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Based on observation, record review, and staff interview, the hospital's infection prevention and control program failed to ensure a clean and sanitary environment and avoid sources of infection transmission in 4 (Main Respiratory Room, 6th Floor Ornealas Tower, 4th Floor Bradley Thompson Tower, Neonatal Intensive Care Unit) of 4 areas of the hopsital when,

A. Patient equipment was not cleaned and stored in a manner which prevented contamination (Main Respiratory Room, 6th Floor Ornelas Tower, and 4th Floor Bradley Thompson Tower).

B. Biohazard waste was not properly discarded (6th Floor Ornelas and 4th Floor Bradley Tompson Tower).

C. Personal protective equipment (PPE) was not worn as required per the hospital's policy and isolation precautions were not initiated timely in 2 (Patient #'s 1 and 8) of 9 sampled patients

D. One (Staff # 5) of 4 staff members entered Patient # 1's room without any personal protective equipment (PPE). The hospital staff failed to follow the hospital policy, "Standard and Transmission Based Precautions".

E. Dust, dirt, and other unknown debris were found within the hospital's Neonatal Intensive Care Unit (NICU) and breast milk storage and supply room. The hospital failed to follow the policy titled "Neonatal Intensive Care Unit Standards of Care".

(Cross Refer to Tag A0747)

Based on observation, record review, and staff interview, the hospital's infection prevention and control program failed to ensure a clean and sanitary environment and avoid sources of infection transmission in 4 (Main Respiratory Room, 6th Floor Ornealas Tower, 4th Floor Bradley Thompson Tower, Neonatal Intensive Care Unit) of 4 areas of the hospital when,

A. Patient equipment was not cleaned and stored in a manner which prevented contamination (Main Respiratory Room, 6th Floor Ornelas Tower, and 4th Floor Bradley Thompson Tower).

B. Biohazard waste was not properly discarded (6th Floor Ornelas and 4th Floor Bradley Tompson Tower).

C. Personal protective equipment (PPE) was not worn as required per the hospital's policy and isolation precautions were not initiated timely in 2 (Patient #'s 1 and 8) of 9 sampled patients

D. One (Staff # 5) of 4 staff members entered Patient # 1's room without any personal protective equipment (PPE). The hospital staff failed to follow the hospital policy, "Standard and Transmission Based Precautions".

E. Dust, dirt, and other unknown debris were found within the hospital's Neonatal Intensive Care Unit (NICU) and breast milk storage and supply room. The hospital failed to follow the policy titled "Neonatal Intensive Care Unit Standards of Care".

Findings include:

During an observation on 04/08/2025 at 10:09 a.m. the following was observed:

Main Respiratory Storage Room

Ten (10) plus ventilators were stored in a room and were tightly packed together on one side of the room. The ventilators were identified as being clean. Some of the ventilators in the room had the tubing attached. The electrical plugs were wrapped around the back of the equipment and hanging loosely. When staff were walking by the ventilators to get other equipment, they were brushing up against the tubing that was attached to the ventilators. The equipment was not covered to prevent dust and contamination. There were four shipping boxes sitting on the floor in the room and were sitting next to open bins of respiratory supplies. An electrostatic spirometry filter was found on top of one of the shipping boxes. An unbagged respiratory tubing was lying on the floor next to one of the ventilators in the room.

Staff #19 and 37 confirmed the observations.


6th Floor Ornelas

An isolation cart in front of Room #6606 had a base that was soiled with dust and dirt particles. The white rubber protective covering at the base was soiled with brown and black marks.

An isolation cart in front of Room #6619 had a base that was soiled with dust and dirt particles. The white rubber protective covering at the base was soiled with brown and black marks. Hair was tangled in one of the wheels on the cart. At the front of the bottom drawer of the cart there was a buildup of dried brown substance. Behind the cart was a glove and paper on the floor.

A Stryker wheelchair was stored in a nook in the hallway. The wheels and frame of the chair was soiled dirt, dust and black substance. One section of the frame had an area that was cracked and there soiled peeling tape over the area.

An isolation cart in front of Room #6647 had a white base which was covered in black scuff marks.


Soiled utility room #OT60037
Had an open hard plastic biohazard bin which had a blue bag stored in it. The blue bag was closed and full. On top of the blue bag was an empty blood bag with the tubing attached. The tubing line was full of red blood. The blood and bag were not contained within a red bag.

