HospitalInspections.org

Based on record review, document review, and interview, the Governing Body of the Hospital failed to ensure the medical staff requirements were met.


This failure of the oversight of the medical staff places any patients receiving hospital services at risk of inadequate medical care.


Findings Include:


1. The Governing Body failed to ensure that the Hospital medical staff oversight requirements are met by following policies and procedures. This deficient practice affected 1 of 31 sampled patients (Patient 18) whose surgical records were reviewed. [Refer to A0044]


2. The Governing Body failed to provide oversight of the medical staff by not ensuring they followed and/or had policies and procedures.This deficient practice affected 1 of 31 sampled obstetrical patients (Patient 1). [Refer to A0049]


3. The Governing Body failed to ensure emergency services are integrated with other departments of the hospital, have policies, protocols, and provisions to meet the emergency needs of patients, and staff are knowledgeable of the emergency services implemented to patients. The Hospital failed to ensure adequate emergency services to 3 of 31 patients reviewed (Patients 12, 14, and 17). [Refer to A0092] (Cross Reference A1100)


4. The Governing Body failed to ensure the hospital was compliant with all of the Conditions of Participation (CoPs) including Immediate Jeopardy (IJ) Situations (a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment, or death) under requirements for Surgical Services at 42 §482.51 (b); §482.51 (a)(4), and 42 §482.51 (b)(2). Additionally, the hospital is out of compliance with Patient Rights at 42 §482.13; Nursing Services at 42 §482.23; Infection Prevention Control and Antibiotic Stewardship at 42 §482.42; and Emergency Services at 42 § 482.55. (Refer to A0015, A0385, A0747, A0940, and A1100)

Based on policy review, observation, staff interview, and record review, the Hospital failed to meet the requirements for the Patient Rights condition of participation by failing to inform patients or their representatives that they were placed in a room with continuous video monitoring.


This deficient practice has the potential to cause an invasion of a patient's personal privacy.


Findings Include:


The Hospital failed to inform patients they were in a room with continuous video monitoring and failed to provide personal privacy for two (Patient 32 and unsampled Patient) of two patients in rooms with video monitoring. (Refer to A-0143)

Based on record review, policy review, document review and interview the hospital failed to ensure it met the requirements for Nursing Services Condition of Participation by failing to supervise and evaluate the nursing care for patients receiving services at this hospital.


The cumulative effect of the hospital's failure to provide safe and effective nursing care with a delay in triage, delay preforming Electrocardiograms (EKG), reassessing pain and failure to initiate rapid response due to abnormal vital signs, taking vital signs as ordered/required that may cause an unsafe outcome with physical and emotional harm and distress.


Findings Include:


The hospital failed to ensure a Registered Nurse (RN) supervised and evaluated the nursing care for 10 of 31 patients reviewed when the nursing staff failed to:


1. Complete Electrocardiogram (EKG) as per policy (Patients 10 and 20);
2. Complete triage and vital signs as required (Patients 2, 12, 14, 19, 21, and 22);
3. Notify provider abnormal vital signs/Initiate Rapid Response (Patient 1 and Patient 19); and
4. Pain reassessment (Patient 15 and 20).

[Refer to tag A0395]

Based on document review, record review, policy review, observation, and interview the Hospital failed to ensure an adequately qualified person directed their infection prevention program adhering to nationally recognized infection prevention and control guidelines. Additionally, the Hospital failed to adhere to written policies and procedures for infection control and prevention such as proper hand hygiene, appropriate use of personal protective equipment, appropriate handling and/or disposal of biohazardous and waste products, and food handling and storage.

The cumulative effect of this deficient practice places all patients, visitors, staff, and community at risk to contract and spread communicable diseases.


Findings Include:


1. The hospital failed to ensure an individual who is qualified through education, training, experience, or certification in infection prevention and control, is appointed by the governing body as the infection control professional. (Refer to tag A0748)


2. The hospital failed to ensure hospital staff followed Infection Control policies and procedures. (Refer to tag A0749)


3. The hospital failed to maintain a clean and sanitary environment. (Refer to tag A0750)


4. The Hospital failed to ensure all hospital acquired infections (HAI's) and other infectious diseases identified by the infection prevention and control program are addressed in collaboration with hospital QAPI leadership. (Refer to tag A0771)

5. The hospital failed to ensure the infection preventionist is responsible for communication and collaboration with the hospital's QAPI program on infection prevention and control issues. (Refer to tab A0774)

Based on policy review, document review, observation, and interview the Hospital failed to meet the emergency needs of patients in accordance with acceptable standards of practice.


This deficient practice places all patients receiving services in the Emergency Department (ED) at risk for reciving sub standard care, delay in care, unmet care needs, and negative outcomes.


Findings Include:


The hospital failed to ensure emergency services are integrated with other departments of the hospital, have policies, protocols, and provisions to meet the emergency needs of patients in place, and have staff knowledgeable of the emergency services implemented for patients. The Hospital failed to ensure adequate emergency services to 3 of 31 patients reviewed (Patients 12, 14, and 17).(Refer to A-0092)

Based on record review, document review, and interview, the Governing Body failed to ensure Hospital medical staff requirements are met by medical staff following policies and procedures. This deficient practice affected 1 of 31 sampled patients (Patient 18) whose surgical records were reviewed. This failure of oversight of the medical staff places the for risk of inadequate medical care resulting in harm, and adverse outcomes.


Findings Include:


Review of "Medical Staff Rules and Regulations," dated 03/21/23, showed, ...Members providing surgical services, the post-operative note must be written or dictated immediately after an operative or other high-risk procedure and entered into the medical record. If the operative or procedural report is not placed in the medical record immediately following the procedure, then a progress note or brief op note must be immediately entered after the procedure to provide information to the next provider of care. ' Immediately after surgery or procedure ' is defined as, "upon completion of procedure before the patient is transferred to the next level of care ...


Patient 18


Review of Patient 18's medical record showed 27-year-old female was admitted to hospital on 10/01/24 for diagnosis of Scheduled Cesarean Section (a surgical procedure to deliver a baby though an incision in the mother's abdomen).


Review of "Op Note" (Operation Note), dated 10/08/24 at 9:21 AM, showed, " ...Date of Service: 10/1/2024 12:47 PM ...Cesarean section ..."


During an interview on 03/04/25 at 9:42 AM, Staff B, Director of Quality and Patient Safety Manager, stated that, the operative report was dictated on 10/08/24 at 8:42 AM.


Patient 18's medical record indicated Staff R, Doctor of Medicine (MD), failed to complete a written or dictated post-operative note immediately after the operative procedure. Staff R, MD, did not complete post-operative note until 6 days and 19 hours after he performed the Cesarian section.

Based on observations, document review, record review, policy review and interview, the Governing Body failed to provide oversight of the medical staff by not ensuring they followed and/or had policies and procedures.This deficient practice affected 1 of 31 sampled obstetrical patients (Patient 1). Failure of the governing body to provide oversight of the medical staff for the quality of care provided to patients places all patients at risk for inadequate medical care resulting in harm, further injury, and ongoing pain.


Findings Include:


Review of policy titled "Code White," dated 07/05/22, showed, ... To provide direction for multidisciplinary emergency response to a critical obstetrical hemorrhage to minimize adverse outcomes ... Any employee, physician, or Advanced Practice Provider (APP) may initiate a Code White Alert or Code White Activation when an obstetrical patient has a postpartum hemorrhage (PPH) that is not responsive to initial measures. 2. Initiate a Code White Alert, Activation, or Massive Transfusion Protocol per facility process including patient location .... Postpartum Hemorrhage (PPH): Blood loss greater than 500 mL for a vaginal delivery ... Primary Patient Care RN ... Dial 55 to call a Code White overhead at Stage 2 ... Birthplace Charge RN/Nurse Manager ... Quantify blood loss using the scale on the top of the Code White cart and document. Alert MD of every 500mL of blood loss ... Responding Physician (LP, OB, ED Doctor) - Respond to all stages; Arrive at site as soon as possible. Receive report of up-to-date interventions from code recorder. Employ all appropriate medical measures necessary to control hemorrhage. Lead team and communicate clear instructions. Consult with anesthesia or intensivist to manage patient hemodynamic stability ...


Review of "Medical Staff Rules and Regulations," dated 03/21/23, showed, ...All Medical Staff Members/APPs shall provide timely, professional care, which meets the standard of quality established by this Hospital and its Medical Staff ... All diagnostic, treatment and patient care services performed at the Hospital shall be under the guidance of an appropriately privileged Medical Staff Member or Advanced Practice Provider. The Attending Member shall be responsible for the overall care provided ...


Review of hospital document titled "Postpartum Hemorrhage - Clinical Key," dated 09/18/24, showed, ...Urgent Action Simultaneous efforts must be made to maintain or restore hemodynamic stability, control source of bleeding, replace lost blood and fluids, and address coagulopathy if present; protocols have been published and their use improves outcomes.


It is suggested that no more than 30 minutes elapse before resorting to the next step in management (eg, primary measures to control bleeding, secondary interventions, hysterectomy) ...Management involves rapid and simultaneous measures: Initiation of fluid resuscitation followed by transfusion of blood, platelets, and fresh frozen plasma as soon as available ...Class 2: 1500 mL (20%-25%) loss Accompanied by tachycardia, tachypnea, diaphoresis, weakness, narrowed pulse pressure, and orthostatic hypotension ...Moderate blood loss may occur without affecting vital signs; presence of tachycardia, tachypnea, or low blood pressure indicates loss of 1500 mL or more ...Treatment ...Replace blood and fluid loss to restore or maintain hemodynamic stability Control bleeding and manage cause ... Transfusion is indicated for patients with ongoing bleeding who have an estimated blood loss of at least 1500 mL or who have abnormal vital signs; A balanced combination of blood, platelets, and fresh frozen plasma is recommended ...Fluid administration ...Administer enough to maintain circulation pending availability of blood, but avoid overhydration to prevent hemodilution and clot disruption; a systolic blood pressure goal of 80 to 100 mm Hg is appropriate ...


Patient 1


Review of Patient 1's discharge medical record indicates patient is a 26-year-old female admitted to labor and delivery on 02/18/24 for a term pregnancy (A period when the baby is considered ready to be born, typically 37-40 weeks pregnant). Post-partum hemorrhaging (Bleeding resulting from trauma after birth) resulted in a total hysterectomy (Surgery to remove the uterus and the cervix) on 02/19/24 at 3:38 AM.


Review of "Revision History for OB DELIVERY LABOR LENGTH" dated 11/19/24 at showed ...Newborn Delivery; Birth date/time:11/19/24 01:04:00 [1:04 AM] ... Delivery Providers; Delivering clinician: Staff A2, Doctor of Medicine (MD) ...


Review of "Complete Notes Log" dated 11/19/24 at 1:22 AM, showed, ...BP (Blood Pressure) 58/32 (reading of blood pressure less than 90/60 are considered hypotension (low blood pressure) low blood pressure may put body ' s organs at risk of not getting enough blood which may lead to shock) ...


Review of "Complete Notes Log" dated 11/19/24 at 1:23 AM, showed, ...BP (Blood Pressure) 58/37 ...

Review of "Complete Notes Log" dated 11/19/24 at 1:26 AM, showed, ...Procedures repairs Completed ...

Review of "Complete Notes Log" dated 11/19/24 at 1:29 AM, showed, ...BP (Blood Pressure) 66/42 ...

Review of "Complete Notes Log" dated 11/19/24 at 1:33 AM, showed, ...BP (Blood Pressure) 64/44 ...

Review of "Complete Notes Log" dated 11/19/24 at 1:34 AM, showed, ...BP (Blood Pressure) 69/43 ...

Review of "Complete Notes Log" dated 11/19/24 at 1:38 AM, showed, ... Medication lactated Ringers (intravenous (IV) fluid to restore fluid balance) infusion/ Amount:/ Unit:/ Route: Intravenous /Site/ Rate 125 ml/hr [4.2 ounces a hour]/ Comment:/ Action RateChange (sic) ...

Review of "Complete Notes Log" dated 11/19/24 at 1:39 AM, showed, ...Personnel: Provider Left Bedside ...

Review of "OB Vaginal Delivery Note" dated 11/19/24 at 1:39 AM, showed, ...EBL [estimated blood loss]: 500 ml ... Perineum, vagina, cervix were inspected, and the following lacerations were noted: a small 2nd degree perineal (tear that involves skin and muscle in the area between vaginal opening and the rectum) as well as 1st degree left periurethral l(small tears or grazes affecting only the skin near at the top of the vulva near the urethra). Any lacerations were repaired in the usual fashion ... Infant and patient in delivery room in good and stable condition. A Foley cathther (sic) was placed and the vagina was tamponaded (sic) (procedure to stop bleeding) with 1 lap. 1000mcg cytotec (medicine for treatment of serious postpartum hemorrhage) was placed rectally. After this uterus was found to be firm and hemostasis was achieved ...


Review of "Postpartum" on 11/19/24 at 1:45 AM, showed, "... Lochia Color: Rubra ... Amount: Moderate...

Review of "Postpartum" on 11/19/24 at 1:55 AM, showed, "... Lochia Color: Rubra ... Amount: Moderate...

Review of "Vital Signs" on 11/19/24 at 2:20 AM, showed, ...blood pressure of 60/27 ...

Review of "Vital Signs" on 11/19/24 at 2:21 AM, showed, ...blood pressure of 55/22 ...

Review of "Vital Signs" on 11/19/24 at 2:23 AM, showed, ...blood pressure of 52/26 ...

Review of "Vital Signs" on 11/19/24 at 2:25 AM, showed, ...blood pressure of 53/31 ...


Review of "LIP [Licensed Independent Practitioner] Notification," dated 11/19/24 at 2:29 AM, showed, ...Notification Reason; Bleeding; Maternal vital sign change; Provider Name/Title; [Staff A2, MD] ...Notification Time; 0229 [2:29 AM]; Method of Communication; Call...


Review of "Postpartum Hemorrhage," dated 11/19/24 at 2:40 AM, showed, ...Hemorrhage Interventions Bimanual exam per MD;Clots (sic) expressed ...


Review of hospital document titled "Ocurrence (sic) Report - 7.1.2024 to 2.25.2025 - MIDAS REPORT," dated 11/19/24, showed, ... code white called for Stage IV maternal hemorrhage, patient underwent hysterectomy I did discuss with [Staff A2, MD] waste of platelets, he expressed understanding ...reviewed wit (sic) him today Maternal Hemorrhage new bundle and he agrees to it and will comply ...


During an interview on 02/28/25 at 9:11 AM with Staff X1, stated that, need to inform the provider with two successive blood pressures exceeding 160/110 or reading below 85/50.


During an interview on 03/13/25 at 2:56 PM with Staff E2, stated that, code white is a tornado warning. Patient 1 had a large amount of blood loss and the room looked like a war zone.

Review of Patient 1's medical record failed to show documented evidence that a code white was paged overhead and/or they quantified the amount of blood loss after delivery of an emergent cesarean section. The delay of treatment has the potential for the patient to have adverse outcomes and increased mortality rate.


Triage and Trauma Alert


Upon request the hospital was unable to provide policies for the following: Triage and Trauma.


Review of the hospital's document titled, "MEDICAL STAFF Rules and Regulations," dated 03/21/23, showed ...The Medical Executive Committee may delegate authority to certain other Medical Staff leaders and designated Medical Directors to approve appropriate departmental/operational policies and procedures, order sets and protocols/guidelines which require Medical Staff oversight to guide the provision of quality patient care and patient safety ...


Review of the hospital's document titled, "MEDICAL STAFF BYLAWS," dated 08/18/22, showed ... developing and implementing policies and procedures that guide and support the provision of care, treatment, and services in the department ...


During an interview on 03/04/25 at 2:30 PM, Staff V, stated that, the education for triage is from computerized training and have limited knowledge from what was learned.


During an interview on 03/04/25 at 4:31 PM, Staff G, Chief Nursing Officer (CNO), stated that, triage in the emergency department is centered on education, as triage is procedure and not a policy.


During an interview on 03/03/25 at 12:52 PM, Staff U, Doctor of Medicine, (MD), stated that, unfamiliar with the criteria that determines a trauma alert.


During an interview on 03/04/25 at 3:32PM, Staff H, Chief Executive Officer (CEO), stated that, there is lack of trauma policy. The decision to classify a patient as a trauma would rest on the individual making the choice.

Based on policy review, document review, observation, and interview the Hospital failed to ensure emergency services are integrated with other departments of the hospital, have policies, protocols, and provisions to meet the emergency needs of patients in place, and staff are knowledgeable of the emergency services implemented for patients. The Hospital failed to ensure adequate emergency services to 3 of 31 patients reviewed (Patients 12, 14, and 17).


Failure to ensure that adequate emergency services are provided places all patients receiving emergency services at risk for a delay in care, unmanaged care needs, and negative outcomes.


Findings Include:


Review of the Hospital policy titled "Severe Sepsis Screening and Alert" last reviewed 04/28/22 showed "EMERGENCY DEPARTMENT SCREENING AND ALERT PROCEDURE ... Severe Sepsis Screening - initiated by either registered nurse (RN) or physician or advance practice provider (APP) upon triage of the patient, or at any point in the ED stay. ... If patient has suspected infection and two SIRS criteria are present, initiate organ dysfunction screening. ... Sepsis Alert Criteria - The criteria to call a sepsis alert is the presence of suspected infection and one (1) acute organ dysfunction deemed due to sepsis or unknown cause, or based on clinical judgement of a physician or APP. ... An RN or physician or APP activates a Sepsis Alert when criteria are met ... When a sepsis alert is called, an overhead announcement in the ED is made alerting sepsis alert responders (physician or APP, Primary RN), and a silent page is sent to the house supervisor. ... As soon as possible within three (3) hours ... Lactate ... Blood Cultures ... Antibiotics ... Do not delay antibiotics if blood cultures cannot be collected".


