HospitalInspections.org

Based on review of facility policy and medical records (MR) and staff (EMP) interview, it was determined the facility failed to follow their approved policy regarding requesting a copy of an advance directive (MR22) and providing information to patients without an advance directive (MR32) for two of seven applicable MRs reviewed.

Findings include:

Review on March 8, 2022, of facility policy "Advance Directives," last reviewed on September 15, 2021, revealed "...Policy: In compliance with the Patient Self-Determination Act and Pennsylvania Law, Act 169 of 2006, it is the policy of the Hospital to ascertain whether or not adult patients being admitted have an advance directive (a living will or power of attorney). The Hospital will provide information to these patients about advance directives. ... Procedures: ...2. General Information Information Regarding Advance Directives a) Printed materials will be offered to patients (or their representative) in the Emergency Department, admitted patients, both inpatient and observation status, or patients having procedures performed in one day/same day surgery. The printed materials will be presented at the time of registration. These materials will provide general information on advanced directives. ... c) Nursing Staff addresses advance directives with patients during the initial nursing assessment. All patients (or their Health Care Representatives, as applicable) will be asked if they have an advance directive upon admission. If the patient has an advance directive, a copy is requested for the chart. If a patients [sic] has an advance directive, but it is not with the patient at the time of arrival, nursing staff shall request the name and contact information for the person or persons who will be requested to bring a copy of the advance directive for inclusion in the patient chart. d) If the patient has no advance directive, the patient (or the Health Care Representative, as applicable) shall be provided with information about advance directives, including direction to the Commonwealth of Pennsylvania's website that offers forms for individuals to use in developing an advance directive. ..."

Review on March 8, 2022, revealed documentation in MR22 indicated s/he had an advance directive. There was no documentation in MR22 of an advance directive or that his/her representative was requested to provide a copy of the advance directive.

Interview with EMP3 on March 8, 2022, confirmed there was no documentation in MR22 requesting a copy of his/her advance directive.

Review on March 8, 2022, revealed documentation in MR32 indicated s/he did not have an advance directive. There was no documentation in MR32 s/he or his/her representative was provided with information about an advance directive.

Interview with EMP5 on March 8, 2022, at 1400 confirmed MR32 did not have an advance directive. EMP5 further confirmed MR32, or his/her representative was not provided with information about an advance directive.

Based on facility documentation, review of medical records (MR) and staff (EMP) interview, it was determined the facility failed to ensure patients were given the opportunity to have a family member or representative of his or her choice and his or her own physician notified promptly of his or her admission to the hospital for four of four medical records reviewed (MR22, MR23, MR24, and MR25).

Findings include:

Review of the facility brochure "Patient Rights and Responsibilities,"no date noted revealed "Your Rights...Communication You have the right to: Have a family member, another person that you choose, or your doctor notified when you are admitted to the Hospital. ..."

Review on March 8, 2022, of MR22, MR23, MR24, and MR25 revealed there was no documentation the patients were given the opportunity to have a family member or representative of his or her choice and his or her own physician notified promptly of his or her admission to the hospital.

Interview with EMP3 on March 10, 2022, at 1045 confirmed there was no documentation MR22, MR23, MR24 and MR25 were given the opportunity to have a family member or representative of his or her choice and his or her own physician notified promptly of his or her admission to the hospital. EMP3 further confirmed the facility did not have a process for querying patients of their wish to have a family member or representative and physician notified of a hospital admission.

Based on review of facility documents, medical records (MR), and staff (EMP) interview, it was determined the facility failed to ensure use of restraint in accordance with physician order for two out of four medical records reviewed (MR67 and MR68).

Findings include:

Review on March 9, 2022, of facility policy "Physical Restraints/Chemical Restraints," last reviewed November 2,2021, revealed "Purpose: The purpose of this policy is to 1. Prevent interference/obstruction with medical treatment (such as self extubation and intubation). 2. protect medical devices (such as intravenous lines, in-dwelling urinary catheters, and feeding tubes). 3. prevent falls and injury. ... Procedures: ... 2. Use of Restraints in Medical or Post-Surgical Care: a) When clinically indicated, the restraint procedure is implemented by an RN who is trained in restraint technique upon physician's/L.I.P. [licensed independent practitioner] order. ... d) If the restraint is discontinued prior to the expiration of the order, and reinitiating of the restraint is indicated, a new order must be obtained. ..."

