had, but they had not kept any documentation regarding these staff members and the completed investigation. The CCO stated once patient 9 tested positive, they "self-reported" to the state and started testing patients and staff for COVID-19.

5. Patient 9 was admitted to the hospital on 9/10/2020 with diagnoses, including respiratory failure, heart failure, extensive wounds, diabetes, asthma, sleep apnea, and end-stage renal disease requiring dialysis.

A review of patient 9's medical record was completed on 10/27/2020.

Physicians documented the following notes in patient 9's medical record:

a. On 9/28/2020 at 9:22 AM, patient 9 was experiencing shortness of breath and a portable chest x-ray was ordered.

b. On 9/30/2020 at 7:26 AM, patient 9 had a cough but no fever.

c. On 9/30/2020, another physician documented, " ...She (patient 9) has had a thick minimally productive cough for the last few days and diagnosed with pneumonia ..."

d. On 10/2/2020, " ...Says she is not feeling well today. She felt well after dialysis ...This morning she has had fatigue, nausea but has not asked for nausea medicines ....She was not coughing while I was in seeing her although she was coughing quite a bit 4 days ago ..."

e. On 10/5/2020 at 9:30 AM, patient 9 continued to have a cough, but her shortness of breath was improving.

f. On 10/6/2020 at 9:39 AM, patient 9 had an increased cough, shortness of breath, and sleepiness. Another chest x-ray was pending, and orders were given for Influenza A, B, and COVID tests to be performed.

g. On 10/6/2020, another physician documented, "She (patient 9) is having a harder time breathing. She is coughing. She is being ruled out for COVID."

h. On 10/7/2020, patient 9 was found to be COVID positive and would be transferred to a local acute care hospital. Note: The laboratory test results regarding patient 9's positive COVID test were verified on 10/7/2020 at 4:10 PM.

Hospital nurses documented the following notes in patient 9's medical record:

i. On 9/28/2020 at 9:28 PM, patient 9 had a cough, was unable to clear secretions, and had course lung sounds.

ii. On 9/30/2020 at 8:30 PM, patient 9 could not stop coughing and could not sleep due to her cough. The physician was notified, and an order for cough medicine was placed.

iii. On 10/4/2020 at 8:00 AM, patient 9 had diminished breath sounds bilaterally, with clear/yellow thick sputum.

iv. On 10/6/2020 at 2:15 PM, " ...Pt (patient) stated having a rough day ...She is able to converse, but does have a hard time speaking. She stated she is having a hard time catching her breath and that's not normal ... BP (blood pressure) slightly high and low grade fever of 99-99.4. will check again in an hour."

v. On 10/6/2020 at 8:30 PM, patient 9 had a cough and was on six liters of oxygen. It was also documented, "I went to do patient's assessment and she was more lethargic than I had seen her before ...Her O2 sats (saturations) kept going off, saying high heart rate. I asked the charge nurse if I should be concerned. I was aware of a hx-of A fib. He told me to plug her into a heart monitor and keep an eye on it. Her bp's were also very low and were beginning to worry about possible sepsis. The charge nurse called the dr, who ordered tele (telemetry) and midodrine to increase her BP."

6. On 10/20/2020 at 11:14 AM, a telephone interview was conducted with IP 1. IP 1 was an employee of the state of Utah and had been working with the hospital. IP 1 stated that they were concerned that patient 9 began developing symptoms of COVID-19 on 9/29/2020 but was not tested for it until 10/6/2020, even with hospital staff members testing positive around the time patient 9 started exhibiting symptoms.

7. On 10/26/2020 at 12:46 PM, an interview was conducted with physician 1, one of the hospital physicians who cared for patient 9. Physician 1 stated that patient 9 had not been tested for COVID-19 until 10/6/2020 because he felt her risk exposure was "almost negligible." Physician 1 further stated he was "not sure where COVID came from" in her case. Physician 1 stated, "None of our staff had it," and that it was "not on our radar." When asked if he had been made aware of housekeeper 1's positive test result on either 9/24/2020 or 9/26/2020 physician 1 stated, "I was not aware of that." When asked if he had been made aware of any other staff members testing positive physician 1 stated, "I don't recall being notified." Physician 1 stated he was unsure how he would think in retrospect, "but if you have someone who has been in and out of patient rooms like a housekeeper ...it would have been more on our radar."