Review of the Hospital document titled "Sepsis Alert Algorithm - Emergency Department" with no documented review date, showed "Acute Organ Dysfunction (OD) ... Mean arterial pressure (MAP) less than 65 mmHg or Systolic Blood Pressure (SBP) less than 90 mmHg ... Acute need for BiPAP or Ventilator ... Acute Mental Status Change (Glasgow Coma Scale (GCS) less than 13) ... Lactate greater than 2.0 mmol/L ... Bilirubin greater than 2.0 mg/dL ... Creatinine greater than 2.0 mg/dL ... Platelet count less than 100 10 10-3/uL ... Systemic Inflammatory Response Syndrome (SIRS) ... Heart Rate (HR) greater than 90 beats per minute (bpm) ... Respiratory Rate (RR) greater than 20 ... Temperature (T) greater than 38.0 degrees Celsius or less than 36.0 degrees Celsius ... White Blood Cell Count (WBC) greater than 12 12(10 -3/µL) or less than 4 (10 10-3/uL) ... Patient arrival ... Identify suspected infection ... OD Present ... Call sepsis alert".


Review of the Hospital document titled "Sepsis Alert Process - Emergency Department" with no documented review date, showed "Make overhead announcement ... Physician/APP ... Respond to patient bedside ... Assess patient condition ... Place orders via sepsis order set ... Complete sepsis alert documentation note ... Primary RN ... respond to bedside ... Execute orders ... Complete sepsis alert documentation in Epic (noting time of sepsis alert called)".


Review of the Hospital document titled "ESI Triage Algorithm, Version 5" with no documented review date, showed "Requires immediate lifesaving intervention? ... 1 ... High-risk situation? or Confused/lethargic/disoriented? or Severe pain/distress? ... 2 ... How many different resources are needed? None ... One ... Many ... High-risk vital signs? ... No ... 5,4,3 ... immediate life-saving intervention required: Airway or respiratory support, emergency medications, hemodynamic interventions such as fluid resuscitation or blood products ... Clinical presentations requiring lifesaving interventions include the following: intubated, unresponsive, pulselessness, apneic, severe respiratory distress, profound hypotension or hypoglycemia. ... High-risk situation: May become unstable, have high risk for deterioration, or exhibit newly altered mental status. Severe pain or distress is determined by patient report, corroborated with clinical observation. ... Resources: Count the number of different types of resources ... Labs ... Electrocardiogram, radiographs ... Computed tomography, magnetic resonance imaging, ultrasound, angiography ... Intravenous fluids ... Intravenous, intramuscular, or nebulized medications ... Specialty consultation ... Simple procedure = 1 ... Complex procedure = 2 ... High-risk vital signs: Reassess to determine whether the patient warrants a higher acuity level if a patient has one or more vital signs outside of the normal parameters".


Patient 12


Review of Patient 12 ' s medical record showed a 42-year-old female admitted to the Hospital's Medical Surgical Unit on 08/14/24 with a diagnosis of sepsis (infection in the blood stream), pulmonary embolism (blood clot in the lung) without acute cor pulmonale (right sided heart failure), pneumonia (lung infection), acute and chronic respiratory failure with hypoxia (low oxygen level), acidosis (increased acidity in the blood). Past medical history of anemia (low iron), restless leg syndrome, anxiety disorder (a mental and behavioral disorder characterized by excessive, uncontrollable, and irrational worry), infectious viral hepatitis (viral disease affecting the liver), and polysubstance (more than one drug) abuse.


Further review of this medical record showed Patient 12 arrived at the Emergency Department via ambulance on 08/14/24 at 1:57 PM with a set of prehospital vitals showing a blood pressure of 105/61. At 2:09 PM, a set of triage vitals showed a temperature of 100.5 degrees Fahrenheit and a pulse of 130 and a triage Emergency Severity Index (ESI) level of 3. Patient 12 ' s labs showed an elevated White Blood Count (WBC) of 14.0 that resulted at 3:12 PM and a Lactate of 2.9 at 3:28 PM. At 4:35 PM the sepsis activation timer was started.


Further review of this medical record showed a physician order on 08/14/24 at 4:35 PM, stating "Vital Signs Every 30 minutes, unless hypotensive, then every 15 minutes until normal BP x 4." Staff failed to obtain a full set of vitals on 08/14/24 from 2:11 PM through 8:26 PM.


Further review of this medical record showed a note titled "H&P" on 08/14/24 at 9:00 PM, showed "On arrival to floor at 2030 (8:30 PM), patient's temperature 99, pulse 123, respirations 40, BP 90/57, SpO2 92% on 4 L nasal cannula. When reviewing most recent vital signs, last set of vital signs documented were at 1400 (2:00 PM)."


Further review of this medical record showed on 08/14/24, a physician ordered a computed tomography angiography (CTA) "STAT" at 5:50 PM. The CTA was not performed until 7:32 PM and resulted at 8:07 PM. The CTA results took greater than 2 hours to result a stat order.


Review of the Hospital Computed Tomography (CT) log for 08/14/24 showed after 5:50 PM 2 urgent level CT scans performed prior to Patient 12 ' s "STAT" level CT scan.


During an interview on 02/28/25 at 9:15 am, Staff W, stated that any "STAT" orders for imaging should be performed as a priority above any other order level including urgent. Staff W stated that the goal of any "STAT" CT scan is to have it performed and resulted within 1 hour. Staff W stated that all radiology staff are trained to perform "STAT" orders immediately and not based on the order it was received in.


During an interview on 03/04/24 at 4:37 PM, Staff Y, stated that sepsis protocol is used by all departments of the hospital and should be activated as soon as signs are identified. StaffY, stated that Patient 12 did not have vitals reassessed in the Emergency Room and was not reassessed by the oncoming ER physician prior to leaving the Emergency Room. Staff Y, stated that Patient 12 would not have been accepted to the Medical Surgical Unit if the vitals were assessed admission protocol dictates an unstable patient would have been sent to the Intensive Care Unit instead. Staff Y, also stated that Patient 12 would not have been admitted to the hospital and transferred to a higher acuity hospital based on the CTA results that were not obtained prior to patient admission.


Patient 14


Review of Patient 14's medical record showed a 70-year-old female admitted to the Hospital Medical Surgical Unit on 01/04/25 with a diagnosis of acute alteration in mental status, sepsis (infection in the blood stream), metabolic encephalopathy (brain dysfunction from toxins in the body), acidosis (increased acidity in blood), and epilepsy (seizures). Past medical history of acute osteomyelitis of cranium (bone infection of the skull), breast cancer, cerebral meningioma (brain tumor), diabetes mellitus, type 2 (a condition of poor insulin production causing high blood sugar), hyperlipidemia (abnormally high levels of fat in the blood), hypertension (high blood pressure), major depressive disorder (a mood disorder causing a persistent feeling of sadness and loss of interest), anemia (low iron), osteopenia (low bone density), rheumatoid arthritis (autoimmune disease causing inflammation of joints), hypothyroidism (when the thyroid fails to produce enough hormone), urinary tract infection, insomnia (difficulty sleeping).


Further review of this medical record showed a note titled "ED Provider Note" dated 01/4/25 at 6:04 AM stating "Patient is a 70-year-old woman ... presenting to the emergency department with concern for altered mental status/sepsis. ... around the new year. ... was evaluated and found to have a UTI for which she has been prescribed amoxicillin ... On exam the patient was noted to be altered. Making eye contact but speaking minimally. ... She did appear to exhibit some suprapubic tenderness. ... No antecedent trauma and progressive nature of patient's altered mental status favors sepsis especially given known infection."


Further review of this medical record showed patient arrival to the Emergency Department via ambulance on 01/04/25 at 6:04 AM with a triage Emergency Severity Index (ESI) level of 3. At 6:14 AM, a physician order for a complete blood count (CBC), 2 sets of blood cultures, lactate venous lab, Ceftriaxone antibiotic, and Vancomycin antibiotic were ordered for Patient 14. A white blood cell (WBC) count showed 13.0 at 6:35 AM, and the lactate read 3.5 at 6:55 AM. The sepsis activation time was not started until 7:00 AM.


Further review of this medical record showed an unsigned consent form reading "ATA Unable (AMS)" and patient bill of rights dated 01/04/25 with no evidence of DPOA signature or authorization.


Patient 17


Review of Patient 17's medical record showed a 74-year-old male seen in the Hospital Emergency Department on 09/29/24 with a diagnosis of Subdural hematoma (brain bleed), fall, leukocytosis (elevated white blood cells), elevated troponin, closed fracture of left hip, increased intracranial (brain) pressure, and Uncal herniation (part of the temporal lobe of the brain that is displaced). Past medical history of arthritis (swelling and pain in the joints), back pain, dyslipidemia (irregular levels of fat in the blood), hypertension (high blood pressure), and mitral valve prolapse (bulging heart valve).


Further review of this medical record showed patient arrived via ambulance to the Emergency Department on 09/29/24 at 2:34 PM and was triaged a level 3 ESI. At 2:39 PM, an urgent order for an Magnetic Resonance Imaging (MRI) of the brain was noted, then at 3:40 PM, an urgent order for computed tomography (CT) scan of the head was noted. No MRI of the brain was performed for an unknown reason on Patient 17 during the visit. At 8:18 PM the CT scan of the head resulted with a diagnosis of a subdural hematoma with Uncal herniation, a noted 5-hour gap to have the CT performed.


Review of the Hospital Computed Tomograpy (CT) log for 09/29/24 showed no CT scans performed from 7:00 AM to 7:00 PM.


Review of the CT maintenance log for 09/29/24 showed no downtime for the machine requiring service.


Review of the radiology communication log for 09/29/24 showed no staffing available for the CT scan and to be placed on diversion from 7:00 AM to 7:00 PM.


During an interview on 02/28/25 at 9:15 AM, Staff W, stated if staffing is unavailable to perform CT scans or the machine is down, then the protocol is to utilize the MRI machine for diagnostic imaging until CT is up and running again. Staff W, stated uncertainty as to why the MRI for Patient 17 was not performed after it was ordered on 09/29/24. Staff W, stated that staff have been training on multiple machines to assist in better coverage for staffing any on call situation. Staff W, stated that any on call response time should be within 30 minutes of the time of the call being placed for the order.


The hospital ED failed to provide timely diagnostic imaging for patients with critical emergency diagnoses, failed to triage patients appropriately based on presentation, failed to follow sepsis protocol, and failed to transfer a patient to the appropriate level of care within the hospital.

Based on policy review, observation, staff interview, and record review, the Hospital failed to provide adequate right of privacy for two patients (Patient 32 and Patient in room 1220) in rooms with video monitoring. This deficient practice invades the patient's rights to privacy without knowledge of cameras being in the room.


Findings Include:


Review of policy titled, "Levels of Observation / Sitter" last reviewed 08/02/22, stated, ... "Patient's[sic] who qualify for increased observation via video monitoring must meet one of the qualifications: ...Patients at High-risk of suicide per C- SRRS; Patients on ... Exparte Emergency Custody Order (Kansas) ... AND are a High Risk for Suicide; ... When lower levels of observation for protection of the patient and associates have failed; Violent/ Aggressive / Homicidal patients. . ."


During an observation on 03/03/25 of Patient 32's room, it was noticed that there was an active camera monitor that streams to the nursing station. The video monitor is in clear view of the hallway on a large television screen. The camera in the room was turned down towards the patient sink and one surveyor was able to see another surveyor on the monitor when investigating the patient's room.


During an observation of a medical-surgical unit on 03/04/25 at 2:15 PM it was noticed the Patient in room 1220 was noted to still have continuous video monitoring. The camera was not pointed downward, and the patient was fully seen on the monitor and was able to visibly see all of the patient's room. It was noted that Patient 32's monitor was also still on.


Further review of Patient 32's chart showed that they signed the consent to treat and patient rights packet. Overview of the chart showed that patient did not meet criteria for continuous video monitoring and there was no signed consent for video monitoring.


During an interview with Staff U1, Registered Nurse, on 03/04/25 at 02:31 PM, it was stated that the monitors are on still. The techs will usually turn the camera facing away from the patient. I am not aware of any consent for the patient to sign but need to use these rooms anyway. When asked if the patients are informed of the camera, the staff member stated, "No, most likely not."

During a subsequent interview on 03/04/25 at 4:48 PM, Staff U1, Registered Nurse, it was stated that the monitors was placed for Covid-19 patients few years ago. We monitored and checked on them during this time. Those rooms were not used too often and usually for patients with an infectious disease. Now we are not quite sure how to turn them off. When asked about consent for video monitoring, she stated that I am sure that the patients are not aware of the video monitoring and would have no idea where we would keep those informed consents if we have them.

Based on observation, policy review, record review, and interview, the hospital failed to ensure a Registered Nurse (RN) supervised and evaluated the nursing care for 10 of 31 patients reviewed when the nursing staff failed to:


1. Complete Electrocardiogram (EKG) as per policy (Patients 10 and 20).
2. Complete triage and vital signs as required (Patients 2, 12, 14, 19, 21, and 22).
3. Notify provider abnormal vital signs/Initiate Rapid Response (Patient 1 and Patient 19).
4. Pain reassessment (Patient 15 and 20).


These deficient practices have the potential to place the health and safety of any patient receiving services at this hospital at risk for injury, harm, or serious impairment.


Findings Include:


1. Complete Electrocardiogram (EKG) as per policy (Patients 10 and 20).


Review of policy titled, "Care of the Suspected Acute Coronary Syndrome Patient," dated 04/12/2022, showed, ...PROCEDURE; Emergency Department Triage 1. All patients arriving in the ED with complaints of chest pain or other symptoms suggestive of ACS (Acute Coronary Syndrome) are triaged immediately with a validated triage tool by a qualified caregiver. 2. Suspected ACS patients are to have a 12-lead ECG (Electrocardiogram) within 10 minutes of arrival ...


Patient 10


Review of Patient 10's medical record showed Patient 10 presented to the Emergency Department on 10/07/24 at 10:29 AM, with a chief complaint of chest pain and admitted as an inpatient for a diagnosis of Acute ST Elevation Myocardial Infarction (STEMI)(heart attack with a completely blocked coronary artery) and Chest Pain STEMI involving right coronary artery. Patient 10 ' s medical record showed the EKG was completed at 10:57 AM, 27 minutes after arrival. The medical record failed to show documented evidence that patient Electrocardiogram (EKG) was completed within 10 minutes of arrival as required by policy.


Patient 20


Review of Patient 20's medical record showed Patient 20 presented to the Emergency Department on 01/21/25 at 10:30 AM, with a chief complaint of chest pain and transferred to higher level of care with a diagnosis of a non-ST elevated myocardial infarction (a type of heart attack usually happens when your heart ' s need for oxygen can ' t be met). Patient 20 ' s medical record showed the EKG was done at 10:50 AM, 20 minutes after arrival. The medical record failed to show documented evidence that Patient 20 ' s EKG was completed within 10 minutes of arrival as required by policy.


During an interview on 02/27/25 at 8:20 AM, Staff S, Registered Nurse, (RN), stated that, Electrocardiogram (EKG) (an electrical recording of the hearts activity) is performed when it is ordered by a physician.


During an interview on 03/03/25 at 12:52 PM, Staff T, RN, Interim Nurse Manager of Emergency Department, stated that, EKG should be performed within 5 minutes of a patient presenting with symptoms of acute coronary syndrome such as chest pain.


During an interview on 03/03/25 at 12:52 PM, Staff U, Doctor of Medicine, (MD), stated that, EKG should be performed within 10 minutes of a patient presenting with symptoms of acute coronary syndrome such as chest pain.



2. Complete triage and vital signs as required (Patients 2, 12, 21, and 22)


Review of policy titled "Assessment, Reassessment, Vital Signs, and Documentation of Patient Care," dated 01/26/2023, showed, " ...Vital Signs (VS) A. Will be completed per the table below, as needed per patient condition or per physician order...Applicable Units; Acute Rehab [Rehabilitation]; ... Ongoing VS; Every 8 hours or per patient condition or physician/APP [Advanced Practice Provider] ... Applicable Units Emergency Department (ED): ED: ESI (Emergency Severity Index) Level 3- Urgent; Nursing Admission History; Chief complaint upon arrival ... Initial Vital Signs, Room Setup, and Safety Screening; Upon arrival; Ongoing Vital Signs Patients with normal VS, minimum every 4 Hours Patients with abnormal VS, minimum every 2 hours (X4) then every 4 hours if clinically stable 1 hour prior to transfer or discharge from the unit ..."


Patient 2

Review of Patient 2's medical record showed a 46-year-old male admitted to the Hospital Rehabilitation Unit on 12/17/2024 with a diagnosis of Acute Kidney Injury, Pleural Effusion (Fluid in the space around the lungs and chest) and Deep Vein Thrombosis (A blood clot located in a leg that can dislodge and cause stroke or heart attacks). Patient has a past medical history of a small bowel obstruction and stroke.

During an interview on 03/04/25 at 2:45 PM, Staff D2, stated that, vitals are obtained in the morning around medication time, lunch and during the end of the shift.

Further review of this medical record showed that staff failed to obtain a full set of vital signs a minimum of every eight hours from 12/18/24 to 01/06/25 per hospital guideline.