Review on March 9, 2022, of MR67, revealed documentation MR67 had bilateral mitt restraints in place on July 9-19, 2021. There were no physician or L.I.P written orders for restraints on July 11 and 14-18, 2021.

Interview with EMP3, on March 9, 2022, at 1335, confirmed MR67 had bilateral mitt restraints in place on July 9-19, 2021. EMP3 confirmed MR67 had no physician or L.I.P written orders for restraints for July 11 and 14-18, 2021. EMP3 confirmed MR67 had restraints on for non-violence, medical use. EMP3 confirmed for non-violent restraint use, medical use, the order is for 24 hours. If the restraint is still needed after the 24 hours, a new order is required.

Review on March 9, 2022, of MR68, revealed documentation MR68 had bilateral wrist restraints in place on October 27-31 and November 1-3, 2021. There were no physician or L.I.P written orders for restraints on October 28-30 and November 2-3, 2021.

Interview with EMP3, on March 9, 2022, at 1345, confirmed MR68 had bilateral wrist restraints in place on October 27-31 and November 1-3, 2021. EMP3 confirmed there were no physician or L.I.P written orders for restraints for October 28-30 and November 2-3, 2021. EMP3 confirmed MR67 had restraints on for non-violence, medical use. EMP3 confirmed for non-violent restraint use, medical use, the order is for 24 hours. If the restraint is still needed after the 24 hours, a new order is required.

Based on review of facility documents, medical records (MR), and staff (EMP) interview, it was determined the facility failed to ensure four physicians writing orders for restraints completed restraint education on hire and annually.

Findings include:

A request was made on March 11, 2022, for the hospital ' s policy for training requirements for physicians and other licensed independent practitioners. No policy was provided.

Interview with EMP7, on March 11, 2022, at 1400, confirmed restraint education was to be completed on hire and yearly.

Review on March 11, 2022, of MR67 revealed OTH1 treated the patient on July 10-11, 2021. There was a written order by OTH1 for bilateral mitts on July 10, 2021.

Interview with EMP7, on March 11, 2022, at 1350, confirmed OTH1 treated MR67 on July 10-11, 2021. EMP7 confirmed OTH1 wrote a restraint order for the bilateral mitts on July 10, 2022.

Review on March 11, 2022, of MR67, revealed OTH2 treated the patient on July 12-18, 2021. There was a written restraint order by OTH2 for bilateral mitts on July 12-13, 2021.

Interview with EMP7, on March 11, 2022, at 1350, confirmed OTH2 treated MR67 on July 12-18, 2021. EMP7 confirmed OTH2 wrote a restraint order for the bilateral mitts on July 12-13, 2022.

Review on March 11, 2022, of MR67, revealed OTH3 treated the patient on July 19-20, 2021. There was a written restraint order by OTH3 for bilateral mitts on July 19-20, 2022.

Interview with EMP7, on March 9, 2022, at 1350, confirmed OTH3 treated MR67 on, July 19-20, 2021. EMP7 confirmed OTH3 wrote a restraint order for the bilateral mitts on July 19-20, 2022.

Review on March 11, 2022, of MR68, revealed OTH2 treated the patient on October 27-31, 2021. There was a written restraint order by OTH2 for bilateral mitts for October 29 and 31, 2021.

Interview with EMP7, on March 11, 2022, at 1355, confirmed OTH2 treated MR68 on October 27-31, 2021. EMP7 confirmed OTH2 wrote a restraint order for the bilateral mitts for October 29 and 31, 2021.

Review on March 11, 2022, of MR68, revealed OTH4 treated the patient on November 1-9, 2021. There was a written restraint order by OTH4 for bilateral mitts for November 1, 4-9, 2021.

Interview with EMP7, on March 11, 2022, at 1355, confirmed OTH4 treated MR68 on November 1-9, 2021. EMP7 confirmed OTH4 wrote a restraint order for bilateral wrist restraints on November 1, 4-9, 2021.

A request was made on March 11, 2022, for the restraint education for OTH1, OTH2, OTH3, and OTH4. No restraint education was provided.