8. On 10/27/2020 at 11:24 AM, a telephone interview was conducted with the hospital's pharmacy director (PD) and co-lead of the antibiotic stewardship program. The PD stated that he and the infectious disease physician co-lead the antibiotic stewardship program, but that the physician was not at the hospital every day and he was, "so a lot falls to me." The PD stated the antibiotic stewardship group used to meet after the hospital's infection prevention committee meeting, but that "we have fallen off our regularity." The PD stated the last formal meeting for the stewardship program was in June or July 2020. The PD stated he tried to perform his antibiotic use analysis but that it had been "two months" since he was last able to complete that analysis. The PD further stated that pharmacy students used to ensure patients were on the correct antibiotics based on the susceptibilities, but that had not been done since April 2020. When asked if he had been completing that process, the PD stated, "Personally I have not done that; I have not had time."

Based on interview and record review it was determined the hospital's infection preventionist did not ensure personnel had competency-based training and education on the practical applications of infection prevention and control guidelines, policies, and procedures. Specifically, employees and contract employees were observed with improper personal protective equipment (PPE) use, and employees/contracted employees (CE) were not trained on infection control policies or PPE use.

Findings include:

On 10/14/2020 at 9:32 AM, a tour of the hospital was provided by the chief clinical officer (CCO). The CCO stated that all patients in the hospital were currently on contact and droplet precautions. The CCO stated all staff should be wearing a gown, mask, and eye protection. The CCO further stated that an N95 mask or PAPR (positive air pressure respirator) was required if a patient had been confirmed COVID positive, was receiving an aerosol producing treatment or had a fever.

1. On 10/14/2020, at approximately 12:00 PM, an interview was conducted with registered nurse (RN) 2. RN 2 stated she was not caring for any patients with any active infections.

A patient census list, including staff assignments, was provided to the survey team. The list indicated RN 2 was caring for patient 3 and that patient 3 was on "STRICT ISO (isolation)" with a Carbapenem-resistant organism and Methicillin-resistant Staphylococcus aureus.

On 10/20/2020, at approximately 9:00 AM, an interview was conducted with RN 2. RN 2 stated she was not aware that patient 3 was on precautions for any infectious diseases. RN 2 further stated she would have to talk to the charge nurse since they were the ones who printed off the "brains" the nursing staff used.

2. On 10/19/2020, the CCO was asked to provide documented training and education of infection control policies, COVID-19 policies and PPE usage.

A document entitled, "Read and Sign 2020 #3 - PPE, N95 Respiratory Mask, PAPR devices & Covid-19 Patient Assessment" was to been given to hospital employees. The employee was to review the information in the document, sign and return the document. There was no documented evidence provided to the survey team that hospital employees or CE had completed the education.

On 3/5/2020 a written document, entitled "Personal Protective Equipment (PPE) Update for our Staff and Medical Team" was given to employees and CE. There was no evidence provided that the hospital employees or CE received, reviewed and understood the PPE update.

No additional information related to infection control was provided.

On 10/15/2020 at 7:22 AM, an observation was made of the kitchen. There was one staff member that did not have a mask on that covered the nose and mouth. When the staff member observed the survey staff, she immediately placed the mask over their nose and mouth.

An interview was conducted with the nutrition manager on 10/15/2020 at 8:00 AM. The nutritional manager stated that she, and her staff, had been trained on COVID-19 and proper PPE usage.


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3. On 10/14/2020 at 10:22 AM, an interview was conducted with the nurse manager (NM). During the interview, an alarm was heard coming from a patient room. The NM proceeded to enter the patient room without a wearing a gown. After leaving the patient's room the NM confirmed all patients were on droplet precautions due to a concern of a COVID-19 outbreak. The NM stated she should have worn a gown into the patient's room.

On 10/14/2020 at 11:04 AM, an interview was conducted with RN 2. RN 2 stated that every patient in the hospital was on droplet precautions due to the concern of a possible COVID-19 outbreak. RN 2 stated she was not sure how many, if any patients were COVID positive, and that she would only need to know, "If they were my patients." During the interview, the call light for room 8 went off. RN 2 was observed to enter room 8 only wearing a surgical mask. A sign was posted on the door which read, "Aerosol-Generating Procedure in Progress DO NOT ENTER AUTHORIZED TRAINED PERSONNEL ONLY PAPR OR N95 (plus) EYE PROTECTION REQUIRED WHILE INSIDE KEEP DOOR CLOSED..." RN 2 was in the patient's room for approximately 30 seconds. RN 2 was then observed to come out of the patient's room and get a hospital gown out of a hall closet; after stepping back into the patient room, RN 2 was observed to place a gown on herself and close the door. Note: RN 2 did not wear an N95 or PAPR either time she entered room 8. RN 2 also left the door to room 8 open when according to the sign posted on the door it should have been kept closed.