Patient 12


Review of Patient 12 ' s medical record showed a 42-year-old female admitted to the Hospital Medical Surgical Unit on 08/14/24 with a diagnosis of sepsis (infection in the blood stream), pulmonary embolism (blood clot in the lung) without acute cor pulmonale (right sided heart failure), pneumonia (lung infection), acute and chronic respiratory failure with hypoxia (low oxygen level), acidosis (increased acidity in the blood). Past medical history of anemia (low iron), restless leg syndrome, anxiety disorder (a mental and behavioral disorder characterized by excessive, uncontrollable, and irrational worry), infectious viral hepatitis (viral disease affecting the liver), and polysubstance (more than one drug) abuse.


Review of medical record Patient ' s 12, showed, "Triage Vitals" dated 08/14/24 at 2:09 PM.


Review of "Orders" dated 08/14/24 at 4:35 PM, showed, ...Vital Signs Every 30 minutes, unless hypotensive, then every 15 minutes until normal BP [Blood Pressure] x 4 ...


Review of "H&P [History and Physical]" dated 08/14/24 at 9:00 PM, showed, ... Move to ICU for closer monitoring ...On arrival to floor at 2030, patient's temperature 99, pulse 123, respirations 40, BP 90/57, SpO2 92% on 4 L nasal cannula. When reviewing most recent vital signs, last set of vital signs documented were at 1400 ...


During an interview on 03/04/24 at 4:37 PM, Staff Y, stated that Patient 12 did not have vitals reassessed in the Emergency Room. Patient 12 would not have been accepted to the Medical Surgical Unit if the vitals were assessed; admission protocol dictates an unstable patient would have been sent to the Intensive Care Unit instead.


Further review of this medical record showed that staff failed to obtain a full set of vital signs as ordered with the minimum of every 30 minutes, unless hypotensive, then every 15 minutes until normal blood pressure times four while in the emergency department.


Patient 19


Review of policy titled "Post Anesthesia and Procedural Areas Phase I and Phase II Discharge Criteria" last published 01/06/2025, showed ". . .Patients to be sent to a nursing unit must meet Phase I Discharge Criteria unless a physician orders otherwise. . ."


Review of Patient 19 ' s medical record showed a 41-year-old female admitted on 01/28/25 for exploratory surgery of a retroperitoneal (the area in the back of the abdomen behind the tissue that lines the abdominal wall and covers most of the organs in the abdomen) mass. The patient received general anesthesia and was taken to post op at 2:53 PM. The post op anesthesia evaluation was documented at 2:58 PM showing it occurred in the post anesthesia care unit (PACU). The surgical time tracking identified the patient as being in PACU from 2:54 until 4:22 PM. An RN ' s attestation is timed at 4:22 PM for Phase I PACU. The event listing shows transfer from Main Operating Room (OR) at 4:31 PM and patient transferring to a medical surgical unit. No postop nurses ' notes were provided from PACU or the medical surgical unit. Multiple requests were made to the facility. It is unclear what nursing care this patient received immediately postoperatively on 01/28/25.


Patient 14


Review of Patient 14 ' s medical record showed a 70-year-old female admitted to the Hospital Medical Surgical Unit on 01/04/25 with a diagnosis of acute alteration in mental status, sepsis (infection in the blood stream), metabolic encephalopathy (brain dysfunction from toxins in the body), acidosis (increased acidity in blood), and epilepsy (seizures). Past medical history of acute osteomyelitis of cranium (bone infection of the skull), breast cancer, cerebral meningioma (brain tumor), diabetes mellitus, type 2 (a condition of poor insulin production causing high blood sugar), hyperlipidemia (abnormally high levels of fat in the blood), hypertension (high blood pressure), major depressive disorder (a mood disorder causing a persistent feeling of sadness and loss of interest), anemia (low iron), osteopenia (low bone density), rheumatoid arthritis (autoimmune disease causing inflammation of joints), hypothyroidism (when the thyroid fails to produce enough hormone), urinary tract infection, insomnia (difficulty sleeping).


Further review of this medical record showed a physician order on 01/04/25 at 7:00 AM, stating "Vital Signs Begin every fifteen minutes vital signs after the fluid bolus is complete ... STAT Q15 Min 01/04/25 0801 - 7 occurrences". No vital signs documented from 6:06 AM until 1:22 PM.


Further review of this medical record showed a physician order on 01/04/25 at 1:46 PM, stating "Vital Signs ... Routine until Discontinued". No vital signs documented from 1:22 PM on 01/04/25 until 4:52 AM on 01/07/25.


Patient 21


Review of Patient 21's medical record showed Patient 21 presented to the Emergency Department (ED) on 03/03/24 at 3:32 PM, with a chief complaint of Knee Pain and dismissed after medical screening exam and a diagnosis of right leg swelling.


During an interview on 03/03/25 at 12:52 PM, Staff T, RN, Interim Nurse Manager of Emergency Department, stated that, patients should be triaged on arrival.


During an interview on 03/04/25 at 2:30 PM, Staff V, RN, stated that, triage is to be completed within 15 minutes of arrival.


The medical record failed to show documented evidence that Patient 21 ' s chief complaint and vital signs were done upon arrival as required by policy. Review of Patient 21 ' s medical record showed ED Triage notes were started at 4:43 PM, 1 hour and 11 minutes after arrival.


Patient 22


Review of Patient 22's medical record showed Patient 22 presented to the Emergency Department on 03/03/24 at 3:58 PM, with a chief complaint of Abnormal Labs and admitted as an inpatient for a diagnosis of AKI (acute kidney injury), Osteomyelitis (inflammation of the bone tissue caused by an infection) of left foot, Acute pain of right shoulder.


The medical record failed to show documented evidence that Patient 22 ' s chief complaint and vital signs were done upon arrival as required by policy. Review of Patient 22 ' s medical record showed ED Triage notes were started at 4:51 PM, 53 minutes after arrival.


3. Notify Provider of abnormal vital signs/initiate rapid response.


Review of policy titled "Rapid Response Team - RRT" dated 05/26/2022, showed, ...This guideline applies to all departments, associates, physicians, and Advanced Practice Providers (APP). PURPOSE To ensure early assessment, recognition, and response to changes in a patient ' s condition or perception of change by an associate, physician, or APP ...The criteria for RRT may include: a. Acute changes in:.. Systolic blood pressure >180mmHg or < 90mmHg ...Acute significant bleeding ...The primary care RN or designee will contact the attending physician ..."


Patient 1


Review of Patient 1 ' s discharge medical record showed patient is a 26-year-old female admitted to labor and delivery on 02/18/24 for a term pregnancy (A period when the baby is considered ready to be born, typically 37-40 weeks pregnant). Post-partum hemorrhaging (Bleeding resulting from trauma after birth) resulted in a total hysterectomy (Surgery to remove the uterus and the cervix) on 02/19/24 at 3:38 AM.


Review of "Vital Signs" on 11/19/24 at 1:23 AM, showed, ...blood pressure of 53/37 (average blood pressure is 120 systolic over 80 diastolic (120/80) ...

Review of "Vital Signs" on 11/19/24 at 1:27 AM, showed, ...blood pressure of 61/40 ...

Review of "Postpartum" on 11/19/24 at 1:35 AM, showed, ... Lochia (discharge that occurs post childbirth, often containing blood.) Color: Rubra (A color that indicates bright or dark bloody discharge) ... Amount: Moderate...

Review of "Postpartum" on 11/19/24 at 1:45 AM, showed, "... Lochia Color: Rubra ... Amount: Moderate...

Review of "Postpartum" on 11/19/24 at 1:55 AM, showed, "... Lochia Color: Rubra ... Amount: Moderate...

Review of "Vital Signs" on 11/19/24 at 2:20 AM, showed, ...blood pressure of 60/27 ...

Review of "Vital Signs" on 11/19/24 at 2:21 AM, showed, ...blood pressure of 55/22 ...

Review of "Vital Signs" on 11/19/24 at 2:23 AM, showed, ...blood pressure of 52/26 ...

Review of "Vital Signs" on 11/19/24 at 2:25 AM, showed, ...blood pressure of 53/31 ...


Review of "LIP [Licensed Independent Practitioner] Notification," dated 11/19/24 at 2:29 AM, showed, ...Notification Reason; Bleeding; Maternal vital sign change; Provider Name/Title; [Staff A2, MD] ...Notification Time; 0229 [2:29 AM]; Method of Communication; Call...


During an interview on 02/28/25 at 9:11 AM with Staff X1, stated that, need to inform the provider with two successive blood pressures exceeding 160/110 or reading below 85/50.


Review of "Procedure Summary" dated 11/19/24 at 5:08 AM, ... Procedure: HYSTERECTOMY TOTAL ABDOMINAL(Abdomen) ... 0338 [3:38 AM] Procedure Start ...


Review of Patient 1 ' s medical record failed to show documented evidence in reporting abnormal vital signs by calling a rapid response. The 66-minute delay of notifying provider has the potential for the patient to have adverse outcomes and increased mortality rate.


Patient 19


Review of Patient 19 ' s medical record showed a 41-year-old female admitted to the Hospital Medical Surgical Unit on 01/28/25 following an exploratory laparotomy with excision of a retroperitoneal cystic lesion, left nephrectomy, and cystoscopy insertion of a stent in the left ureter. Past medical history of anemia (low iron) and hypertension (high blood pressure).


Further review of this medical record showed a Post Anesthesia Care Unit (PACU) physician order stating "Vital Signs PACU routine ... 01/28/25 1440 - Until Specified". The staff failed to obtain a full set of vitals in PACU.


Further review of this medical record showed that Patient 12 transferred to the Medical Surgical Unit on 01/28/25 at 4:31 PM. A physician order stated "Vital Signs ... 01/28/24 1501 - Until Specified". The staff failed to obtain a full set of vital signs until 7:05 pm, a gap of greater than 2 hours after admitting to the unit before the first set of vital signs were obtained.


Further review of this medical record showed a physician order on 01/28/25 at 3:00 PM, stating "Notify if Vital Signs ... Temperature greater than: 38.5 ... Systolic blood pressure less than 90". The physician order did not state a parameter to call with a low temperature.


Review of "Vital Signs" on 01/28/25 at 7:05 PM, showed, "BP 94/66 ... Temp 36.6 C (97.8 F)"

Review of "Vital Signs" on 01/29/25 at 12:17 AM, showed, "BP 90/52"

Review of "Vital Signs" on 01/29/25 at 1:49 AM, showed, "BP 86/58"

Review of "Vital Signs" on 01/29/25 at 4:00 AM, showed, "BP 85/58"

Review of "Vital Signs" on 01/29/25 at 4:45 AM, showed, "BP 79/54 ... Temp 32.6 C (90.7 F)"


Review of Patient 19 ' s medical record failed to show documented evidence of reporting abnormal vital signs to the assigned physician or calling a rapid response.


During an interview on 03/04/25 at 4:37 PM, Staff Y, stated that Patient 19 ' s was not a patient of the hospitalist and was under the care of the Staff B2. Staff Y, stated that Staff E3 was concerned with Patient 19 ' s condition and requested an assessment. Staff Y, stated performing a bedside evaluation of Patient 19 and then calling Staff B2 to report the deterioration of the patient ' s condition at 5:24 AM.


4. Pain reassessment


Review of policy titled, "Pain Management," dated 10/02/23, showed, ... PURPOSE; To define the criteria for safe and reliable pain management through assessment, intervention and evaluation of progress toward treatment goals ... Documentation of pain assessment is completed on admission, during and after any known pain-producing event, with each new report of pain, and at least once a shift or per unit protocol ... Reassessment of pain includes: ... Progress toward pain goal ... Intervention ... Ask the patient if they want/need a pain medication to treat their pain ...


Review of document titled "The Ethical Responsibility to Manage Pain and the Suffering It Causes," dated 2018, written by: ANA (American Nurses Association) Center for Ethics and Human Rights, showed, ...Effective pain control strategies emphasize shared decision-making, informed and thorough pain assessment ...Current approaches include pharmacological and a variety of complementary health approaches, such as meditation ...Nurses have an ethical responsibility to relieve pain and the suffering it causes ...


Review of hospital document titled "Chest Pain Order Set," undated, showed ...Analgesics [medication that relieve pain] ...Fentanyl 25micrograms (mcg) intravenous once ...Morphine 2 milligrams (mg) intravenous once ...


Patient 20


Review of Patient 20's medical record showed Patient 20 presented to the Emergency Department on 01/21/25 at 10:30 AM, with a chief complaint of chest pain and transferred to higher level of care with a diagnosis of a non-ST elevated myocardial infarction (a type of heart attack usually happens when your heart ' s need for oxygen can ' t be met).


Review of "Pain Assessment- Brief" dated 01/21/25 at 10:43 AM, showed, ... How would you rate your pain on a scale of 0-10? 8 ...


During an interview on 03/04/25 at 2:30 PM, Staff V, RN, stated that, pain is assessed at triage to establish a baseline, before medication administration and again upon discharge.


The medical record failed to show documented evidence that Patient 20 ' s pain was reassessed or addressed in emergency department.


Patient 15


Review of Patient 15 ' s medical record showed an 84-year-old male admitted to the Hospital Medical Surgical Unit on 02/24/25 with a diagnosis of injury due to fall, closed fracture of right hip, anemia (low iron), and open reduction internal fixation of the right hip (hip pinning). Past medical history of benign prostatic hyperplasia (BPH, enlargement of the prostate gland causing decreased urinary flow), diabetes mellitus (a condition of poor insulin production causing high blood sugar), cerebrovascular accident (CVA, a stroke causing poor blood flow to the brain causing cell death), and hypothyroidism (when the thyroid gland fails to produce enough hormone).


Further review of this medical record showed Patient 15 arrival to the Hospital Emergency Department on 02/24/25 at 1:51 PM via EMS and a triage ESI of 3. The ED physician note at 1:51 PM stated "84-year-old male presents with right hip pain after fall at home earlier. Presents by EMS ... Received fentanyl en route ... Severity: Moderate ... External rotation with shortening of right leg. Range of motion unable to obtain due to discomfort.".


Further review of this medical record showed a physician order on 02/24/25 at 3:05 PM for acetaminophen 975 mg by mouth. A second physician order was noted at 3:34 PM for morphine 2 mg to be given intravenously. Both medications were documented being given at 3:41 PM. No evidence of pain scale assessment performed by staff in the Emergency Department.


During an interview on 02/27/25 at 12:15, Patient 15 ' s family, stated "It took a very long time to get pain medication, more than 1 hour to get some from when the staff said they were going to give it and he was exhibiting a lot of pain from the hip fracture."

Based on policy review, observation, and interview the Hospital failed to ensure that staff repeatedly exposed to radiation are checked periodically, by the use of exposure meters or badge tests, for amount of radiation exposure for the Operating Room (OR) staff.


Failure to ensure that staff exposed to radiation are checked periodically places those staff at risk for excessive radiation exposure.


Findings Include:


Review of the Hospital policy titled "ALARA & Occupational Safety Guidelines", last reviewed 04/02/24, stated "Requirement for Occupational Exposure Monitoring ... The occupational exposure to ionizing radiation will be monitored for workers who meet the following criteria: i) Adults likely to receive, in one-year from external sources, a dose greater than 10% of the annual limits; and ii) Declared pregnant women likely to receive, over the course of gestation, a fetal/embryo dose greater than 50.0 mrem (0.5mSv). iii) Workers who enter a High Radiation Area or a Very High Radiation Area. These workers will be identified specifically by the RSO. iv) Minors who are likely to exceed public dose limits."


Review of the Hospital policy titled "Personnel Dosimetry Responsibilities and Procedure" last reviewed 04/02/24, stated "Procedure for use of badges: ... Always wear your personal monitoring device when on duty and working near radiation sources ... Don ' t wear a monitoring device assigned to another person ... If you are wearing a lead apron, the badge should be worn on the outside of the apron".


During a tour of the Hospital Operating Room on 02/25/25 at 11:45 AM, it was observed that individual dosimetry badges were not being used for any personnel in the operating room when utilizing radiology. Staff C, stated that OR staff do not have badges and must request a badge if they want one.


During an interview on 02/26/25, at 3:30 PM, Staff W stated that radiology badges for OR staff are not used unless requested by the staff member. Staff W stated during a radiology safety meeting at an unknown date in the past, a decision was made to stop routine use of dosimetry badges for the OR staff stating that they did not feel they were necessary with a review of exposure readings. Staff W stated that there were also some compliance issues with staff using the dosimetry badges routinely.


During an interview on 02/28/25, at 9:38 AM, Staff X, stated that approximately 5 years ago they stopped the mandatory use of dosimetry badges in the OR for radiology technologist and surgical staff. Staff X, stated that based on the discussion of the Radiation Safety Committee at that time, polling results with staff, and measure of dosimetry badge exposure of the OR staff, dosimetry badges were determined unnecessary and optional for staff by request. Staff X, stated that staff only needed dosimetry badges if they were likely to exceed safe radiation levels defined by the radiation policy. Staff X, stated that the hospital follows radiation standards set by the contracted provider for the radiology department of the hospital. Staff X, stated that they did not know if the changes in radiation badge requirements were ever changed or documented within the hospital policies.

Based on policy review and interview, the Utilization Review (UR) committee failed to ensure that at least two members of the committee consisted of two or more practitioners for 3 of 5 meetings reviewed.


The failure to have two or more practitioners places patients at risk of inadequate review of services provided by the hospital.


Findings Include:


Review of policy titled, "Clinical A-008 Utilization Review Plan Policy" last published 08/17/2024, showed ". . . 3. Composition of the UR Committee a. A UR committee consisting of two or more practitioners must carry out the UR function. At least two of the members of the committee must be Doctor of Medicine or osteopathy. . ."