Interview with EMP7, on March 11, 2022, at 1400, confirmed there was no documentation OTH1, OTH2, OTH3, and OTH4 completed the hospital restraint education.

Cross Reference
482.13(e)(5) Patient Rights: Restraint or Seclusion

Based on review of facility policy and medical records (MR) and staff (EMP) interviews, it was determined the facility failed to ensure staff followed established policies and procedures regarding pain reassessment for four of ten applicable MRs reviewed (MR22, MR14, MR15, and MR30).

Review on March 8, 2022, of the facility's "Medication Administration" policy, last reviewed January 24, 2022, revealed ..."Purpose: The purpose of this policy is to establish guidelines to promote the health and safety of persons served by ensuring the safe administration of medication and treatments or other necessary procedures. ...Procedures: ...3. Charting - In Areas Using Scanning...f. Pain Control Effectiveness i. The effectiveness of pain medications should be assessed and documented within one hour after the dose is administered. ..."

Review on March 8, 2022, revealed MR22 was administered pain medication on March 4, 2022, at 2107, March 5, 2022, at 1127, and March 6, 2022, at 0807. There was no documentation in MR22 of pain reassessment following administration of the pain medications on those dates and times.

Interview with EMP3 on March 8, 2022, at 1100, confirmed no documentation was present in MR22 of pain reassessment following pain medication administration on March 4, 2022, at 2107, March 5, 2022, at 1127, and March 6, 2022, at 0807.

Review on March 7, 2022, revealed MR14 was administered pain medication on September 28, 2021, at 0748. There was no documentation in MR14 of pain reassessment following administration of the pain medication.

Interview with EMP4, on March 7, 2022, at 1500, confirmed no documentation was present in MR14 of pain reassessment following pain medication administration on September 28, 2021, at 0748.

Review on March 8, 2022, revealed MR15 was administered pain medication on December 6, 2021, at 1155, and December 8, 2021, at 0854. There was no documentation in MR15 of pain reassessment following administration of the pain medications on those dates and times.

Interview with EMP7, on March 8, 2022, at 1440, confirmed no documentation was present in MR15 of pain reassessment following pain medication administration on December 6, 2021, at 1155, and December 8, 2021, at 0854.

Review on March 8, 2022, revealed MR30 was administered pain medication on December 31, 2021, at 2028, January 1, 2022, at 1025, January 1, 2022, at 2101, January 2, 2022, at 2109, and January 3, 2022, at 1139. There was no documentation in MR30 of pain reassessment following administration of the pain medications on those dates and times.

Interview with EMP7, on March 8, 2022, at 1455, confirmed no documentation was present in MR30 of pain reassessment following pain medication administration on December 31, 2021, at 2028, January 1, 2022, at 1025, January 1, 2022, at 2101, January 2, 2022, at 2109, and January 3, 2022, at 1139.

Based on review of facility policy, tour and observation, and staff (EMP) interview, it was determined the facility failed to ensure proper storage of sterilized instruments and clean equipment, failed to maintain solid surface bottoms of storage carts of clean supplies, failed to follow facility policy regarding dating supplies with expiration dates and failed to properly warm patient cleansing cloths; the facility failed to ensure blanket warmer at the appropriate temperature in accordance with policy and failed to document the corrective actions taken for out-of-range temperatures; the facility failed to ensure nutrition refrigerator temperature taken daily in accordance with policy and failed to document corrective actions taken for out-of-range temperatures and the facility failed to ensure supplies/medication maintained within expiration dates.

Findings include:

Review of facility policy "Cleaning, Disinfection, Sterilization & Storage of Patient Care Equipment," last reviewed August 2020 revealed "Purpose: The purpose of this policy is to provide supplies and equipment that are adequately cleaned, disinfected and/or sterilized. Policy: This policy provides guidelines for the recognition of clean or soiled equipment and guidelines for storage. ... Procedure: 1. Only clean equipment is stored in the clean equipment area. ... All other equipment that is not clean or cannot be cleaned immediately after use shall be placed in the dirty utility area until cleaned. 2. Only soiled equipment is stored in the soiled or "dirty" area. ... 6. a) Critical items i. Objects that enter sterile tissue or the vascular system are defined by the CDC [Centers for Disease Control] as critical items. They carry a high risk of infection if they become contaminated. Critical items must be sterile. ii. ... a. Items purchased as sterile must be used before the manufacturer's expiration date if one is given. Inspect package integrity before use and if packaging compromised (i.e. wet, torn, or appears to have been wet at one time) do not use the item. ..."