On 10/14/2020 at 11:11 AM, after leaving room 8, RN 2 was again interviewed. RN 2 stated she did not need to wear a gown when she initially entered room 8 because she did not get "close" to patient 8. RN 2 further stated that N95 masks were required in "droplet rooms." RN 2 stated 8 was on continuous aerosolization and she should have worn an N95 mask. RN 2 stated, "I completely forgot." RN 2 further stated she changed her surgical mask out every "couple of days" and sprayed her surgical mask at the beginning and end of her shift. RN 2 then stated that she was "new" and, "I haven't had any COVID training. I have never got training." When asked if during orientation infection control was discussed, she stated, "No." RN 2 stated, "I mean PPE, you just know your PPE's." RN 2 further stated she was an agency nurse prior to being hired on as an employee a couple of weeks prior, and "I did not get the six weeks everybody else did."

On 10/14/2020 at 1:04 PM, an observation was made of certified nursing assistant (CNA) 1 taking a patient's vital signs. CNA 1 was in a patient's room, standing next to the patient and taking a blood pressure cuff off of the patient's right arm. CNA 1 was wearing a facemask and gloves. Immediately after leaving the patient room, CNA 1 was interviewed. CNA 1 stated although each patient was on droplet precautions, she did not need to wear a gown into patient rooms unless she was "changing them or something."

On 10/14/2020, from 1:54 PM to 1:57 PM, the door to room 8, a room with continuous aerosolization occurring, was left open by hospital staff. At 1:57 PM the hospital's dietician asked another hospital staff member if the door to room 8 should be closed. The staff member stated it should be, and the dietician proceeded to shut the door.

On 10/15/2020 at 8:00 AM, CNA/telemetry technician 2 was sitting at the main nursing station screening the surveyors for signs or symptoms of COVID-19. CNA/telemetry technician 2 was observed to have his surgical facemask down underneath his nose; in the middle of checking the surveyors in, he was observed to pull his facemask over his nose.

On 10/15/2020 at 8:10 AM, charge nurse (CN) 1 was observed to enter a patient's room wearing a mask. CN 1 did not don any additional PPE. Upon exiting the patient room, CN 1 did not perform hand hygiene.

CN 1 was immediately interviewed upon exiting the patient room. CN 1 was asked why he only donned a mask and did not perform hand hygiene. CN 1 stated, "I haven't worked in two weeks and I'm not sure about all of the changes." CN 1 stated a mask, gown, and gloves were required prior to entering a patient room. CN 1 was asked if he had been educated on recent COVID-19 changes. CN 1 stated "Not really, this is my first shift in two weeks."

On 10/15/2020 at 8:23 AM, an observation was made of CNA 2 passing a meal tray. CNA 2 was observed to enter a patient's room with the meal tray, talk with the patient for several seconds, and then leave the patient room. The only PPE CNA 2 was observed to be wearing throughout the observation was a surgical facemask.

On 10/15/2020 at 8:27 AM, an interview was conducted with CNA 2. CNA 2 stated each patient was on droplet precautions. CNA 2 stated that if a patient was on droplet precautions staff were supposed to wear a mask, gown, gloves, and eye protection when in the patient's room. CNA 2 then stated she was told she did not have to wear a gown into a patient room unless "I am going to do cares."

On 10/20/2020, from 7:45 AM to 8:15 AM, several observations were made of the door to room 30 being open. A sign on the door read, "Aerosol-Generating Procedure in Progress DO NOT ENTER AUTHORIZED TRAINED PERSONNEL ONLY PAPR OR N95 (plus) EYE PROTECTION REQUIRED WHILE INSIDE KEEP DOOR CLOSED..."

4. On 10/14/2020 at 10:09 AM, an interview was conducted with respiratory therapist (RT) 1. RT 1 was unaware that each patient was on droplet precautions due to a concern of a COVID-19 outbreak at the hospital.

An interview was conducted with CN 3 on 10/14/2020, related to education and training. CN 3 stated that there was online training specific to COVID-19. CN 3 stated that competency packets were given to employees to review and that there was a question and answer period during staff meetings. CN 3 stated, "I don't have a lot of extra time for the training."

An interview was conducted with RN 2 on 10/15/2020 at 10:15 AM. RN 2 was asked if she had training related to infection control. RN 2 stated that she had a lot of infection control material to review as well as almost daily updates on COVID-19. RN 2 stated that she did not have time to complete these trainings.