According to signs on the wall above the biohazard box the following was recorded:

"ALL ITEMS MUST BE PLACED IN RED BAGS PRIOR TO PLACEMENT IN HAZMAT CONTAINER"

"REGULATED MEDICAL WASTE. These DO go in the red bag:
Saturated Gauze
Saturated Bandages
Blood Saturated Items
Blood & Body Fluids
Closed Sharps Disposable Containers
Visibly Bloody Gloves
Visibly Plastic Tubing"
Visibly Contaminated PPE


In the hallway on the 6th floor there was a food tray cart which was filled with patient trays. The outside of the cart was covered with dried brown spills. The base of the cart had a build-up of dried brown substance.

Soiled utility room #OT600014
An oxygen tank holder had a base that was covered in rust. The rust build-up prevented the ability to sanitize the equipment.
Staff #'s 19 and 20 confirmed the observations.

4th Floor Bradley Thompson Tower

BT4055 (intensive care unit) Soiled utility room
An open trash can was in the room and did not have a bag lining it. Inside the trash can was used intravenous bag, tubing, respiratory tubing and gloves.


BT4041 (intensive care unit) Soiled utility room
Two clean pillows were on top of a soiled cart.
The top and back of a bear hugger in the room was soiled with white debris.
A rapid infuser pump had dried red substance on the wheels which had the appearance of blood.

Staff #34 identified the room as a clean utility room and said that the equipment was cleaned daily.


Patient #8

Review of the record of Patient #8 revealed she was a 55 -year -old female who presented to the Emergency department (ED) on 04/03/2025 for left flank pain. Patient #8 had diagnoses which included sepsis, urinary tract infection and pyelonephritis.

Review of lab revealed Patient #8 had a blood culture collected on 04/02/2025 and it resulted on 04/04/2025 as being positive for gram positive clusters.

Review of a lab communication record revealed that nursing was notified of the results on 04/04/2025 at 8:05 a.m.

Review of lab revealed Patient #8 had a second blood culture on the specimen collected on 04/02/2025 and it resulted on 04/05/2025 as being positive for Staphylococcus aureus.

Review of lab revealed Patient #8 had a third blood culture collected on the specimen that was collected on 04/02/2025 and it resulted on 04/06/2025 as being positive for Methicillin-Resistant Staphylococcus aureus (MRSA).

Review of a lab communication record revealed that nursing was notified of the results on 04/06/2025 at 6:31 a.m.

Review of nursing documentation revealed that on 04/06/2025 at 7:52 a.m., the physician was notified that the cultures were growing MRSA. "Waiting for response and no new orders."

According to the medical record Patient #8 was placed on contact isolation on 04/07/2025 3:51 am was the first documentation of Patient #8 being in isolation. Patient #8 was not placed in isolation timely.

During an interview on 04/09/2025 after 9:00 a.m., Staff #28 confirmed the lab results, not finding a physician order for isolation and that the first mention of isolation was by nursing on 04/07/2025.

During an interview on 04/09/2025 after 11:58 a.m.., lab Staff #'s 35 and 36 confirmed the lab results and notification made to nursing staff.

Review of the hospital's policy titled, "Standard and Transmission Based Precautions" dated 02/2023 revealed,
"...In addition to standard precautions, transmission-based precautions should be used for patients with documented or suspected infection with highly transmissible or epidemiologically-important pathogens for which additional precautions are needed to prevent transmission."




48653

Findings include:

D.

A review of Patient # 1's medical records with Staff # 11 on 04/08/2025 in the administrative board room revealed,

Patient # 1

Patient # 1 was admitted to the Neonatal Intensive Care Unit (NICU) on 10/18/2024 at 7:25 PM following an emergent cesarean section due to maternal hemorrhage. The patient was born extremely pre-maturely at 22 weeks and 0 days of gestation and required neonatal resuscitation protocol (NRP).

The patient tested positive for MRSA (Methicillin-Resistant Staphylococcus Aureus) of the nares on 02/04/2025 at 5:20 AM.

The patient was placed on contact isolation precautions on 02/04/2025 by Physician # 38.