Tour and observation of the outpatient pain clinic with EMP1, EMP11 and EMP12 on March 10, 2022, at 1110 revealed storage of sterilized instruments in a sterile pack located in the dirty utility room.

Interview with EMP11, on March 10, 2022, at 1115, confirmed the sterilized instruments were in the dirty utility room and indicated the courier must have dropped them off in the soiled utility room without the clinic's knowledge.

Tour and observation of the outpatient wound clinic with EMP1, EMP13 and EMP14 on March 10, 2022, at 1135, revealed two storage carts in the clean supply closet and two storage carts in the clean equipment storage with open wire bottoms and each area with storage of patient clean and/or sterile supplies on the bottom racks in cardboard boxes which have the potential for contamination during wet mopping.

Interview with EMP13 on March 10, 2022, at 1140, confirmed the open wire bottoms of the four shelving units including two in the clean supply and two in the clean equipment storage rooms with storage of patient clean and/or sterile supplies on the bottom racks in cardboard boxes.

Review of facility policy "[Name of] Glucose Meter Reagent Expiration Monitoring Protocol," last reviewed July 15, 2021, revealed "Purpose: To ensure Standard Operating Reagent labeling Procedures are being followed by all Point of Care Certified Operators on all ECH hospital units performing WBG testing with the [Name of] Meter. ...Protocol The [Name of] Blood Glucose Meter Opened Reagent vials must contain an open vial expiration date. Quality Controls The QC vials must be dated when opened: 90-day expiration after opening (Open Date + 3 Months - 3 days)... "

Tour and observation with EMP5 and EMP15 of the Acute Care Unit on March 8, 2022, revealed two of four bottles of the quality control reagents for the glucose meters were not dated with an expiration date.

Interview with EMP5 on March 8, 2022, at approximately 1330, confirmed two bottles of quality control reagents for the glucose meters were not dated with an expiration date.

Review on March 8, 2022, of documentation provided by the facility from the manufacturer for [name of] cleansing cloths, dated March 4, 2022, revealed "... [Name of] Products recommends that the product be stored according to the conditions listed on the package label. The product packaging refers to the storage temperature during the shelf life of the [Name of] product. However, if warming is desired prior to use, the following guidelines have been established. According to the United States Pharmacopeia (USP 36) general chapter <1079> Good Storage and Distribution Practices for Drug Products, drug products may be held at temperatures outside their labeled storage requirements as determined by an appropriate stability study. Additionally, stability data kept on file indicates that the [Name of] cloths may be warmed at temperatures not exceeding 125°F for a period no longer than 84 hours. Once the product has been warmed for the maximum time period, it should be removed from the warmer and discarded. Product that has been warmed should not be subsequently returned to the warmer. Please note, [Name of] Products can only support this data for the [Name of] cloths warmed in a [Name of] Warmer. ..."

Tour and observation with EMP3 of the Intensive Care Unit on March 8, 2022, revealed eight packets of [Name of] cloths in a functioning blanket warmer and not in the approved warmer for the product.

Interview with EMP3 on March 8, 2022, at approximately 0945, confirmed the cloths were in the blanket warmer. EMP3 stated "Those should not be in the warmer. Staff must have put them in there to warm the cloths for patients".

Tour with EMP8, on March 9, 2022, at 1000, of the Cardiac Cath. Lab, revealed the blanket warming cabinet log with blank spaces and out of range temperatures.

Review on March 9, 2022, of facility policy, "Warming cabinet for Blankets & Solutions," last reviewed June 9, 2021, revealed "Purpose: To ensure that patient care items that are warmed prior to use meet appropriate/safe temperature standards. ... f) Monitoring and documenting the temperature of warming cabinets to verify that the temperature settings are maintained within specific limits including: i. Blankets: 1. Monitoring and documenting the temperature will be performed daily and recorded on the Blanket Warmer temperature log by the department. If the department is closed for an entire day then document "C" for closed. 2. The acceptable temperature range for blankets is 130 degrees F. or less. ...g) If the warmer exceeds the recommended temperature range: i. Adjust the temperature and document in the log. ... ii. Recheck the temperature approximately two hour post adjustment and document on log. ... 2. If the temperature is still above acceptable range then: ... iv. Reporting the malfunction to Clinical Engineering for maintenance. ..."