Review of hospital's document titled, "Meeting Agenda Utilization Review Committee" dated 05/16/2024, showed "Attendees:" blank with no names. "Meeting Agenda Utilization Review Committee" dated 07/15/2024 showed no doctors next to "Attendees." "Meeting Agenda Utilization Review dated 10/24/2024 showed only one doctor next to "Attendees."

During an interview on 02/27/25 at 09:10 AM, Staff B, Director of Quality, stated that all the Utilization Review Committee Meetings (UR) have one doctor that attends and that it usually is the medical director.

During an interview on 03/04/25 at 4:45 PM, Staff B, Director of Quality, stated that she wanted to clarify that two doctors attend the UR meetings. When she was informed that not all meetings showed two doctors in attendance, she said she would look at the minutes.

In an email on 03/04/25 at 5:36 PM, Staff B, Director of Quality, stated "There are 2 meetings that do not have 2 physicians present."

Based on document review, employee record review, and interview the Hospital failed to ensure an individual who is qualified through education, training, experience, or certification in infection prevention and control, is appointed by the governing body as the infection control professional responsible for the infection prevention and control program.


Findings Include:


Review of the Hospital document titled "Infection Prevention and Control Plan [IPCP] FY24 [Fiscal Year 2024]" last reviewed and approved on 12/27/23, showed "The Infection Prevention Program Manager is an Infection Preventionist who facilitates and coordinates the IPCP at [The Hospital]. The manager is responsible for tracking and trending in-house infection rates, education of staff, and visitors and reporting of data to hospital staff. The Infection Prevention Program Manager is a trained professional, certified in Infection Prevention and Control within 6 months of eligibility of the certifying examination, who is assigned the full-time responsibility of supervising and coordinating the multiple facets and the daily management of the hospital's IPCP."


Review of the Hospital document titled "Infection Prevention and Control Plan FY25 [Fiscal Year 2025]" with no documented review or approval date, showed "Authority and Responsibility: ... By approving this Infection Control Plan, the Board is appointing the Infection Prevention Program Manager from recommendations by Medical Staff and Nursing Leadership through the Infection Prevention Committee. All Infection Preventionists serving before 7/1/22 are appointed by the Board through approval of this addendum ..."


Review of policy titled "Sterile Processing Procedures" dated 10/02/2023, showed, " ... To provide procedures for sterilizing items to be used in the surgical environment. One of the measures for preventing surgical site infections is to provide surgical items that are free of contamination at the time of use. This can be accomplished by subjecting them to cleaning, inspection and decontamination, followed by a sterilization process ...All immediate use sterilization devices will be monitored for trending and results reported monthly to Infection Prevention Department and the appropriate Quality and Safety Committee(s) ... Should a processed biological or a failed Class 5 integrating chemical indicator (CI) demonstrate a failure, the entire load will be considered unsterile and will be immediately reported to the appropriate supervisor, infection prevention and control department and administration. This notification will be followed by a written report. The report and notification will include the following information: a. The time and date of the questionable sterilizer cycle b. A description of the sterilizer and load, with reference to the appropriate lot control number c. The results of physical monitoring and of internal CIs as obtained from the user department d. Any other information that could be useful in determining the cause of indicator failure. 3. If the cause of failure is immediately identified and confined to one load or one item in the load, the cause of the failure will be corrected, and the load will be reprocessed. If the cause of the failure is not immediately identified, the load will be quarantined and all loads back to the last negative BI will be recalled. Items in these loads will be retrieved, if possible, and reprocessed ..."


Review of a document titled, "Infection Prevention Program Manager" dated 01/30/24 showed, " ...Responsible for the collaborative approach and implementation of an entity specific facility-wide infection prevention and control program. Reports to the entity Director of Quality and Patient Safety Officer ... Provides strict and continuous oversight on equipment and environmental cleaning, as well as low and high level disinfection and sterilization processes throughout the operating group. Assures that there are preventive, surveillance, and control procedures relating to sterilization, disinfection, and cleaning practices in all departments throughout the operating group ..."


Staff B2, Registered Nurse (RN), Infection Preventionist (IP)


Review of Staff B2's employee record on 02/05/25 at 5:15 PM showed an initial Registered Nurse (RN) licensure date of 06/14/21 and an initial hire date of 07/11/21.


Further review of Staff B2's employee record found a document titled "Infection Preventionist Residency" with a start date of 04/16/24 showed "This Residency program serves as the formative training for novice IPs. ... Competence is defined as having the knowledge and skills to do a job or task successfully. ... Additionally, the IP will be expected to complete and pass the Infection Prevention Core Competency Pathways Module as the final stage to show a full understanding of the material. Upon completion of the checklist items and IP Competency module, the IP will receive a certificate for their records. ... Estimated time for completion: 6-9 months."


Review of a document titled, "Infection Preventionist Residency" dated 04/16/24 showed, " ...Estimated time for completion: 6-9 months (save your exercises). When you have completed this "IP Residency" you need to pass the "IP Core Competency Training" (annually) located within Pathways ..." Several components missing as of 02/05/25 including the following: " ...Surveillance as a Methodology ... CLABSI ...Post-exposure evaluation for risk ...Performance Improvement ...Training Staff/Physicians ...Microbiology Lab ...Microbiology for IPs ...Antibiotic Stewardship ... Disinfection & Sterilization, Role of IP in Disinfection & Sterilization ...HLD- pre clean/HLD/storage ...Water Management Plan ...Linen ...Endoscopy ...Outbreak Management ... Emergency Management ...Dialysis ...Ambulatory Care ...Neonates ...Pediatrics ... Rehabilitation ..."


Further review of Staff B2's employee record showed no evidence Infection Preventionist Residency Program was completed in 6-9 months.


During an interview on 01/29/25 at 9:20 AM, Staff B2, stated that he/she has been in the infection preventionist position approximately 6-8 months covering three hospitals infection control program. Currently enrolled in the hospital residency program. Staff B2 went on to state that she is not an expert and being very new to the role has been very challenging.


During an interview on 01/29/25 at 9:20 AM, Staff B2, Infection Prevention Manager, stated that I am not an expert in sterile processing, we had multiple incident reports, so we had an outside auditor come to hospital in December 2024 and the auditor let us know that there were concerns related to sterile processing.

Based on document review, record review, policy review, observation, and interview the Hospital failed to ensure adherence to nationally recognized infection prevention and control guidelines and hospital policies and procedures for infection control and prevention when staff failed to: 1. perform proper hand hygiene; 2. use appropriate personal protective equipment; 3. appropriately handle and dispose of trash and biohazardous waste; 4. maintain clean storage spaces; 5. appropriately consume and store food and drink in a patient care area; 6. clean and sterilize surgical and durable medical equipment; and 7. ensure routine upkeep and cleanliness of patient care areas.


This deficient practice has the potential to place all patients, visitors, staff, and the community at risk to contract and spread infectious and/or communicable diseases.


Findings Include:


Review of the Hospital document titled "Infection Prevention and Control Plan FY24" last reviewed on 12/27/23 and approved on 12/27/23, showed "All employees are always required to observe proper infection prevention and control practices. ... The activities of the IPCP are part of a hospital wide plan of action to: ... Identify potential infection risks to patients, visitors, and staff and address those prioritized risks ... Pursue improved compliance with hand hygiene guidelines at all levels of patient care. ... The Infection Prevention Program Manager performs the following functions: ... Interdepartmental collaboration to ensure appropriate cleaning and disinfection of equipment is occurring and to establish practices and standards for appropriate waste management. ... perform regular observational rounds to gauge compliance with evidence-based practices ... including but not limited to hand hygiene, environmental hygiene, appropriate use of personal protective equipment, appropriate institution of isolation precautions, and adherence to other infection prevention and control policies."


Review of the Hospital document titled "Infection Prevention and Control Plan FY25" with no documented review or approval date, showed "Infection Prevention and Control Committee ... is a multidisciplinary group ... The following areas must be represented in the Committee: ... Quality ... Nursing ... Occupational Health ... Pharmacy ... Perioperative Department ... Laboratory ... Facilities Management ... Environmental Services/Laundry ... Sterile Processing ... The Committee will review and approve guidelines, policies and/or procedures relating to infection prevention and control including but not limited to isolation precautions ... appropriate storage, cleaning, disinfection, sterilization, and/or disposal of supplies; reuse of disposable equipment; the use of personal protective equipment (PPE) and reducing the risk from animals brought into facilities ... the Committee will evaluate new equipment , procedures, and clinical services for cleaning, decontamination, sterilization, and other practices as they relate to infection prevention and control".


Review of the hospital policy titled "Hand Hygiene" dated 01/06/25, showed " ...All HCP [Healthcare Personnel] including employees, credentialed providers, advanced practice professionals, volunteers, students and contractors will follow the CDC [Centers for Disease Control] indications for hand hygiene: a. Wash hands with soap and water when hands are visibly soiled, when caring for a patient with C. difficile, before eating, and after using the restroom ...b. If hands are not visibly soiled, use alcohol-based hand rub or soap and water ...c. Perform hand hygiene before direct contact with patient and/or patient surroundings ...d. Perform hand hygiene before donning clean or sterile gloves ...e. Perform hand hygiene before inserting indwelling urinary catheter, peripheral vascular catheters, or other invasive devices that do not require a surgical procedure ...f. Perform hand hygiene after contact with patient's intact skin ...g. Perform hand hygiene after contact with body fluids, excretions, mucous membranes, nonintact skin, and wound dressings ...h. Perform hand hygiene if moving from a contaminated body site to a clean body site ... i. Perform hand hygiene after contact with inanimate objects and medical equipment in the patient's vicinity ...j. Perform hand hygiene after removing gloves ...2. All HCP have the responsibility to protect patients by intervening when hand hygiene is not performed by a member of the patient's treatment team ...a. The HCP can either provide in the moment peer-to-peer coaching or report observations to a member of the leadership team or the Infection Preventionist ...b. If a trend or pattern of noncompliance is identified for an HCP, review of possible barriers to compliance should be included in any coaching sessions. These barriers should be communicated to the Infection Preventionist or other hand hygiene champion for inclusion in data analysis activities ...3. Hand hygiene is monitored routinely in clinical areas ..."


Review of the hospital policy titled, "Isolation: Standard and Transmission Based Precautions" dated 03/23/22 showed "A. Standard Precautions are designed to reduce the risk of transmission of microorganisms by the following interventions: ...a. Performing Hand hygiene b. Wearing proper Personal Protective Equipment (PPE) for the task performed (gloves, mask, eye protection, gown) ...c. Cleaning/disinfecting Patient-Care Equipment ...d. Carefully handle laundry & textiles ...e. Respiratory etiquette ...A. General Guidelines ...The standard is to follow the CDC recommendations for type and duration of isolation for the disease. ... 3. Bring isolation supplies to the room ...4. Place disposable equipment in room ...5. Post correct sign on door and leave in place until room is terminally cleaned ...7. Educate patient and visitors on appropriate precautions ...D. Contact Precautions ...1. Personal protective equipment ... a. Gloves and hand hygiene ...b. Gown ...c. Dedicated Patient-Care Equipment ...e. Staff should not wear contaminated PPE during transportation. Dispose of PPE after preparing patient for transport ..."


Review of the hospital policy titled "Clinical Competency, Orientation, and Education" dated 07/11/2024, showed, " ...All employees participate in orientation and complete ongoing education to the following elements which are documented upon completion: ... Infection prevention and control including medication multi-drug resistant organism (MDRO), surgical site infections (SSIs), central line acquired blood stream infections (CLABSI), catheter associated urinary tract infections (CAUTIs), and influenza ..."


Review of the Hospital policy titled "Regulated & Unregulated Waste" last reviewed 08/19/24, last approved 08/19/24, showed "Regular Solid (General) Waste: ... Discard waste in containers that are lined with clear/white plastic bags. ... Processed like household trash. ... Infectious Waste: ... biohazardous waste that is capable of producing an infectious disease such as pathological waste, cultures and stocks of infectious agents, human blood and blood products, and sharps. ... Place in red plastic bag in patient care area. ... Examples: ... Gloves and tubing ... Medical Devices that contain blood/body fluids".


Review of the Hospital document titled "Patient Death, Postmortem Care, Autopsy, Organ/Tissue Donation" last reviewed 10/02/23, last approved 10/02/23, showed "If the Coroner has released the body: ... If the Coroner has released the body: ... Remove all clothing, jewelry, and other valuables. ... Give all patient belongings to NOK/family at bedside. ... If NOK not present, send valuables to Security or secured location. ... Other belongings remain on patient unit for NOK to pick up ... Note known or suspected infectious diseases on the designated tag." The policy failed to show the process for handling of patient remains on contact precautions for an infectious disease.


Review of a website Centers for Disease Control (CDC) showed a document titled, "About Ventilation and Respiratory Viruses" dated 10/03/24 showed, " ... Good ventilation is essential to maintaining a healthy indoor environment and protecting building occupants from respiratory infections in the workplace ...When indoors, ventilation mitigation strategies can help reduce viral particle concentration. A lower concentration results in fewer viral particles inhaled into the lungs, which lowers the inhaled dose. Additionally, it also reduces the amount of viral particles that people can come into contact with through their eyes, nose, and mouth, as well as the amount that can accumulate on surfaces ..."


During an observation on 01/21/25 at 12:20 PM, an unidentified dietary staff member was observed wearing gloves passing meal trays. The unidentified staff was observed using hand sanitizer with gloves on. Staff then proceeded to meal cart obtaining a food tray for another patient. Staff L2 present at time of observation, real time education not provided to staff.


During an interview on 02/06/25 at 8:37 AM, Staff N2, Chief Nursing Officer (CNO), stated that staff should be wearing PPE in contact isolation room and then remove the PPE when exiting the room. Failing to do so puts both patients and staff at risk for infection.


During an observation on 01/21/25 at 12:22 PM, on the Medical Surgical Unit, room 1207, the isolation cabinet outside of the room had an empty box of isolation gowns.


During an observation on 01/21/25 at 12:26 PM, on the Medical Surgical Unit, room 1211, the isolation cabinet outside of the room had one unwrapped used white duckbilled N-95 (respirator to protect against severe diseases, one time use) mask stored inside of the cabinet.


During an observation on 01/21/25 at 12:26 PM, on the Medical Surgical Unit, room 1227, the isolation cabinet outside of the room had two unwrapped used green N-95 mask stored inside of the cabinet.


During an interview on 01/29/25 at 9:20 AM, Staff B2, Infection Prevention Program Manager, stated, " ...N95 masks are individual packaged, it's disappointing that they are in the cabinet not wrap it looks they are used N95 masks place back in the isolation cabinet, I'm not sure if they clean the cabinet ..."


During an observation on 01/21/25 at 12:44 PM of the Emergency Department (ED) showed two plastic trash cans with cracks and visible debris present.


During an observation on 01/21/25 at 12:59 PM of the Outpatient infusion Clinic, multiple recliners had a significant amount of visible deterioration of headrest, seat and armrests.


During an observation on 01/21/25 at 12:59 PM of the Outpatient Infusion Clinic, an empty medication bottle with used open intravenous (IV) tubing was laying on the seat of a recliner that had visible deterioration of the material on the headrest and seat.


During an observation on 01/28/25 at 9:43 AM, of the Intensive Care Unit (ICU), showed a piece of balled up gauze noted on the floor in the corner of the clean utility room.


During an observation on 01/28/25 at 9:44 AM, of the Intensive Care Unit (ICU), showed, the storage of durable medical equipment (DME) of a sonogram machine and blood pressure machine were stored in the clean utility room with no cleaning log or dated clean tag.


During an observation on 01/28/25 at 9:45 AM, of the ICU, in the medication storage room, a large biohazard disposable container directly sitting on hospital floor and a wheeled biohazard bin containing used IV tubing and medications from patients present in clean storage.


During an observation on 01/28/25 at 9:46 AM, of the ICU, showed on the counter of the nursing station, a food tray was sitting on the counter with opened food items from a patient room.


During an interview on 01/28/25 at 9:46 am, Staff R, stated, that housekeeping is responsible for cleaning equipment and the floors of the clean utility room. Staff R, stated, that a food cart is usually sitting beside the nursing station for opened patient meal trays to be stored for pickup but must have been taken to the kitchen. Staff R, stated, when the food cart is not present, then food tray is taken to the dirty utility room for later pickup from food services.


During an observation on 01/28/25 at 12:30 PM, on the Medical Surgical Unit, In the hallway outside of room 1205 a bag of trash was sitting on the floor against the wall outside of the room.


During an observation on 01/28/25 at 12:35 PM, on the Medical Surgical Unit, the protective personal equipment (PPE) supply storage cabinet outside of room 1207 did not have any procedural masks or gowns stocked with posted contact precaution signs.


During an observation on 01/28/25 at 1:04 pm, of the emergency department, the bed in room 7 had a dark stain on the sheet.


During an interview on 01/28/25 at 1:08 PM, Staff S, RN stated that the ED technicians (techs) turn over rooms wiping the bed, chairs, and equipment, and making the bed if environmental services is not available. Staff S, RN stated that if the sheet has a small stain, it will still be used on a newly cleaned bed and if the stain is large then the sheet will be thrown away.


During an observation on 01/28/25 at 1:20 PM, of the Outpatient Infusion Clinic, showed two staff members actively eating within a few feet of freshly drawn biohazard materials and in the same room with patients receiving transfusions approximately 10 feet away.


During an observation on 01/28/25 at 1:22 PM, of the Outpatient Infusion Clinic, an intravenous (IV) bag of bodily fluids from a patient was sitting on the bottom of a wheeled stool near the floor with a blood pressure cuff sitting on upper portion of the same stool.