A review of video footage dated 02/18/2025, released by the hospital's risk management department, revealed the patient was in contact isolation precautions and required respiratory therapy support. Staff # 5 (Respiratory Therapist) was seen on the video entering the patient's room on 02/18/2025 at 1:29 PM without any personal protective equipment (PPE) donned. Staff # 5 entered the patient's contact isolation room without taking the required precautions, including donning an isolation gown.

This deficient practice had the likelihood to result in the spread of MRSA to other neonatal patients in the hospital's NICU by failure to wear the required personal protective equipment.

A review of the hospital's policy titled "Standard and Transmission-Based Precautions" dated 02/2023 revealed,
"...In addition to standard precautions, transmission-based precautions should be used for patients with documented or suspected infection with highly transmissible or epidemiologically important pathogens for which additional precautions are needed to prevent transmission."

A review of the hospital's policy titled "Neonatal Intensive Care Unit Standards of Care" with a date of 08/2024 revealed,
"...POLICY: 1. Safety: 1.1 General: a. All healthcare team members will provide safe and secure environment for patients, employees, medical staff, and visitors....d. PPE. i. PPE will be worn as directed based on the potential risk of exposure.
ii. Entrance to room without PPE is prohibited and will only increase the spread of nosocomial infections, especially to our extremely vulnerable population..."

A review of Staff # 5's personnel file revealed Staff # 5 received training titled, "Personal Protective Equipment (PPE)" on 04/04/2024. The training includes, "Verbalizes understanding of Standard, Airborne, Droplet & Contact isolation precautions".

An interview was conducted with Staff # 11 on 04/08/2025 at 11:45 AM. Staff # 11 confirmed that Staff # 5 entered the patient's room without the appropriate PPE. Staff # 11 confirmed Staff # 5 did not receive any additional education or corrective action following the video footage findings.


E.

During a tour of the hospital's Neonatal Intensive Care Unit (NICU) on 04/08/2025 at 9:30 AM with Staff # 11 and # 12, the surveyor observed the following environmental infection control issues,

There was a build-up of dust located on top of patient care supplies and equipment within the "acute side" of the neonatal intensive care unit's supply storage area. There were various arts and crafts supplies mixed in with patient care supplies. The counters were cluttered, and there was a thick layer of dust buildup on the patient supplies.
The hand sanitizer dispenser located outside of the milk storage and supply room had a thick build-up of dust on the top.

The surveyor entered the milk room storage and supply room and observed 3 large refrigerators and 1 large freezer used to store breast milk. The refrigerators had a build-up of a dried, white, crusty substance on the bottom shelf. There was also a build-up of dust, dirt, and other particles located in the bottom of the refrigerator. The vents located at the top of the refrigerators had a build-up of unknown black substances.

There was dust, dirt, and other unknown debris located inside 4 clear, plastic storage bins within the milk storage and supply room. The bins were used to hold supplies used in patient care.

There were computers and keyboards located at the stations outside of the patient rooms. There was a build-up of dust on the computer and keyboard located on the "acute side" directly in front of the patient's cardiac monitoring screens.

A review of the hospital's policy titled "Neonatal Intensive Care Unit Standards of Care" with a date of 08/2024 revealed,
"...POLICY: 1. Safety: 1.1 General: a. All healthcare team members will provide a safe and secure environment for patients, employees, medical staff, and visitors....d. PPE. i. PPE will be worn as directed based on the potential risk of exposure ...
g. Cleaning:
i. Patient care areas will be cleaned using hospital-approved disinfectant at the start of every shift, including monitors, keyboards, mouse, bedside carts, chairs, pumps, isolette doors and drawers, cribs and drawers, milk warmers, etc.
iv. Computer stations will be cleaned using hospital-approved disinfectant at the start of every shift, including monitors, keyboards, mouse, chairs, countertops, etc ...."

An interview was conducted with Staff # 11 and # 12 on 04/08/2025 at 10:30 AM, which confirmed the presence of environmental infection control issues in the NICU. Staff # 11 and # 12 were present during all of the observations inside the NICU.

Based on observation, interview and record review the facility failed to ensure 2 of 9 sampled patients who were on non-invasive ventilation and oxygen therapy had physician's orders and waivers for home equipment usage (Patient #'s 3 and 9).

Patient #9 was on continuous positive airway pressure (C-PAP) ventilation and staff failed to get physician's orders for settings and usage. Staff failed to obtain a waiver for home equipment usage.