Review on March 9, 2022, of Cardiac Cath. Lab "Blanket Warmer Temperature" log for 2021, revealed no temperature logged on January 17, 21, 22, 23, 30 and 31, February 3, 4, 5, 12, 15, 16 and 18, and December 20, 24 and 31.

Interview with EMP8, on March 9, 2022, at 1045, confirmed the Cardiac Cath. Lab "Blanket Warmer Temperature" log for 2021, with no temperature's logged on January 17, 21, 22, 23, 30 and 31, February 3, 4, 5, 12, 15, 16 and 18, and December 20, 24 and 31. EMP8 confirmed if the Cardiac Cath. Lab is closed, the nursing supervisor is responsible for logging the blanket warmer temperature those days.

Review on March 7, 2022, of Emergency Department (ED) "Blanket Warmer Temperature" log for 2021, revealed a temperature exceeding the recommended range of 130, on April 23, of 132, April 27, May 13, 17, June 9, of 133, June 18, of 134, and December 7, of 133. There was no documentation on the blanket warmer temperature log of adjusting or rechecking the temperature or reporting to maintenance on those days.

Interview with EMP6, on March 8, 2022, at 1400, confirmed the ED "Blanket Warmer Temperature" log for 2021, with temperatures exceeding the recommended range of 130, on April 23 and 27, May 13, 17, June 9 and 18, and December 7. EMP6 confirmed there was no documentation on the blanket warmer temperature log of adjusting or rechecking the temperature or reporting the temperatures to maintenance on those days.

Tour with EMP8, on March 9, 2022, at 1045, of the Cardiac Cath. Lab, revealed the nutrition refrigerator/freezer log, for 2021, with blank spaces and out of range temperatures.

Review on March 9, 2022, of facility policy "Required Documentation of Environmental Temperatures and Humidity Levels," last reviewed November 2, 2021, revealed "... Policy: This policy will ensure that consistent documentation of the temperature in all medication and nutritional refrigerators, ... will be completed daily ... b) The temperature of all nutritional refrigerators to ensure the temperature is 33-40 degrees F. ..."

Review on March 9, 2022, of Cardiac Cath. Lab nutrition refrigerator/freezer log for 2021, revealed no temperature noted on January 17, 18, 21, 22, 23, and 31, February 1, 3, 4, 5, 12, 15, 16, 18, and 19, and December 20, 23, 24, and 31.

Interview with EMP8, on March 9, 2022, at 1110, confirmed the Cardiac Cath. Lab, nutrition refrigerator/freezer log for 2021, with no temperature's noted on January 17, 18, 21, 22, 23, and 31, February 1, 3, 4, 5, 12, 15, 16, 18, and 19, and December 20, 23, 24, and 31. EMP8 confirmed the refrigerator temperature is to be monitored daily, and if the Cardiac Cath. Lab is closed, the nursing supervisor is responsible for logging the nutrition refrigerator/freezer temperature those days.

Review on March 9, 2022, of Cardiac Cath. Lab nutrition refrigerator/freezer log for 2021, revealed temperatures exceeding the recommended range of 40 F., on February 23, 24, 25 and 26, March 1, 8, 9, 10, and 11, May 31, July 19 and 28, and August 7. There was no documentation on the nutrition refrigerator/freezer log of adjusting or rechecking the temperature.

Interview with EMP8, on March 9, 2022, at 1120, confirmed the Cardiac Cath. Lab nutrition refrigerator/freezer log for 2021, with temperatures exceeding the recommended range of 40 F., on February 23, 24, 25 and 26, March 1, 8, 9, 10, and 11, May 31, July 19 and 28, and August 7 and was no documentation on the log of adjusting or rechecking the temperatures EMP8 confirmed the refrigerator temperature is to be monitored daily, and if the Cardiac Cath. Lab is closed, the nursing supervisor is responsible for logging the nutrition refrigerator/freezer temperature those days.