During an observation on 01/28/25 at 1:24 PM, of the Outpatient Infusion Clinic, kitchen utensils, kitchen supplies, and staff food and drink items were sitting right next to the sink used for hand hygiene of staff between patient infusions.


An observation of the Outpatient Infusion Clinic on 01/28/25 at 1:26 PM showed a food tray with a scalpel and an open tube of glue. The food tray was sitting next to clean, unopened supplies.


During an observation on 01/28/25 at 1:26 PM, in Outpatient Infusion Clinic, showed, a food tray with a scalpel and an open tube of project glue with staining in the food tray was sitting next to clean unused supplies in supply storage office.


During an observation on 01/28/25 at 1:35 PM, of the Outpatient Infusion Clinic, showed, two trash cans unlabeled for biohazard had used IV bags, tubing, and cannulas from patient infusions.


During an observation on 01/28/25 at 1:40 PM, of the Outpatient Infusion Clinic, an unidentified nurse performing removal of an IV cannula after transfusing a patient placed the cannula on top of the IV pump and then dropped it to the floor. Neither the IV pump or the floor was cleaned after having the IV cannula come in contact with each surface.


During an observation on 01/28/25 at 1:44 PM, at the Outpatient Infusion Clinic, the medication and IV preparation cart not cleaned after using area for preparation of previous patients' transfusion medication and biohazard sharps container on side of cart used for placement of IV cannula.


During an observation on 01/28/25 at 1:48 PM, of the Outpatient Infusion Clinic, Staff U, removed an IV cannula from a patient, wrapped it in a glove, and placed it in a non-biohazard trash can with the IV tubing in front of the kitchen sink area.


During an observation on 01/28/25 at 1:55 PM, of the Outpatient Infusion Clinic, two IV pumps were not wiped down between transfusions performed on patients.


During an observation on 01/28/25 at 2:05 PM, of the Outpatient Infusion Clinic, the blood pressure cuff on the vitals machine were not cleaned between patients.


During an interview on 01/28/25 at 2:10 pm, Staff U, stated that they perform therapeutic phlebotomy, administer IV fluids, blood, and albumin often and any biological material is disposed of in the biohazard bin after the fluids are taken off. Staff U, stated that between each patient infusion the chair being used and IV pump is wiped down between patients, however the IV pumps are sometimes missed because they are not a direct contact surface from the patient. Staff U went on to state that the medication and IV prep cart should be wiped down between each use. IV cannulas from a patient after infusion do not have to be placed in a biohazard trashcan if the IV cannula is flushed prior to removing it from the patient and may be placed in a non-biohazard trashcan.


During an observation on 01/29/25 at 8:47 AM, on the Medical Surgical Unit, showed room 1225, an unidentified nurse performed no hand hygiene when exiting the patient's room, then performed documentation tasks at the nursing station.


During an observation on 01/29/25 at 8:50 AM, on the Medical Surgical Unit, room 1223, an unidentified nurse performed no hand hygiene when exiting the patient's room.


During an observation on 01/29/25 at 8:51 AM, on the Medical Surgical Unit, room 1205, an unidentified nurse performed no hand hygiene when entering the patient's room.


During an observation on 01/29/25 at 8:54 AM, on the Medical Surgical Unit, room 1212, an unidentified nurse performed no hand hygiene when exiting the patient's room, that was receiving a dialysis treatment.


During an observation on 01/29/25 at 8:54 AM, on the Medical Surgical Unit, room 1215, two unidentified nurses performed no hand hygiene when exiting the patient's room.


During an observation on 01/29/25 at 8:55 AM, on the Medical Surgical Unit, room 1215, an unidentified nurse performed no hand hygiene when entering the patient's room.


During an observation on 01/29/25 at 8:57 AM, on the Medical Surgical Unit, room 1206, an unidentified nurse performed no hand hygiene when entering the patient's room.


During an observation on 01/29/25 at 8:59 AM, on the Medical Surgical Unit, room 1212, two unidentified nurses performed no hand hygiene when entering the patient's room, that was receiving a dialysis treatment.


During an observation on 01/29/25 at 9:01 am, on the Medical Surgical Unit, room 1212, two unidentified nurses performed no hand hygiene when exiting the patient's room, that was receiving a dialysis treatment.


During an observation on 01/29/25 at 9:02 AM, on the Medical Surgical Unit, room 1214, with a posted contact isolation sign, an unidentified nurse exited the patient's room wearing personal protective equipment (PPE) gown and gloves carrying a food tray, placed the food tray on top of a trash can placed in the hallway, doffed the gown and gloves in the trash can in the hallway, carried the food tray to the soiled utility room, and performed no hand hygiene after.


During an observation on 01/29/25 at 9:03 AM, on the Medical Surgical Unit, room 1215, Staff Y, exited the patient's room with a gloved hand carrying a laboratory specimen, placed it into a transport tube in the nursing station, discarded the glove, did not perform hand hygiene, and then returned to performing documentation at the nurse's station.


During an observation on 01/29/25 at 9:06 AM, on the Medical Surgical Unit, room 1203, an unidentified Doctor dressed in blue Operating Room (OR) scrubs and scrub cap placed an open drink cup in the PPE supply storage cabinet outside of the patient's room, performed no hand hygiene when entering or exiting the patient's room, retrieved the drink cup from the PPE supply storage cabinet, entered the nursing station, filled the cup with ice and water, and then exited the unit.


During an observation on 01/29/25 at 9:12 AM, on the Medical Surgical Unit, room 1205, an unidentified nurse performed no hand hygiene when exiting the patient's room.


During an observation on 01/29/25 at 9:17 AM, on the Medical Surgical Unit, room 1214, with a posted contact isolation sign, Staff Y, performed no hand hygiene or don PPE upon entry of the room, performed bedside tasks, and then exited the patient room without performing hand hygiene.


During an observation on 01/29/25 at 9:21 AM, on the Medical Surgical Unit, Room 1212, an unidentified nurse performed no hand hygiene when entering the patient's room, that was receiving a dialysis treatment.


During an observation on 01/29/25 at 9:25 AM, on the Medical Surgical Unit, Room 1205, an unidentified nurse performed no hand hygiene when entering the patient's room.


During an observation on 01/29/25 at 9:26 AM, on the Medical Surgical Unit, Room 1214, with a posted contact isolation sign, an unidentified dietary staff member performed no hand hygiene, did not don PPE when entering the patient's room, delivered a food tray to patient bedside, and exited the patient's room without performing hand hygiene.


During an observation on 01/29/25 at 9:40 AM, on the Medical Surgical Unit, Room 1226, with a posted contact isolation sign, an unidentified nurse performed no hand hygiene, did not don PPE when entering the patient's room, and performed no hand hygiene when exiting the patient's room.


During an observation on 01/29/25 at 9:46 AM, on the Medical Surgical Unit, Room 1214, with a posted contact isolation sign, an unidentified staff dressed in blue OR scrubs and OR scrub cap entered the room without putting on PPE, approached the patient bedside, then exited the room, performed hand hygiene and put on a gown and gloves then re-entered the patient's room.


During an observation on 01/29/25 at 9:49 AM, on the Medical Surgical Unit, Room 1227, with a posted contact isolation sign, an unidentified chaplain and two funeral home attendants, performed no hand hygiene or donned PPE when entering the patient's room and did not perform hand hygiene when exiting the patient's room with the patient's body.


During an observation on 01/29/25 at 9:55 AM, on the Medical Surgical Unit, Room 1215, an unidentified nurse performed no hand hygiene when entering the patient's room.


During an observation on 01/29/25 at 9:56 AM, on the Medical Surgical Unit, Room 1212, an unidentified nurse performed no hand hygiene when entering the patient's room, that was receiving a dialysis treatment.


During an interview on 01/29/25 at 10:05 AM, Staff Y, stated that all staff receive orientation and training from the hospital for infection control safety and contact isolation precautions. Staff Y went on to state that when entering any patient room, hand hygiene must be performed. When a patient is on contact precautions, any staff and family entering the room should be wearing a gown, gloves, and if on respiratory isolation precautions, a surgical mask is required.


During an interview on 01/29/25 at 10:23 AM, Staff Z, stated that all staff should be performing hand hygiene when entering and exiting any patient room and when a patient is on contact precautions, any staff or family entering the room should be wearing a gown, gloves, and if on respiratory isolation, a surgical mask is required.


During an interview on 01/29/25 at 10:35 AM, Staff D, stated that the trash cans in the hallway outside of room 1214 and room 1219 have always been placed in the hallway. Staff D stated that the infection control nurse previously made routine monthly rounds on the unit to observe staff and go over findings from the observations and audits with education for staff. Staff D stated that these audits did not appear to be happening for the past several months.


During an observation on 01/30/25 at 10:55 AM, showed, unidentified staff at Neonatal Intensive Care Unit (NICU) bed 2, taking off gloves and threw in trash can one glove missed trash can, unidentified staff then picked up glove off floor and threw in trash, NICU bed 3 alarm went off, went to monitor and adjusted settings, then exited the NICU pushing a green exit button without hand hygiene.


During an interview on 02/03/25 at 2:00 PM Staff E2 stated " ...Washing hands in the NICU is to prevent infections and germs between babies ..."


During an interview on 02/06/25 at 9:05 am, Staff N2, Chief Nursing Officer (CNO), stated that any staff entering a patient room who is on contact isolation should be wearing the appropriate PPE of a gown, gloves and mask before entering the patient room and dispose of the PPE upon exiting the patient room, then perform hand hygiene. Staff N2, stated that all staff and visitors should be performing hand hygiene when entering and exiting any patient room. Staff N2, stated that any trash or biohazardous materials from a patient room should not be placed directly on the floor and should be disposed of promptly in the dirty utility room. Staff N2, stated that items used in patient rooms should not be taken to or placed in any designated clean areas and should be placed in the proper disposal area within the dirty utility room. Staff N2, stated that no open food items or trays from a patient room should be stored anywhere except in the designated food cart or dirty utility room on the unit. Staff N2, stated that no staff should be eating meals in a designated patient care area.



During an observation on 02/03/25 at 2:01 PM showed a patient room open with contact and airborne isolation signs present on the door.


During an interview on 02/03/25 at 2:02 PM an unidentified staff stated that the patient had Influenza A.


During an on interview on 01/28/25 at 9:25 AM Staff O, stated that Staff N was sitting outside the operating room suite and was getting ready to do a total joint surgery when ceiling tile fell right next to him.


During an observation on 01/30/25 at 8:23 AM ceiling tiles in board room noted to be water damaged and moist to the touch.


During an interview on 01/28/25 at 3:52 PM Staff Q stated that in over 20 years the ducts (tubes that move air throughout hospital) have not been cleaned. Staff Q went on to state that they were unaware the ducts were to be cleaned.


The hospital failed to provide High efficiency particulate air filters (HEPA) filter changing logs from October, November and December 2024.


During an interview on 01/28/25 at 3:30 PM Staff W stated that air vents are cleaned monthly.


During an interview on 02/04/25 at 4:17 PM an unidentified Environmental Services staff stated that he/she been working in housekeeping eight years and have not cleaned intake vents.


On 02/06/24 at 2:21 PM three surveyors were in basement board room, when strong smell of fuel was coming through air vents. Surveyors at this time went to assess situation and observed helicopter being fueled.

Based on observation, interview, policy and document review, the Hospital failed to ensure a clean and sanitary environment for all patients currently at this hospital receiving dietary, surgical services, and health care. This deficient practice effects all patients receiving services at this hospital and has the potential to place them at risk for food borne infection, transmission of infection, or other adverse outcomes.


Findings Include:


Review of the Hospital document titled "Infection Prevention and Control Plan FY24" last reviewed on 12/27/23 and approved on 12/27/23, showed "All employees are always required to observe proper infection prevention and control practices. ... The activities of the IPCP are part of a hospital wide plan of action to: 1. Identify healthcare associated infections in patients receiving services ... 2. Identify opportunities to reduce the risk of disease transmission to any person in contact with ... an associate, contracted staff member, patient, or visitor. ... 3. Recommend practices that reduce the risk of disease transmission by integrating current evidenced-based infection control practices and principles. This includes a focus on limiting the transmission of infections associated with procedures and use of medical equipment, devices, and supplies. 4. Identify potential infection risks to patients, visitors, and staff and address those prioritized risks by setting strategic goals and implementing actions to minimize those risks. 5. Pursue improved compliance with hand hygiene guidelines at all levels of patient care. ... The Infection Prevention Program Manager performs the following functions: ... 12. Interdepartmental collaboration to ensure appropriate cleaning and disinfection of equipment is occurring and to establish practices and standards for appropriate waste management. ... To provide supporting data for IPCP objectives, the Infection Preventionist, or designee, will perform regular observational rounds to gauge compliance with evidence-based practices which control the spread of infection including but not limited to hand hygiene, environmental hygiene, appropriate use of personal protective equipment, appropriate institution of isolation precautions, and adherence to other infection prevention and control policies."


Review of the Hospital document titled "Infection Prevention and Control Plan FY25" with no documented review or approval date, showed "Infection Prevention and Control Committee ... is a multidisciplinary group of key stakeholders who influence the patient care and physical environment in ways that may prevent the transmission of disease. ... The following areas must be represented in the Committee: ... Quality ... Nursing ... Occupational Health ... Pharmacy ... Perioperative Department ... Laboratory ... Facilities Management ... Environmental Services/Laundry ... Sterile Processing ... The Committee will review and approve guidelines, policies and/or procedures relating to infection prevention and control including but not limited to isolation precautions ... appropriate storage, cleaning, disinfection, sterilization, and/or disposal of supplies; reuse of disposable equipment; the use of personal protective equipment (PPE) and reducing the risk from animals brought into facilities ... the Committee will evaluate new equipment , procedures, and clinical services for cleaning, decontamination, sterilization, and other practices as they relate to infection prevention and control ... Infection Control Risk Assessment ... General surveillance activities include those designed to prevent and control infection in patients, medical staff (physicians, nurse practitioners, physicians' assistants, etc.), employees, dependent healthcare personnel, contract staff, volunteers, students, and visitors. ... Targeted surveillance will focus on device-associated infection, procedure-associated infections, and infections with multidrug-resistant organisms as described below: ... Central Line Associated Bloodstream Infections (CLABSI) ... Catheter Associated Urinary Tract Infections (CAUTI) ... Surgical Site Infections (SSI) ... Clostridioides difficile ... Candida auris ... MRSA Carbapenem - resistant Enterobacteriaceae (CRE) ... ESBL ... Environment of Care ... Hand hygiene ... SPD ... Dialysis ... OR".


Review of the Hospital policy titled "Regulated & Unregulated Waste" last reviewed on 08/19/24 stated "This policy is for the safety of all associates who are handling regulated and unregulated waste. It will also identify and define what regulated waste is and how it will be disposed. All waste will be handled using Standard Precautions. ... Waste disposal will be accomplished in accordance with the following: 1. Regular Solid (General) Waste ... Ordinary trash and construction demolition waste that is disposed of as municipal solid waste. ... Always wear the appropriate Personal Protective Equipment (PPE) ... Discard waste in containers that are lined with clear/white plastic bags. ... Processed like household trash. ... 2. Infectious Waste ... Regulated Medical Waste (RMW) or biohazardous waste that is capable of producing an infectious disease such as pathological waste, cultures and stocks of infectious agents, human blood and blood products, and sharps. ... Place in red plastic bag in patient care area. ... All red bags must be placed into labeled biohazard bins prior to transport to the collection area."


Review of a document titled, "Weekly Endoscope Cabinet Cleaning Log" dated 2024, showed the last cleaning to be completed on 12/13/24. The endoscope drying cabinet had not been cleaned for about 5 weeks.


Review of a document titled, "Weekly Endoscope Cabinet Cleaning Log" showed the cabinet had last been cleaned on 01/31/25.


During an interview on 01/23/25 at 10:16 AM, Staff E stated that the endoscope cabinet should have been cleaned weekly.


The Hospital failed to provide hospital policies as requested by surveyors on 01/29/25 at 11:46 AM and 02/03/25 at 3:35 PM related to food service damaged boxes, cans, date of receiving and expiration of food.


The hospital failed to provide High efficiency particulate air filters (HEPA) filter changing logs from October, November and December 2024.


During an observation on 01/21/25 at 12:26 PM, on the Medical Surgical Unit, room 1211, the isolation cabinet outside of the room had one unwrapped used white duckbilled N-95 (respirator to protect against severe diseases, one time use) mask stored inside of the cabinet.


During an observation on 01/21/25 at 12:26 PM, on the Medical Surgical Unit, room 1227, the isolation cabinet outside of the room had two unwrapped used green N-95 mask stored inside of the cabinet.


During an observation on 01/21/25 at 12:44 PM of the Emergency Department (ED) showed two plastic trash cans with cracks and visible debris present.


During an observation on 01/21/25 at 12:59 PM of the Outpatient infusion Clinic, multiple recliners had a significant amount of visible deterioration of headrest, seat and armrests.


During an observation on 01/21/25 at 12:59 PM of the Outpatient Infusion Clinic, an empty medication bottle with used open intravenous (IV) tubing was laying on the seat of a recliner that had visible deterioration of the material on the headrest and seat.


During an interview on 01/27/25 at 4:04 PM, Staff N, stated that some flies were getting into the pre-operation area and maintenance had special lights installed and provided fly swatters.


During an on interview on 01/28/25 at 9:25 AM, Staff O, stated that Staff N was sitting outside the operating room (OR) suite and was getting ready to do a total joint surgery when ceiling tile fell right next to him. Staff O, stated that the OR has had issues with flies and has personally killed 16 flies in one day in the operating suites.


During an observation on 01/28/25 at 9:44 AM, of the ICU, showed, a sonogram machine and blood pressure machine were stored in the clean utility room with no cleaning log or dated clean tag.