On 10/16/2020 at 2:38 PM, a telephone interview was conducted with CNA 5. CNA 5 stated that staff members, especially agency staff members, did not know the appropriate infection control practices because they had not received training. CNA 5 stated the hospital did not have an infection control manager "because they cut that position." CNA 5 stated she had been in patient 1's room providing care to him just before he was diagnosed with COVID and had only been wearing gloves. CNA 5 stated another co-worker told her that patient 1 had tested positive but had not been told by the administration about her exposure.

On 10/19/2020 at 11:32 AM, a telephone interview was conducted with CNA 4. When asked what training she had received on isolation precautions and the PPE required, CNA 4 stated, "I was never really trained in precautions." CNA 4 stated she asked a lot of questions to find out what she was supposed to be doing but that she has been getting "mixed messages." CNA 4 stated that as an example, she was not sure how long she could use her N95 mask for. When she asked, she was told she could wear the same mask for multiple days and then later she was told that if she reused her N95 mask, she needed to wait five days between uses. CNA 4 stated she had worn the same N95 mask for three shifts in a row because she "did not know." CNA 4 stated she was fit tested for an N95 mask but did not receive any training regarding its use.

On 10/19/2020 at 12:41 PM, a telephone interview was conducted with RN 3. RN 3 stated that the infection control and education departments had been "eliminated." RN 3 stated, "They did not even teach us how to do a COVID test. We had to look it up on YouTube to figure it out." RN 3 then stated when the hospital had its COVID unit staff showed up to work, was handed a "little" packet, and told, "we have this COVID unit, and you need to work over there." RN 3 stated, "You are responsible for your own education."

Based on interview and record review, it was determined that the antibiotic stewardship program leaders did not ensure the program was fully functional. (Patient identifiers: 1)

Findings include:

1. On 10/27/2020 at 11:24 AM, a telephone interview was conducted with the hospital's pharmacy director (PD) and co-lead of the antibiotic stewardship program. The PD stated that he and the infectious disease physician co-lead the antibiotic stewardship program, but that the physician was not at the hospital every day and he was, "so a lot falls to me." The PD stated the antibiotic stewardship group used to meet after the hospital's infection prevention committee meeting, but that "we have fallen off our regularity." The PD stated the last formal meeting for the stewardship program was in June or July 2020. The PD stated he tried to perform his antibiotic use analysis but that it had been "two months" since he was last able to complete that analysis. The PD further stated that pharmacy students used to ensure patients were on the correct antibiotics based on the susceptibilities, but that had not been done since April 2020. When asked if he had been completing that process, the PD stated, "Personally I have not done that; I have not had time."


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2. Patient 1 was admitted to the hospital on 9/18/2020 with diagnoses which included right chest wall empyema necessitans with necrotizing fasciitis of the overlying tissue and rib osteomyelitis, recent septic shock, acute respiratory failure and methicillin-susceptible staphylococcus aurea urinary tract infection.

Patient 1's medical record was reviewed on 10/22/2020.

Admission orders to the hospital were reviewed. Cefazolin (Ancef) 8 grams (g) was to be administered intravenously (IV) every 24 hours.

On 9/22/2020, the wound care team obtained an order to do a culture and sensitivity, aerobic and anaerobic, to the right chest wall wound.

On 9/25/2020 at 7:24 AM, the wound culture returned with Enterobacter cloacae with gram negative bacilli. The organism was resistant to Cefazolin.

Patient 1 was seen by the primary care physician on 9/26/2020 at 7:37 AM and 9/27/2020 at 7:31 AM. The primary care physician did not address the wound culture results that were resistant to Cefazolin.
Patient 1 continued to receive the Cefazolin until 9/28/2020 when the primary care physician wrote an order to discontinue the Cefazolin and start Zosyn 3.375 g IV every six hours. Patient 1 received the first dose of Zosyn on 9/28/2020 at 3:00 PM.

An interview was conducted with patient 1's nurse manager (NM) on 10/21/2020 at 3:04 PM related to the wound culture. The NM stated that laboratory results were doubled checked by the nurses and the providers every morning. The NM stated that laboratory results were also sent to the pharmacist for review. The NM stated that she was not sure why patient 1 remained on the Cefazolin after 9/25/2020 when the wound culture results were available.

An interview was conducted with the chief clinical officer (COO) on 10/26/2020 at 11:04 AM related to the wound culture results and why the results were not acted on until 9/28/2020. The COO stated the physician that was working 9/25/2020 through 9/27/2020 was not patient 1's primary care physician and was not sure why the laboratory results were not acted on until 9/28/2020.