Patient #3 was on a Bilevel positive airway pressure (Bi-PAP) ventilation and continuous oxygen therapy and staff failed to get physician's orders for rate and settings for both. Staff failed to obtain a waiver for home equipment usage.

This deficient practice had the likelihood to affect all patients on non-invasive ventilation and oxygen therapy.

Findings include:


Patient #9

During an interview on 04/08/2025 at 11:05a.m, Staff #24 said that respiratory staff were responsible for setting up C-PAP and BIPAP's and then nursing takes over the care.

During an observation on 04/08/2025 at 11:15 a.m., Patient #9 was observed to have a C-PAP on the nightstand at bedside. Patient #9 and his spouse confirmed it belonged to him and that he uses it at night and anytime during the day when he is sleeping.


Review of the clinical record on Patient #9 revealed he was a 53-year-old male who presented to the Emergency department (ED) on 04/05/2025 for complaints of a possible seizure.

Review of a physician's history and physical dated 04/05/2025 revealed Patient #9 was C-PAP dependent and had sleep apnea.

Review of the record revealed no documentation of physician's orders for usage and settings for the C-PAP.

During an interview on 04/08/2025 after 11:20 a.m. the following was stated:

Staff #21 confirmed she could not find a physician's order for the usage of a C-PAP on Patient #9.

Respiratory staff #25 said that usually when the patient comes in through the ED with a C-PAP the ED physician writes an order for it. That order follows the patient throughout their stay. If they bring theirs from home, they have to sign a waiver that they are responsible for it. The physician writes an order for usage of the equipment.
Staff #25 confirmed she could not find a physician's order nor a waiver for Patient #9.

Staff #'s 19 and 20 said a waiver had been found. The waiver was provided to the surveyor, it was dated for 04/08/2025, but it was not timed. When asked when it was signed, they said today at 11:15 a.m.


Patient #3

Review of the clinical record of Patient #3 revealed she was a 63-year-old female who presented to the ED on 01/23/2025 with complaints of shortness of breath. According to the record Patient #3 had Stage IV chronic obstructive pulmonary disease (COPD) and hypertension. There was documentation that Patient #3 was held overnight at Good shepherd, on continuous oxygen at 3 liters per nasal cannula and uses a BIPAP at night.

On 01/24/2025 Patient #3 was transferred to the Tyler facility and admitted to inpatient status.

Review of physician's orders revealed Patient #3 was to have oxygen to keep her oxygen saturation above or equal to 92 percent. There was no order for how many liters to infuse the oxygen.

Review of nurses and respiratory notes revealed the following:

On 01/26/2025 at 8:00 a.m. Patient #3 was on oxygen at 3 liters per nasal cannula. At 10:34 a.m. Patient #3 had an oxygen saturation of 91 percent.
On 01/26/2025 at 8:10 p.m. Patient #3 was on oxygen at 3 liters per nasal cannula. At 11:16 p.m. Patient #3 had an oxygen saturation of 90 percent.
On 01/28/2025 at 8:51 a.m. Patient #3 was on oxygen at 3 liters per nasal cannula and had an an oxygen saturation of 90 percent.
On 01/28/2025 at 11:32 p.m. and 01/29/2025 at 3:52 a.m. there was documentation of Patient #3 being on a BiPAP home unit.
On 01/28/2025 at 11:32 p.m. and 01/29/2025 at 3:52 a.m. there was documentation of Patient #3 being on a BiPAP home unit.

During an interview on 04/09/2025 after 9:00 a.m., Staff #28 confirmed not finding documentation of interventions for the decreases in the oxygen saturations, no physician's order for the BIPAP, nor a waiver for usage of a home unit.

Review of a facility's policy named "Patient Privately-Owned Medical Equipment" revised on 10/2021 revealed the following:

" ...VI STAKEHOLDERS: ...
. B. Physician: The physician is responsible for determining the suitability of using the patient's privately-owned equipment. The physician is also responsible for documenting, in the patient's medical record, the basis for the decision to approve or deny its use, and, if approved, and preparing an order for the use of the equipment.
C. Clinical Department: The appropriate clinical department is responsible for obtaining a signed Consent & Waiver upon admission or initiation of privately -owned equipment use ..."