During an observation on 01/28/25 at 9:45 AM, of the ICU, showed, the medication storage room with a large biohazard disposable container directly sitting on hospital floor; a wheeled biohazard bin containing used IV tubing and medications from patients present in clean storage.


During an observation on 01/28/25 at 9:46 AM, of the ICU, showed on the counter of the nursing station, a food tray was sitting on the counter with opened food items from a patient room.


During an interview on 01/28/25 at 9:46 am, Staff R, stated, that housekeeping is responsible for cleaning equipment and the floors of the clean utility room. Staff R, stated, that a food cart is usually sitting beside the nursing station for opened patient meal trays to be stored for pickup but must have been taken to the kitchen. Staff R, stated, when the food cart is not present, then food tray is taken to the dirty utility room for later pickup from food services.


During an interview on 01/28/25 at 11:20 AM, Staff P, stated that, there has been issues with flies coming into the OR suites since the trash and loading dock is next to OR. We try to make sure that the fly doesn't land on the sterile field.


During an observation on 01/28/25 at 12:30 PM, on the Medical Surgical Unit, In the hallway outside of room 1205 a bag of trash was sitting on the floor against the wall outside of the room.


During an observation on 01/28/25 at 1:04 pm, of the emergency department, the bed in room 7 had a dark stain on the sheet.


During an interview on 01/28/25 at 1:08 PM, Staff S, stated that the ED technicians (techs) turn over rooms wiping the bed, chairs, and equipment, and making the bed if environmental services is not available. Staff S stated that if the sheet has a small stain, it will still be used on a newly cleaned bed and if the stain is large then the sheet will be thrown away.


During an observation on 01/28/25 at 1:20 PM, of the Outpatient Infusion Clinic, showed two staff members actively eating within a few feet of freshly drawn biohazard materials and in the same room with patients receiving transfusions approximately 10 feet away.


During an observation on 01/28/25 at 1:22 PM, of the Outpatient Infusion Clinic, an intravenous (IV) bag of bodily fluids from a patient was sitting on the bottom of a wheeled stool near the floor with a blood pressure cuff sitting on upper portion of the same stool.


During an observation on 01/28/25 at 1:24 PM, of the Outpatient Infusion Clinic, kitchen utensils, kitchen supplies, and staff food and drink items were sitting right next to the sink used for hand hygiene of staff between patient infusions.


During an observation on 01/28/25 at 1:26 PM, in Outpatient Infusion Clinic, showed, a food tray with a scalpel and an open tube of project glue with staining in the food tray was sitting next to clean unused supplies in supply storage office.


During an observation on 01/28/25 at 1:40 PM, of the Outpatient Infusion Clinic, an unidentified nurse performing removal of an IV cannula after transfusing a patient placed the cannula on top of the IV pump and then dropped it to the floor. Neither the IV pump or the floor was cleaned after having the IV cannula come in contact with each surface.


During an observation on 01/28/25 at 1:44 PM, at the Outpatient Infusion Clinic, the medication and IV preparation cart not cleaned after using area for preparation of previous patients' transfusion medication and biohazard sharps container on side of cart used for placement of IV cannula.


During an observation on 01/28/25 at 1:55 PM, of the Outpatient Infusion Clinic, two IV pumps were not wiped down between transfusions performed on patients.


During an observation on 01/28/25 at 2:05 PM, of the Outpatient Infusion Clinic, the blood pressure cuff on the vitals machine were not cleaned between patients.


During an interview on 01/28/25 at 2:10 pm, Staff U, RN, stated that between each patient infusion the chair being used and IV pump is wiped down between patients, however the IV pumps are sometimes missed because they are not a direct contact surface from the patient. Staff U, RN, went on to state that the medication and IV prep cart should be wiped down between each use.


During an interview on 01/28/25 at 3:52 PM Staff Q, stated that in over 20 years the ducts (tubes that move air throughout hospital) have not been cleaned.


During an interview on 01/29/25 at 8:54 AM, Staff A2, Dietary Supervisor, stated that the hospital has not provided any updated food related policies since switching companies on 12/08/24.


During an observation on 01/29/25 at 8:54 AM, in the Hospital Kitchen
1. Heavily dented can of Cream of Mushroom soup
2. Heavily dented can of crushed tomatillos
3. Tuna Salad with open date 01/22
4. Grilled Chicken shredded prep date 01/23/35 use by 1/26/25


During an interview on 01/29/25 at 8:54 AM, Staff A2, Dietary Supervisor, stated that dented cans are kept for 30 days, if not used, they are donated to homeless shelter. Staff A2, stated, " ...tuna salad is only supposed to be used 3 days after opened then thrown away ..."


During an observation on 01/29/25 at 9:02 AM, on the Medical Surgical Unit, room 1214 and 1218, the room trashcans were placed outside of the rooms in the hallway for use.


During an observation on 01/29/25 at 9:03 AM, on the Medical Surgical Unit, room 1215, Staff Y, exited the patient's room with a gloved hand carrying a laboratory specimen, placed it into a transport tube in the nursing station, discarded the glove, did not perform hand hygiene, and then returned to performing documentation at the nurse's station.


During an observation on 01/29/25 at 9:06 AM, on the Medical Surgical Unit, room 1203, an unidentified Doctor dressed in blue Operating Room (OR) scrubs and scrub cap placed an open drink cup in the PPE supply storage cabinet outside of the patient's room, performed no hand hygiene when entering or exiting the patient's room, retrieved the drink cup from the PPE supply storage cabinet, entered the nursing station, filled the cup with ice and water, and then exited the unit.


During an interview on 01/29/25 at 9:20 AM, Staff B2, Infection Prevention Program Manager, stated, "N95 masks are individual packaged, it's disappointing that they are in the cabinet not wrap it looks they are used N95 masks place back in the isolation cabinet, I'm not sure if they clean the cabinet."


During an interview on 01/29/25 at 10:35 AM, Staff D, stated that the trash cans in the hallway outside of room 1214 and room 1219 have always been placed in the hallway.


During an observation on 01/30/25 at 8:23 AM ceiling tiles in board room noted to be water damaged and moist to the touch.


During an observation on 02/04/25 at 9:49 AM adjacent to OR nurses' station, four cardboard boxes on floor one stacked on top of the other, two blue plastic tubs one stacked on top of the other, red plastic box with partially open lid, another cardboard box on floor with blue box on top of the cardboard box.


During an interview on 02/04/25 at 4:17 PM an unidentified Environmental Services staff stated that been working in housekeeping eight years and have not cleaned intake vents.


Review of the Hospital Kitchen "Produce Wash Log" and "Salad Cleaning Log" were incomplete for the month of February of 2025.


The observation was made on 02/25/25 at 10:02 AM, on the Emergency Room Fast Track, room 24, there were soiled sheets on bed and open drink items on counter of an empty room for an unknown period of time.


The observation was made on 02/25/25 at 10:28 AM, on the Pediatric Unit, an unidentified housekeeping staff member placed a full red biohazard bag on the floor of the hallway to prop open dirty utility room in the hallway, opened the door to empty other trash from the room and letting it close on the bag several times before placing the bag in the bin for removal.


The observation was made on 02/25/25 at 10:45 AM, on the Pediatric Unit, an unidentified nurse entered the sterile Obstetrician (OB) operating suite with no gown, gloves, or mask, and performed no hand hygiene before or after leaving the suite.


The observation was made on 02/25/25 at 10:57 AM, on the Pediatric Unit, room 1113, an unidentified housekeeping staff member exited the room wearing gloves after cleaning the room, pushed the cleaning cart up the hall to another room, entered the nursing station and then went into another room to clean.


The observation was made on 02/25/25 at 11:07 AM, on the Medical Surgical Unit, room 1216, an unidentified housekeeper placed a trash bag on the floor of the hallway outside of the patient room while cleaning it.


The observation was made on 02/25/25 at 11:10 AM, on the Medical Surgical Unit, room 1221, with posted contact precautions, an unidentified housekeeping staff member exited the room wearing a gown, gloves, and mask, accessed multiple areas of the cleaning cart in the hallway, then re-entered the patient room.


The observation was made on 02/25/25 at 11:15 AM, on the Medical Surgical Unit, room 1219, 1220, 1221, and 1222, trashcans for the patient rooms were located outside of the patient rooms in the hallways and were being used to dispose of contact isolation personal protective equipment (PPE).


During an interview on 02/25/25 at 11:16 AM, Staff O, stated that housekeeping placed the trashcans in the hallway outside of Covid 19 positive patients on contact isolation for staff to place their gowns, gloves, and masks in because the trash was getting too full in the patient rooms.


The observation was made on 02/25/25 at 11:22 AM, on the Rehabilitation Unit, an unidentified staff member and patient were wearing contact isolation gowns and gloves and performing exercises in the gym area.


The following observations were made on 02/26/25 at 9:12 AM, in the Hospital Kitchen:


In the food preparation area for patient trays, the cooking area, and the pots and pan storage area, used gloves were found on the counter tops and surfaces of these areas.


In the refrigerated areas, the following food items were not labeled or illegibly marked:


Fresh cilantro.
Cucumbers.
Lettuce.
Cheese.


In the refrigerated areas the following foods were stored incorrectly and open to air:


Cheese slices.
Heavy cream.
Parmesan cheese.
Ham slices. Lettuce.


In the dry storage areas the following foods the following items were expired:


Barbeque sauce.
Several condiments.
A dented can of tomatoes.


During an interview on 02/26/25 at 9:32 AM, Staff Y, stated that all open items are to be labeled and stored properly until the best by date and expired items are disposed of. Staff Y, stated that a daily a daily cleaning log, temperature check log, and produce wash log are all filled out daily for monitoring of the kitchen.


The observation was made on 02/26/25 at 11:49 AM, on the Rehabilitation Unit, an unidentified housekeeping staff member was dragging a sack full of soiled linens from a patient room to the dirty utility room and placed them in the soiled linen bin.


The observation was made on 02/26/25 at 12:36 PM, on the Rehabilitation Unit, the hand sanitizer machine was missing the drip tray by the private treatment room.


The observation was made on 02/26/25 at 2:25 PM, on the Medical Surgical Unit, room 1225, several rolled up towels were placed at the bottom of the door. Staff W2, stated the towels were in place for bedbugs and the room needed to be sprayed.


The observation was made on 02/26/25 at 3:00 PM, on the Medical Surgical Unit, soiled utility room that the wall between the clean storage and dirty utility rooms stopped at the drop ceiling of the room and did not extend completely to the roof to encapsulate the soiled utility room.


During an interview on 02/26/25 at 3:00 PM, Staff W2, stated that the soiled utility rooms on the Medical Surgical Unit were originally bigger but had since been remodeled to make the room smaller and create additional clean storage on the other side of the dividing wall. Staff W2, stated that the air handling system is shared between the 2 rooms and the wall only extends to the ceiling.


The observation was made on 02/27/25 at 9:55 AM, Medical Surgical Unit, room 1219, with posted contact precautions, an unidentified nurse exited room 1219 with a hair cover still on, went up the hallway to the nurse station, then returned back to room 1219 and removed the hair cover and did not perform any hand hygiene.


Personnel Health:


Review of policy document titled "Post-Offer Screening, Category: Human Resources" last approved 07/16/24 showed ". . .Purpose: To ensure prospective employees can perform the essential functions of their position, with or without a reasonable accommodation, and any relevant physical requirements of those essential functions, as identified in the position job description and pose no direct threat/safety risk to themselves, patients, or co-workers. Statement of Policy: The post-offer screening process will be initiated in the Human Resources department and will be completed by Occupational Health and/or designated provider. An employee health file will be initiated and maintained on all employees during and after employment. Post-Offer Process 1. Health screen appointments are completed by Occupation Health and/or designated provider. . .3. The Health Screen will be completed by Occupational Health and/or designated provider and will include the following: a. Post Offer Health Questionnaire in Ready Set . . .Eye screening for new hire candidates in the follow positions/areas: Nurses, Certified Nursing Assistants, Medical Assistants, Medical Providers, Respiratory Therapists, Diagnostic Imaging Staff, Laboratory Staff, EVS, Pharmacy, Electricians, Sterile Processing and employees that use CAPR. . .All new hire candidates who are requiring additional medical evaluation. . .The candidate will be responsible for taking a copy of his/her job description and description of his/her essential job functions to the treating medical provider in order to obtain a note indicating that the candidate can perform the essential function of the proposed job. . ."


Review of policy document titled "Attachment A.1 Medical Examination and Testing Consent Drug and Alcohol Screening Consent", dated 07/18/24, showed "I, (employee name), do hereby give my consent for job related procedures as necessary for an occupational health screening at any (organization name) facility. These may include a complete blood count, urinalysis, rubella titer, rubeola titer, tuberculosis screening,, chest x-ray, hearing evaluation, vision evaluation, physical examination, and other procedures and follow-up tests that may be needed in order to evaluate my physical condition and ability to perform the essential functions of my job and/or whether I pose a direct threat to myself or others. In addition to my initial occupational health screening, I consent to other job-related medical examinations or other testing at any time during my employment consistent with (organization name) policies and/or applicable law. . ."


Upon request, no policy was provided by the facility specific to initial medical examinations or periodic health assessments for personnel.


Review of document titled "Kansas Hospital Regulations", last reviewed 10/22/21, showed regulation 28-34-8a. Administrative services. (a) General provisions. There shall be an adequate administrative staff to provide effective management of the hospital. . .(f) Personnel health requirements. Upon employment, all hospital personnel shall have a medical examination which shall consist of examinations appropriate to the duties of the employee, including a chest X-ray or tuberculin skin test. Subsequent medical examinations or health assessments shall be given periodically in accordance with hospital policies. Each hospital shall develop policies and procedures for control of communicable disease, including maintenance of immunization histories and the provision of educational materials for patient care staff. (Authorized by and implementing K.S.A. 65-431; effective June 28, 1993.)


Review of personnel records provided for Staff A1, Diagnostic Medical Sonographer, showed a hire date of 01/21/25 and no initial medical exam.


Review of personnel records provided for Staff B1, Sterile Processing Technician, showed a hire date of 12/16/24 and no initial medical exam.


Review of personnel records provided for Staff C1, Surgical First Assistant, showed a hire date of 01/02/19 and no period health assessments.


Review of personnel records provided for Staff D1, Certified Surgical Technician, showed a hire date of 03/04/24 and no initial medical exam.


Review of personnel records provided for Staff E1, Registered Nurse (RN), showed a hire date of 03/09/15 and no initial medical exam or periodic health assessments.


Review of personnel records provided for Staff F1, RN, showed a hire date of 12/01/24 and no initial medical exam.


Review of personnel records provided for Staff G1, Certified Nursing Assistant (CNA), showed a hire date of 05/01/23 and no periodic health assessments.


Review of personnel records provided for Staff S, Registered Nurse (RN), showed a hire date of 04/11/22 and no periodic health assessments.


Review of personnel records provided for Staff H1, RN, showed a hire date of 08/12/19 and no periodic health assessments.


Review of personnel records provided for Staff I1, RN, showed a hire date of 11/04/19 and no periodic health assessments.


Review of personnel records provided for Staff J1, certified mammographer, showed a hire date of 08/22/22 and no periodic health assessments.


Review of personnel records provided for Staff K1, RN, showed a hire date of 12/13/21 and no periodic health assessments.


Review of personnel records provided for Staff L1, Certified Nursing Assistant (CNA), showed a hire date of 04/15/24 and no initial medical exam.


Review of personnel records provided for Staff M1, Magnetic Resonance Imaging (MRI) Tech, showed a hire date of 06/30/13 and no period health assessments.


Review of personnel records provided for Staff N1, RN, showed a hire date of 10/14/24 and no initial medical exam.


Review of personnel records provided for Staff O1, CNA, showed a hire date of 06/30/13 and no period health assessments.


Review of personnel records provided for Staff P1, RN, showed a hire date of 12/11/23 and no initial medical exam or periodic health assessments.


Review of personnel records provided for Staff Q1, Pharmacist, showed a hire date of 08/11/14 and no initial medical exam or periodic health assessments.


Review of personnel records provided for Staff R1, RN, showed a hire date of 06/30/13 and no periodic health assessments.


Review of personnel records provided for Staff S1, Respiratory Therapist, showed a hire date of 03/20/23 and no initial medical exam or periodic health assessments.


Review of personnel records provided for Staff T1, Multi-Modality Tech II, showed a hire date of 03/08/21 and no periodic health assessments.


During an interview on 03/04/25 at 10:50 AM, Staff I, Employee Health Nurse, confirmed there is no policy specific to initial medical exam or periodic health assessments.

Based on document review and program review, the Hospital failed to ensure all hospital acquired infections (HAI's) and other infectious diseases identified by the infection prevention and control program are addressed in collaboration with hospital QAPI leadership.


Findings Include:


Review of the Hospital document titled "Infection Prevention and Control Plan FY25" with no documented review or approval date, showed "FISCAL YEAR 2025 GOALS ... Hand Hygiene Compliance ... Goal ... Achieve 99% Compliance within one year. ... Catheter Associated Urinary Tract Infection ... GOAL: 0.43 ... Central Line Associated BSI (CLABSI) ... GOAL: 0.50 ... C. difficile ... GOAL: 0.22 ... Surgical Site Infections ... Abdominal hysterectomy (HYST) Goal: 0.31 ... Colon surgery (COLO) Goal: 0.34 ... Candida auris ... no transmission. ... PROGRAM EVALUATION ... C. diff HAI's ... FY 24 Goal ... 0.23 ... Goal Met ... 3 ... Central Line Associated BSI (CLABSI) ... FY 24 Goal ... 0.43 ... Goal Met ... Yes ... Ventilator Associated Events ... FY 24 Goal ... Predicted 2.37 VAE events ... Goal Met ... 1 IVAC ... Surgical Site Infections (SSI) ... FY 24 Goal ... Strive to reduce surgical site infections to "zero' during the next year ... Goal Met ... No ... Hand Hygiene ... FY 24 Goal ... Hand Hygiene Compliance 100% ... Goal Met ... No Overall 99.28% ... Low level Disinfection Processes (cleaning of shared equipment) ... FY 24 Goal ... Place easy-to reference cleaning/disinfection tags on frequently used patient equipment for staff reference ..."