Tour with EMP6, on March 7, 2022, at 0945, of the Emergency Department (ED), revealed four bottles of Pedialyte with expiration date of October 2021 and four packets of Ensure Hydration with expiration date of January 2021, in the nutrition station.

Interview with EMP6, on March 7, 2022, at 0945, confirmed the ED nutrition station had four bottles of Pedialyte with expiration date of October 2021 and four packets of Ensure Hydration with expiration date of January 2021.

Request on March 7 and March 9, 2022, revealed the facility has no policy on discontinued or outdated supplies.

Interview with EMP6, on March 7, 2022, at 0945, confirmed EMP6 was unaware of policy for outdated supplies. EMP6 confirmed the ED staff are assigned to check all supplies monthly.

Interview with EMP6, on March 9, 2022, at 1315, confirmed the ED staff have a "First of the Month Completed Outdates" log. The log is to be signed off with the staff initials when they have completed the assigned task area.

Review on March 9, 2022, of the ED "First of the Month Completed Outdate" log, revealed monthly assigned areas (41) to monitor. No documented initials noted for two areas in January and February 2021, ten areas in March and August 2021, 28 areas for April 2021, 30 areas for May 2021, 31 areas for June and October 2021, 13 areas for July 2021, 36 areas for September and December 2021, 26 areas for November 2021, one area for January 2022, three areas for February 2022, and 16 areas for March 2022.

Further interview with EMP6, on March 9, 2022, at 1315, confirmed the ED "First of the Month Completed Outdates" log, with no documented initials noted for numerous areas in 2021 and 2022. EMP6 confirmed the ED staff are to initial the areas when they have assessed that area for outdated items.

Interview with EMP7, on March 9, 2022, at 1515, confirmed the facility had no policy for outdated supplies.

Tour with EMP4, on March 7, 2022, at 1400, of the Excluded Rehab Unit, revealed 38 22-gauge needles with expiration date of October 31, 2021, in the medication room.

Interview with EMP4, on March 7, 2022, at 1435, confirmed the unit medication room had 38 22-gauge needles with expiration date of October 31, 2021. EMP4 confirmed the unit staff monitor for expiration dates on items monthly, but they do not document this anywhere. EMP4 confirmed EMP4 was unaware of a policy for outdated supplies.

Tour with EMP9, on March 9, 2022, at 1100, of the Cardiac Rehab area, revealed a sealed medication box with an aerosol spray bottle of Nitroglycerin 0.4 mg. in it. The expiration date was 1/2022.

Review on March 9, 2022, of facility policy "Medications Stored & Used in Rehab Department," last reviewed October 19, 2021, revealed "Purpose: To identify which medications are approved for use in the cardiac rehabilitation department .... To ensure that medications are available when needed in an emergency. ... Procedures: ... 4. Medication replacement: a. Staff authorized to use the above medications [Nitroglycerin 0.4 mg. aerosol spray] is responsible for checking the supply on hand and the expiration dates monthly. ..."

Interview with EMP9, on March 9, 2022, at 1130, confirmed the sealed medication box, with an aerosol spray bottle of Nitroglycerin 0.4 mg. in it, with the expiration date 1/2022. EMP9 confirmed medication and fluids outdates are reviewed monthly. The expiration dates are documented on a "Meds/Fluids Outdates" sheet. EMP9 confirmed the dates are updated as the expired medications are replaced. Further interview with EMP9 revealed the sheets do not have the month on them, only the items being reviewed and items expiration date.

Based on review of facility policy, tour and observation, review of facility documentation and staff (EMP) interview, it was determined the facility failed to ensure the morgue body cooler temperatures were maintained, monitored, and documented per policy, failed to document corrective action taken for out-of-range temperatures and failed to ensure blanket warmer at the appropriate temperature in accordance with policy and failed to document the corrective actions taken for out-of-range temperatures,

Findings include:

Review of facility policy "Morgue Refrigerator Temperature Monitoring Laboratory Operations Manual," last reviewed July 30, 2021, revealed "Policy: A morgue refrigerator temperature log will be maintained in the morgue, to document the temperature is maintained at 2-8 degrees centigrade. Procedure: The morgue refrigerator has an installed temperature alarm with an audible alarm in the hallway. The alarm is monitored by security personnel on routine rounds, as well as all alarms sent to the hospital operation station via [Company name] monitoring..."