Review of the Hospital document titled "Clinical Quality Assurance, Patient Safety, and Process Improvement Plan FY2025" last reviewed August of 2024, showed, " ...the responsible party for the core measure for sepsis (a life-threatening complication of infection) as "Quality" and "Clinical Leadership". Additionally, the QAPI plan showed "Core Measures Team" with "QM RN" as the facilitator, and a goal of "Improve Compliance with Sepsis Bundle ... FY25 Primary Goals Established ... Reduce SIR for C. Diff ... 0.23 ... Reduce SIR for CLABSI ... 0.43 ... Meet the Sepsis Management Bundle compliance ... 72%(Percent)..."


Review of the Hospital QAPI program failed to address all infections identified in infection prevention and control plan. The QAPI plan did not address catheter associated urinary tract infections (CAUTI's), surgical site infections (SSI's), or candida auris infections that were listed as goals for 2025 in the infection prevention and control plan.


During an interview on 02/05/25 at 3:11 PM Staff C stated that the hospital surgical, sterile processing department infection prevention action plan is protected under Patient Safety Work Product (PSWP). Therefore, the hospital failed to provide evidence of a performance improvement plan (PIP).

Based on document review, program review, log review, and interview the Hospital failed to ensure the infection control preventionist had adequate communication and collaboration with the hospital's quality assurance and performance improvement (QAPI) program on infection prevention and control issues.


Findings Include:


Review of the Hospital document titled "Infection Prevention and Control Plan FY25" with no documented review or approval date, showed "FISCAL YEAR 2025 GOALS ... Hand Hygiene Compliance ... Goal ... Achieve 99% Compliance within one year. ... Catheter Associated Urinary Tract Infection ... GOAL: 0.43 ... Central Line Associated BSI (CLABSI) ... GOAL: 0.50 ... C. difficile ... GOAL: 0.22 ... Surgical Site Infections ... Abdominal hysterectomy (HYST) Goal: 0.31 ... Colon surgery (COLO) Goal: 0.34 ... Candida auris ... no transmission. ... PROGRAM EVALUATION ... C. diff HAI's ... FY 24 Goal ... 0.23 ... Goal Met ... 3 ... Central Line Associated BSI (CLABSI) ... FY 24 Goal ... 0.43 ... Goal Met ... Yes ... Ventilator Associated Events ... FY 24 Goal ... Predicted 2.37 VAE events ... Goal Met ... 1 IVAC ... Surgical Site Infections (SSI) ... FY 24 Goal ... Strive to reduce surgical site infections to "zero' during the next year ... Goal Met ... No ... Hand Hygiene ... FY 24 Goal ... Hand Hygiene Compliance 100% ... Goal Met ... No Overall 99.28% ... Low level Disinfection Processes (cleaning of shared equipment) ... FY 24 Goal ... Place easy-to reference cleaning/disinfection tags on frequently used patient equipment for staff reference ..."


Review of the Hospital document titled "National Healthcare Safety Network SIR [standardized infection ratio] for Urinary Catheter -associated UTI Data in Acute Care Hospital" dated 01/29/25, showed 1 reported catheter associated urinary tract infection (UTI) in the last 381 days.


Review of the Hospital hand hygiene log dated 07/01/24 through 01/31/25 showed a total of 7655 total opportunities for hand hygiene improvement.


Review of the Hospital Quality And Performance Improvement (QAPI) document titled "Clinical Quality Assurance, Patient Safety, and Process Improvement Plan FY2025" last reviewed August of 2024, showed," ...the responsible party for the core measure for sepsis (a life-threatening complication of infection) as "Quality" and "Clinical Leadership". Additionally, the QAPI plan showed "Core Measures Team" with "QM RN" as the facilitator, and a goal of "Improve Compliance with Sepsis Bundle ... FY25 Primary Goals Established ... Reduce SIR for C. Diff ... 0.23 ... Reduce SIR for CLABSI ... 0.43 ... Meet the Sepsis Management Bundle compliance ... 72%(Percent) ..."

Review of the Hospital QAPI program failed to include the infection control preventionist as a listed member of the team to monitor sepsis, did not show the hospital's current measured compliance percentage for sepsis management bundles, or define the new performance improvement plan (PIP) created to increase sepsis management bundle compliance.


Further review of the Hospital QAPI program failed to show the goals of hand hygiene compliance, catheter associated urinary tract infections (CAUTI's), surgical site infections (SSI's) or candida auris infections established in infection prevention and control plan.


Further review of the Hospital QAPI program failed to show or review the previous year's infection control PIP's that were defined in the infection prevention and control plan, did not show the hospital's current standardized infection ratio (SIR) for Clostridium Difficile (C. diff) infections and central line-associated bloodstream infections (CLABSI's), or define the new PIP's created to reduce the rates of CLABSI's and C. diff infections.


During an interview on 01/29/25 at 10:35 AM, Staff D, stated that the infection preventionist is supposed to make routine rounds on the floor to observe and educate staff about the infection control plan and monitor for infection control concerns like hand hygiene, wound care, central line dressing changes, and contact precautions. Staff D, RN, stated that the infection preventionist does not make routine rounds anymore, likely contributing to poor adherence to hand hygiene protocols and inadequate use of contact precautions.


During an interview on 01/29/24 at 9:20 AM, Staff B2, Infection Prevention Program Manager (IPPM), Registered Nurse (RN), stated that hand hygiene concerns exist throughout the hospital and audits are performed by leadership rounding daily during the week to monitor for compliance. Staff B, IPPM, RN, stated tracking SSI's very closely, monitoring even superficial infections due to the concern of multiple incident reports made on surgical trays with unidentified foreign objects (UFO's) found in the trays prior to surgery being performed on patients.


During an interview on 02/06/25 at 9:05 am, Staff N2, RN, Chief Nursing Officer (CNO), stated Staff N2, RN, CNO, stated that hand hygiene has been an ongoing concern throughout the hospital and all staff should be following hand hygiene protocols and department leaders should be performing audits. Staff N2, RN, CNO, stated an increased concern for the potential of SSI's due to number of reported issues discovered with the sterilization process of surgical tools over the past 3 months.

Based on document review, record review, staff and patient interview, the Hospital failed to ensure staff followed policies and procedures to achieve standards of medical practice and patient care. The Hospital failed to ensure surgical privileges with competencies were met prior to a surgeon performing a surgical procedure for 2 of 3 surgeons (Surgical Staff J2, MD and Surgical Staff K2, MD) reviewed.

The hospital failed to ensure Surgical Staff had privileges to perform a surgical procedure prior to performing a non-emergent surgical procedure. This deficient practice places patients at risk for harm and injury during surgical procedures.


Findings Include:


Review of a document titled, "Medical Staff Rules and Regulations" approved 03/21/23 showed, " ...SURGICAL CASES 1. Surgical procedures shall be scheduled with the appropriate OR supervisor/staff. The history and physical, informed consent, and the provisional diagnosis shall be documented in medical record before any surgical procedure begins, except when such delay would constitute a hazard to the patient's life. The Member must certify that such a situation exists. 2. Members shall be on time for scheduled surgical procedures, and Members must be in the OR department prior to the patient being taken into the OR suite and anesthesia being initiated ...6. Members are responsible for determining if the complexity of the procedures requires an appropriate surgical assistant or other surgeon; and, if so, is responsible for ensuring the assistant or surgeon is scheduled and in attendance at the start of the procedure ...An informed consent for non-emergent cases will be obtained in accordance with the Informed Consent - [The Hospital] policy ..."


Review of Patient 8's medical record showed a 41-year-old female presented to surgical pre-op on 01/28/25 at 6:27 AM for an elective surgery. Past medical history includes hypertension (elevated blood pressure).


Review of a document titled, "CT [Computed Tomography] Abdomen Pelvis with and without Contrast" dated 09/12/24 at 8:16 AM showed, " ...Impression: 1. Large cystic left retroperitoneal mass measuring approximately 21 x 19 x 26 cm [8.26 x 7.48 x 10.24 inches] with thin peripheral calcifications and a few slightly thickened internal septations, no discrete solid enhancing mass. This results in significant mass effect with displacement of the spleen, left kidney, pancreas, and bowel, although does not appear to be splenic, renal, or ovarian in origin. Surgical consultation is recommended ..."


Review of a document titled, "H&P Notes" dated, 01/28/25 at 7:22 AM, showed, " ...Patient with large cystic left retroperitoneal mass here for open excision ... Large left retroperitoneal mass. I have discussed the case with my partner [assisting surgeon] and we will proceed with the surgery here. Given the size of the lesion, an open approach will be taken... . I have discussed her case with [Staff K2] and it is felt that the surgery can be completed here. She continues to have the same symptoms of constipation, left abdominal pain as well as back pain. She is otherwise eating well ..."


Review of a document titled, "Operative Report" dated 01/28/25 at 8:07 AM, showed, " ...Procedure(s) (LRB): EXPLORATORY LAPAROTOMY W/ [with] EXCISION OF RETROPERITONEAL CYSTIC LESION, LEFT NEPHRECTOMY (Left) CYSTOSCOPY INSERTION STENT URETER (Left) Surgeon(s) and Role:* [Staff J2, MD - Primary] * [Staff K2, MD] (An assistant was needed for retraction, exposure, and control of bleeding) ... Imaging depicted the same and it was felt that the mass was abutting the left kidney and spleen but not arising from either one of these structures. We therefore discussed proceeding with excision of the mass ... Findings: 35cm x 25cm [9.84 X 13.89 inches] cystic mass arising from the left kidney. Multiple intra-abdominal organs were adherent to the mass in question- spleen, pancreas, transverse colon and its mesentery, left lobe of liver, duodenum. These were all dissected free from the cyst capsule. The mass was noted to be originating from the left kidney, therefore, a left nephrectomy was performed ..."


Review of Patient 8's medical record from 09/12/24 at 8:16 AM through 01/28/25 at 8:07 AM the medical record failed to show any follow up imaging. Therefore Patient 8's cystic mass had a significant growth from 21 x 19 x 26 cm [8.26 x 7.48 x 10.24 inches] to 35cm x 25cm [9.84 X 13.89 inches].


Review of document titled, "Operative Report" dated 01/29/25 at 7:02 AM, showed, " ...Indications: Patient post op day 1 from exploratory laparotomy, resection of large retroperitoneal cystic mass originating from the left kidney, left nephrectomy. Patient was noted to be hypotensive early this morning. She then became hypothermic and coagulopathic. Decision was made to take her back to the OR emergently for abdominal exploration. The procedure was discussed with the patient and she wished to proceed. Findings: Ischemic and nonviable right colon ...Diffuse bleeding from all raw surfaces intra-abdominally. Severe acidosis, coagulopathy noted on intraoperative labs. Patient hypothermic ... Complications: None immediately apparent ...EBL [Estimated blood loss] 300 ml [approximate 10oz] ..."


Review of a document titled, "Event Tracking" dated 01/28/25 showed that Procedure Start time 8:07 AM and Procedure Finish 2:46 PM.


Review of a document titled, "Surgery Information" dated 01/28/25 showed, Staff K2, MD start time 10:26 AM. Approximately 2 hours after procedure start time. Per hospital rules and regulations Staff K2, MD must be in in attendance at the start of the procedure.


Review of a document titled, "Nephrology Consultation" dated 01/29/25 at 10:26 AM, showed, " ...Is a 41-year-old female who was found to have a large left retroperitoneal mass and who was admitted to the hospital on 1/28/2025 , and underwent Exploratory laparotomy with excision of retroperitoneal cystic lesion, left nephrectomy and ureteral stent placement. Postoperatively, patient has developed hypotension with systolic blood pressure into the 70s, decreased urine output and patient was hypothermic. Patient received IV fluids and was transferred to ICU. Patient continued to be hypotensive and was emergently taken to the OR this morning and was found to have ischemic right colon diffuse bleeding from all surfaces intra-abdominal he thought to be due to DIC ...."


Review of a document titled, "Delineation Of Privileges" failed to show Staff J2, MD had approved privileges to perform an Nephrectomy.


Review of a document titled, "Delineation Of Privileges" failed to show Staff K2, MD had approved privileges to perform an Nephrectomy.

During an interview on 02/05/25 at 1:47 PM Staff L2 stated that a nephrectomy would fall under urology and would be specified on the privileges and would not be a general surgery. Staff L2 went on to state that the hospital does not have a urologist.


During an interview on 02/05/25 at 1:51 PM, Staff F2, stated that, Staff J2, MD is a colorectal surgeon it was the first time seeing Staff J2 performing a nephrectomy. Urologists are the only ones who perform nephrectomy surgeries, and even the former Urologist did not perform nephrectomies at this hospital.


Review of a document titled, "Discharge Summary Note" dated 01/29/25 at 3:56 PM, showed, " ...Postoperatively the patient developed DIC, acute kidney injury, hemorrhagic shock. The patient expired at 1549 [3:49 PM]..."

The plan of removal the hospital provided on 02/06/25 and approved by CMS on 02/07/25 included but was not limited to the following:

1. On February 6th, 2025, all surgeons with active General Surgeon Privileges, received a copy of their delineation of privileges (DOP's). An attestation was provided to these surgeons, acknowledging and attesting that no procedures will be conducted outside their DOP.

2. OR staff members (OR RN's, First Assists, and Scrub Techs) will be provided education by February 12, 2025 or at the beginning of the next scheduled shift, with returned demonstration, on how to access E-Privilege, our electronic system utilized to search and review provider privileges.

The surveyors verified the completion of the actions on the plan of removal during the full survey ending on 03/05/25.

Based on document review, record review, staff and patient interview, the Hospital failed to ensure staff followed policies and procedures to meet standards of medical practice and patient care. The hospital failed to ensure staff executed a properly executed informed consent prior to performing non-emergent surgical procedures for 2 of 17 surgical patients (Patients 8 and 9). This deficient practice places patients at risk for harm and injury during surgical procedures.


Findings Include:


Review of policy titled "Acute Care and Subacute Care Facilities, Emergency Urgent Care Centers, Home Care-Hospice, Clinical Patient Care" dated 03/09/2021, showed, "...Signed authorization should be obtained from the patient on the ' Consent for Treatment or Procedure ' form prior to the initiation of care and treatment...The credentialed physician/APP presents the information to the patient so that an informed decision can be made. b. The informed consent is freely given by the patient and is expressed in writing. The responsible physician/APP signs the informed consent form as an attestation to the content of the discussion and the patient ' s consent..."


Review of a policy titled, "Informed Consent" dated 09/08/2021 showed, "This policy applies to all physicians, Advanced Practice Providers (APPs), and authorized practitioners as well as all patient care departments ... Informed Consent 1. The duty to obtain informed consent is a two-step process. a. The credentialed physician/APP presents the information to the patient so that an informed decision can be made. b. The informed consent is freely given by the patient and is expressed in writing. The responsible physician/APP signs the informed consent form as an attestation to the content of the discussion and the patient ' s consent. 2. It is the responsible physician/APP ' s responsibility to obtain informed consent from the patient, and to discuss sufficient medical information to enable the patient to decide whether to accept or refuse treatment. The responsible physician/APP shall also be available to respond to questions the patient or representative may have. The informed consent discussion should include at least the following information. a. Patient ' s name b. Date c. A fair explanation and description of the proposed procedure or treatment, including the anesthesia to be used ... Guidelines for Situations where Procedural Consent should be obtained: ·When there is an inherent risk of death or serious body harm, or ·When the usual risk is substantially increased because of some aspect of the patient ' s medical condition, or ·Major or moderate entry into the body, either through an incision/puncture or through a natural body opening; ·All procedures in which anesthesia or a regional block is used, regardless of whether an entry into the body is involved; ·Non-procedural treatments, including the administration of medicines, that involve more than a moderate risk to the patient or that cause a change in the patient's body structure (e.g., chemotherapy, hormone treatments); and ·Any surgical procedure ..."


Patient 8


Review of Patient 8's medical record showed a 41-year-old female presented to surgical pre-op on 01/28/25 at 6:27 AM for an elective surgery. Past medical history includes hypertension (elevated blood pressure).


Review of a document titled, "H&P Notes" dated, 01/28/25 at 7:22 AM, showed, " ...Patient with large cystic left retroperitoneal mass here for open excision ... Large left retroperitoneal mass. I have discussed the case with my partner [assisting surgeon] and we will proceed with the surgery here. Given the size of the lesion, an open approach will be taken..."


Review of Patient 8's medical record failed to show a signed informed consent for the surgical procedure by Staff J2 on 01/28/25.


Review of a document titled, "Discharge Summary Note" dated 01/29/25 at 3:56 PM, showed, " ...Postoperatively the patient developed disseminated intravascular coagulation (DIC - a complicated condition that can occur when someone has severe sepsis or septic shock. . .Small blood clots can develop throughout your bloodstream, especially in the microscopic blood vessels called capillaries. This blocks the blood flow to many parts of your body, including your limbs and your organs. Blood is then not able to bring oxygen and nutrients to the tissues. On the reverse side of the cycle,. . .The body uses up so many of the blood clotting proteins for the multiple blood clots in the blood vessels that there are not enough left to clot the blood elsewhere), acute kidney injury, hemorrhagic shock. The patient expired at 1549 [3:49 PM]..."