Tour and observation of the morgue conducted with EMP1 and EMP2 on March 7, 2022, at 1310, revealed there was no visible thermometer on the outside or inside of the morgue cooler. There was a digital readout display monitor on the outside of the cooler that was no longer functioning. There was no documentation of a morgue refrigerator temperature log. There was one deceased body stored in the morgue cooler at the time of observation.

Interview with EMP2 on March 7, 2022, at 1315 confirmed there was no visible thermometer present for the morgue cooler. EMP2 also confirmed there was no morgue refrigerator temperature log documentation in the morgue.

Interview with EMP1, on March 7, 2022, at 1315, offered to reach out to plant engineering to see if there was remote monitoring of the temperatures.

Interview with EMP10 on March 7, 2022, at 1400, confirmed the temperatures on the morgue cooler were set to audibly alarm at switchboard between 30- 50 degrees Fahrenheit (-1- +10 degrees Celsius which is inconsistent with policy) and that the facility could only produce temperature logs through [Company name] of when the temperatures alarmed for out-of-range temperatures, but not a daily temperature log.

Review of facility documentation on March 7 and 10, 2022, of the audible alarms at switchboard included 7 alarms for out-of-range temperatures for the morgue cooler on the following dates/times: December 11, 2021 at 1403, 2 alarms on December 23, 2021 at 1303, December 24, 2021 at 1957, December 29, 2021 at 1732, January 31, 2022, at 0436, and February 22, 2022 at 1332. The alarm documentation did not indicate what the temperature was at the time. There was no documented action taken for the out-of-range temperatures.

Further interview with EMP1 on March 11, 2022, at 1215, confirmed there was no follow-up documentation when morgue cooler temperatures alarmed and out-of-range at switchboard, in security or the plant engineering departments.

Review on March 9, 2022, of facility policy, "Warming cabinets for Blankets & Solutions," last reviewed June 9, 2021, revealed "Purpose: To ensure that patient care items that are warmed prior to use meet appropriate/safe temperature standards. ... f) Monitoring and documenting the temperature of warming cabinets to verify that the temperature settings are maintained within specific limits including: i. Blankets: 1. Monitoring and documenting the temperature will be performed daily and recorded on the Blanket Warmer temperature log by the department. If the department is closed for an entire day then document "C" for closed. 2. The acceptable temperature range for blankets is 130 degrees F. or less. ...g) If the warmer exceeds the recommended temperature range: i. Adjust the temperature and document in the log. ... ii. Recheck the temperature approximately two hour post adjustment and document on log. ... 2. If the temperature is still above acceptable range then: ... iv. Reporting the malfunction to Clinical Engineering for maintenance. ..."

Review on March 7, 2022, of Emergency Department (ED) "Blanket Warmer Temperature" log for 2021, revealed a temperature exceeding the recommended range on April 23, of 132, April 27, May 13, 17, June 9, of 133, June 18, of 134, and December 7, of 133. There was no documentation on the blanket warmer temperature log of adjusting or rechecking the temperature or reporting to maintenance on those days.

Interview with EMP6, on March 8, 2022, at 1400, confirmed the ED "Blanket Warmer Temperature" log for 2021, with temperatures exceeding the recommended range of 130,on April 23 and 27, May 13, 17, June 9 and 18, and December 7. EMP6 confirmed there was no documentation on the blanket warmer temperature log of adjusting or rechecking the temperature or reporting the temperatures to maintenance on those days.

Review on March 9, 2022, of Cardiac Cath. Lab "Blanket Warmer Temperature" log for 2021, revealed no temperature logged on January 17, 21, 22, 23, 30 and 31, February 3, 4, 5, 12, 15, 16 and 18, and December 20, 24 and 31.

Interview with EMP8, on March 9, 2022, at 1045, confirmed the Cardiac Cath. Lab "Blanket Warmer Temperature" log for 2021, with no temperatures logged on January 17, 21, 22, 23, 30 and 31, February 3, 4, 5, 12, 15, 16 and 18, and December 20, 24 and 31. EMP8 confirmed if the Cardiac Cath. Lab is closed, the nursing supervisor is responsible for logging the blanket warmer temperature those days.