Patient 9


Review of Patient 9's medical record showed a 58-year-old male that presented to surgical pre-op on 01/23/25 at 7:35 AM for an elective surgery with primary diagnosis of calculus (stone) of gallbladder and bile duct without cholecystitis (inflammation) or obstruction (blockage) and epigastric (area above the abdomen) pain.


Further review of Patient 9's medical record showed an operative report on 01/23/25 at 10:05 PM, showing the procedure of a cholecystectomy laparoscopy with cholangiogram performed by Staff K.


Review of Patient 9's medical record failed to show a signed informed consent for surgical procedure by Staff K2 on 01/23/25.


Review of the plan of removal the hospital provided on 02/06/25 and approved by CMS on 02/07/25 included but was not limited to the following:


1. On February 6th, 2025 we reviewed our policy for consent and identified a physician opportunity to clearly document the need for emergency consent according to the Informed Consent Policy under Emergency Consent. Education to all surgeons will be provided on the need for clear documentation of clinical rationale for unplanned surgeries and consent.


2. Effective immediately on February 6, 2025, no patient will cross the red line to the operating rooms without verification that an informed consent has been completed and signed. All OR RN's will be provided education today February 6, 2025 or at the beginning ofthe next scheduled shift, attesting that no patient will be brought to the operating room without a complete informed consent. All education will be completed by February 7, 2025.


The surveyors verified the completion of the actions on the plan of removal during the full survey ending on 03/05/25.

Based on record review, observation and staff interview, the hospital failed to ensure that a postanesthesia evaluation was completed for 9 of 9 surgical patients (Patient 4, 15, 19, 26-31) whom received general anesthesia. This deficient practice put patients receiving general anesthesia at risk for unidentified complications following discharge from the post op area.


Findings Include:


Review of document titled "Post-Anesthesia Evaluation" published by the American Society of Anesthesiologists", August 2014, showed ". . .The postanesthesia evaluation for anesthesia recovery must be completed in accordance with State law and with hospital policies and procedures that have been approved by the medical staff and that reflect current standards of anesthesia care. The postanesthesia evaluation must be completed and documented by any practitioner who is qualified to administer anesthesia. . .The evaluation generally should not be performed immediately at the point of movement from the operative area to the designated recovery area. Rather, accepted standards of anesthesia care indicate that the evaluation should not begin until the patient is sufficiently recovered from the acute administration of the anesthesia so as to participate in the evaluation, e.g., answer questions appropriately, perform simple tasks, etc. . .For those patients who are unable to participate in the postanesthesia evaluation . . .should be completed and documented within 48 hours with notation that the patient was unable to participate. . ."


Review of document titled "Sedation and Anesthesia - Understanding the Assessment Requirements. What are the assessment requirement organizations need to understand?" published by The Joint Commission, last reviewed by Standards Interpretation: November 17, 2022, showed ". . .In deemed organizations, completion of the post-anesthesia assessment for both inpatient and outpatient must be completed within 48 hours by an anesthesia practitioner or credentialed LP. This assessment may not be delegated. The calculation of the 48-hour timeframe begins at the point the patient is moved into the designated recovery area. The evaluation generally should not be performed immediately at the point of movement from the operative area to the recovery area. The assessment should not begin until the patient is sufficiently recovered from the administration of the anesthesia so as to participate in the evaluation, e.g. answer questions appropriately, perform simple tasks, etc. . ."


Review of policy titled "Post Anesthesia and Procedural Areas Phase I and Phase II Discharge Criteria" last published 01/06/25, showed ". . .Patients to be sent to a nursing unit must meet Phase I Discharge Criteria unless a physician orders otherwise. . . Patients discharged to home must meet Phase II Discharge Criteria and have a post-anesthesia evaluation completed and documented by an anesthesia care provider unless a physician orders otherwise. . .The PACU nurse discharges the patient after determining that the patient meets discharge approved criteria. . ."


Patient 4


Review of Patient 4's medical record showed a 67-year-old male admitted on 02/25/25 for outpatient surgical repair of a left inguinal hernia (a bulge in the groin area that occurs when tissue pushes through a weak spot in the abdominal wall). The patient received general anesthesia and was taken to the post op area at 9:13 AM. The post op anesthesia evaluation was documented at 9:17 AM. It showed "Patient participated; awake and alert Respiratory status, face mask, room air and spontaneous ventilation." The nurses note in post op at 9:19 AM showed "level of consciousness, sedated; orientation level, unable to assess. No further anesthesia evaluation was documented prior to discharge at 11:29 AM.


Patient 15


Review of Patient 15's medical record showed an 84-year-old male admitted on 02/24/25 following a fall and injury to his right hip. The patient underwent an open reduction internal fixation of right hip (repair and fixation of fractured hip) on 02/25/25. The patient received general anesthesia and was taken to the post op area at 3:23 PM. The post op anesthesia evaluation was documented at 3:32 PM. It showed "patient could not participate; awake and alert; nasal cannula & spontaneous ventilation." The nurses note in post op at 3:24 PM showed "sedated; consciousness, unable to assess." At 4:00 PM, the nurses note showed "needs oxygen inhalation to maintain oxygen saturation greater than 90%." No further anesthesia evaluation was documented postoperatively prior to Patient 15's discharge to a rehabilitation unit (pending at this time on 02/27/25).


Patient 19


Review of Patient 19's medical record showed a 41-year-old female admitted on 01/28/25 for exploratory surgery of a retroperitoneal (the area in the back of the abdomen behind the tissue that lines the abdominal wall and covers most of the organs in the abdomen) mass. The patient received general anesthesia and was taken to post op at 2:53 PM. The post op anesthesia evaluation was documented at 2:58 PM and showed "Patient could not participate, sleepy but conscious; respiratory status, face mask and spontaneous ventilation." No postop nurses notes were provided. No further anesthesia evaluation was documented on this day. Patient returned for emergency surgery on 01/29/25. The staff failed to conduct any further post anesthesia evaluation as the patient went back to the intensive care unit and died later that day.


Patient 26


Review of Patient 26's medical record showed a 62-year-old female admitted on 02/10/25 for outpatient surgeries to include Insertion of Port-a-cath (a small mechanical device utilized to make intravenous treatment less painful) left side and EGD percutaneous placement of gastrostomy tube (Endoscopic gastrostomy tube inserted through the abdominal wall and into the stomach providing direct route for administering nutrition, fluids, and medications) The patient received general anesthesia and was taken to the post op area at 3:17 PM. The postop anesthesia evaluation was documented at 3:21 PM. It showed "Patient could not participate. Sleepy but conscious. Criteria for PACU discharge per facility unit discharge criteria." No further anesthesia or physician evaluation was documented postoperatively prior to discharge at 5:25 PM.


Patient 27


Review of Patient 27's medical record showed a 63-year-old female admitted on 10/07/24 for further evaluation of osteomyelitis (an infection of the bone tissue) of left ankle with ulcer. A below the knee amputation was performed on 10/08/24. The patient received general anesthesia along with a pain block at the completion of the procedure. She was taken to the post op area at 8:18 PM. The post op anesthesia evaluation was documented at 8:26 PM. It showed "Patient participated, awake and alert, at baseline and sleepy but conscious." The nurses note in post op at 8:28 PM showed "Arousal on calling. Needs oxygen inhalation to maintain saturation greater than 90%." No further anesthesia evaluation was documented postoperatively prior to discharge on 10/11/24.


Patient 28


Review of Patient 28's medical record showed a 67-year-old female admitted on 11/26/24 for bilateral lower extremity cellulitis (bacterial infection of skin and underlying tissues) with open wounds, possible SIRS (systemic inflammatory response syndrome). Patient underwent surgical debridement of both lower extremities with general anesthesia on 12/02/24. The patient was taken to the post op area at 1:14 PM. The post op anesthesia evaluation was documented at 1:19 PM. It showed "Patient participated, awake and alert, respiratory status face mask." The nurses note in post op at 1:14 PM showed "level of consciousness, sedated; consciousness orientation level, unable to assess." No further anesthesia evaluation was documented postoperatively prior to discharge on 12/04/24.


Patient 29


Review of Patient 29's medical record showed a 49-year-old male admitted on 11/12/24 for a left hip replacement. Patient underwent surgical hip replacement, receiving general anesthesia. He was taken to the post op area at 11:36 AM. The post op anesthesia evaluation was documented at 11:39 AM. It showed "Patient could not participate; level of consciousness, sedated; respiratory status, face mask and spontaneous ventilation." The nurses post op note at 11:36 AM showed "level of consciousness, lethargic and drowsy." At 11:40 AM it showed "patient sleeping, unable to move extremities voluntarily or on command; needs oxygen inhalation to maintain oxygen saturation greater than 90%." No further anesthesia evaluation was documented postoperatively prior to discharge on 11/13/24.


Patient 30


Review of Patient 30's medical record showed a 73-year-old male admitted on 01/07/25 for an outpatient colonoscopy (procedure examining the large intestine). Patient underwent colonoscopy with general anesthesia. He was taken to the post op area at 8:33 AM. The post op anesthesia evaluation was documented at 8:48 AM. It showed "patient participated, awake and alert." No further anesthesia evaluation was documented postoperatively prior to discharge at 9:34 AM.


Patient 31


Review of Patient 31's medical record showed a 68-year-old male admitted on 03/04/25 for a laparoscopic cholecystectomy (surgical procedure to remove the gallbladder). Patient underwent outpatient surgery with general anesthesia. He was taken to the post op area at 10:40 AM. The post op anesthesia evaluation was documented at 10:43 AM. It showed "Patient participated, sleepy but conscious." The nurses post op note at 10:40 AM stated "Arousal, tactile; level of consciousness, sedated; Orientation level, unable to assess." No further anesthesia evaluation was documented postoperatively prior to discharge at 12:23 PM.


During observation on 03/04/25 of Patient 31 from admission through discharge showed the Certified Registered Nurse Anesthetist (CRNA) was observed to escort the patient to the post op area following his surgical procedure. The CRNA gave a verbal report to the Registered Nurse in the post op area and left. The CRNA did not return to the post op area to evaluate the patient prior to his discharge.


During an interview on 03/04/25 at 8:00 AM, Staff Z, Registered Nurse, Clinical Coordinator, stated that the anesthesia provider accompanies the patients to the post op area after surgery. Normally the CRNA does not return to see the patient again. There are order sets for discharge. The nurse is responsible for assessing Aldrete scores (a scale used to assess recovery from anesthesia) and discharge.

Based on document review and staff interview, the hospital failed to ensure a director of respiratory care services who was a doctor of medicine or osteopathy with knowledge, experience, and capabilities to supervise the services. This failure of oversight of respiratory services places patient at potential risk of inadequate care resulting in harm or adverse outcome.


Findings Include:


Review of document titled "Medical Staff Rules and Regulations" approved by the medical executive committee (MEC) on 03/21/23, showed ". . . E. Clinical Departments and Sections . . . The Medical Staff will be organized into Clinical Departments and Sections, with Medical Staff Members assigned to Departments in accordance with the Bylaws.


The departments listed in the Medical Staff Rules and Regulations failed to address the responsible party for respiratory care services.


Review of job description document titled "Director Respiratory Care" dated January 29, 2024 showed ". . . Education Requirements . . . Bachelor Degree Specialty Healthcare Administration . . . Credential . . . Registered Respiratory Therapist-NBRC National Board for Respiratory Care Required . . . Respiratory Therapist License (Department of Regulatory Agencies or Kansas Licensure) Required . . ."


During an interview on 03/03/25 at 10:50 AM, Staff Q, director of respiratory and a respiratory therapist, stated, "Staff D is who I go to for advice and guidance until we get a permanent person in place."


During credentialing review and personnel review with human resources on 03/03/25 at 10:30 AM and 03/03/25 at 1:00 PM respectively, Staff D, was not credentialed or given privileges for active patient oversight and care.


During an interview on 03/03/25 at 3:15 PM, Staff H, Chief Executive Officer, stated that Respiratory care services orders were obtained by a physician who was caring for the patient. We do not have a doctor that is the director of the respiratory department. If questions arise, the staff members will follow chain of command, our hierarchy.


In an email from Staff B, director of quality, on 03/03/25 at 11:27 AM, she stated "We do not have a Medical Director of Respiratory Therapy."

Based on document review, and observation, the hospital failed to ensure that an physical examination was completed after admission and prior to the same day as their surgical procedure for 2 of 9 (Patient 19 and 31) surgical patients whose surgical records were reviewed according to the hospital's Medical Staff Bylaws.

This deficient practice allows for potential risks or complications to go unidentified prior to a surgical procedure for any patients receiving surgical care in this facility.

Findings Include:

Review of document titled "Medical Staff Rules and Regulations" last approved 03/21/23, showed ". . .Surgical procedures shall be scheduled with the appropriate OR supervisor/staff. The history and physical, informed consent, and the provisional diagnosis shall be documented in medical record before any surgical procedure begins, except when such delay would constitute a hazard to the patient's life. The Member must certify that such a situation exists. . ."

Review of document titled "Medical Staff Bylaws" last approved 08/18/22, showed ". . .Performance Improvement Functions. . .the required content and quality of history and physical examinations, as well as the time frames required for completion, all of which are set forth in Appendix A of these Bylaws. . .Appendix A History and Physical Examinations; (1) General Documentation Requirements; (a) A complete medical history and physical examination must be performed and documented in the patient's medical record within 24 hours after admission or registration (but in all cases prior to surgery or an invasive procedure requiring anesthesia services) by an individual who has been granted privileges by the Hospital to perform histories and physicals. (b) The scope of the medical history and physical examination will, at a minimum, include: patient identification; chief complaint; history of present illness; personal medical history, including medications and allergies; physical examination, to include pertinent findings in those organ systems relevant to the presenting illness and to co-existing diagnoses; assessments, including problem list; and plan of treatment. . .(2) H&P's Performed Prior to Admission; (a) Any history and physical performed more than 30 days prior to an admission or registration is invalid and may not be entered into the medical record. (b) If a medical history and physical examination has been completed within the 30-day period prior to admission or registration, a durable, legible copy of this report may be used in the patient's medical record. However, in these circumstances, the patient must also be evaluated within 24 hours of the time of admission/registration or prior to surgery/invasive procedure, whichever comes first, and an update recorded in the medical record. (c) The update of the history and physical examination shall be based upon an examination of the patient and must reflect (i) any changes in the patient's condition since the date of the original history and physical that might be significant for the
planned course of treatment or (ii) state that there have been no changes in the patient's condition. . .Based on document review, and observation, the hospital failed to ensure that an physical examination was completed after admission and prior to the same day as their surgical procedure for 2 of 9 (Patient 19 and 31) surgical patients whose surgical records were reviewed according to the hospital's Medical Staff Bylaws. This deficient practice allows for potential risks or complications to go unidentified prior to a surgical procedure for patients receiving surgical care in this facility.


Review of document titled "Medical Staff Rules and Regulations" last approved 03/21/23, showed ". . .Surgical procedures shall be scheduled with the appropriate OR supervisor/staff. The history and physical, informed consent, and the provisional diagnosis shall be documented in medical record before any surgical procedure begins, except when such delay would constitute a hazard to the patient ' s life. The Member must certify that such a situation exists. . ."


Review of document titled "Medical Staff Bylaws" last approved 08/18/22, showed ". . .Performance Improvement Functions. . .the required content and quality of history and physical examinations, as well as the time frames required for completion, all of which are set forth in Appendix A of these Bylaws. . .Appendix A History and Physical Examinations; (1) General Documentation Requirements; (a) A complete medical history and physical examination must be performed and documented in the patient ' s medical record within 24 hours after admission or registration (but in all cases prior to surgery or an invasive procedure requiring anesthesia services) by an individual who has been granted privileges by the Hospital to perform histories and physicals. (b) The scope of the medical history and physical examination will, at a minimum, include: patient identification; chief complaint; history of present illness; personal medical history, including medications and allergies; physical examination, to include pertinent findings in those organ systems relevant to the presenting illness and to co-existing diagnoses; assessments, including problem list; and plan of treatment. . .(2) H&P ' s Performed Prior to Admission; (a) Any history and physical performed more than 30 days prior to an admission or registration is invalid and may not be entered into the medical record. (b) If a medical history and physical examination has been completed within the 30-day period prior to admission or registration, a durable, legible copy of this report may be used in the patient ' s medical record. However, in these circumstances, the patient must also be evaluated within 24 hours of the time of admission/registration or prior to surgery/invasive procedure, whichever comes first, and an update recorded in the medical record. (c) The update of the history and physical examination shall be based upon an examination of the patient and must reflect (i) any changes in the patient ' s condition since the date of the original history and physical that might be significant for the planned course of treatment or (ii) state that there have been no changes in the patient ' s condition. . .(4) Short Stay Documentation Requirements; For ambulatory or same day procedures, a Short Stay History and Physical Form, approved by the MEC, may be utilized. These forms shall document, at a minimum, the patient ' s chief complaint or reason for the procedure, relevant history of the present illness or injury, current clinical condition, general appearance, vital signs, and an assessment of the heart and lungs."


Patient 19


Review of Patient 19's medical record showed a 41-year-old female admitted on 01/28/25 for exploratory surgery of a retroperitoneal (the area in the back of the abdomen behind the tissue that lines the abdominal wall and covers most of the organs in the abdomen) mass. Surgery preop H&P (history and physical) dated 01/28/25 at 7:22 AM showed "Patient with large cystic left retroperitoneal mass here for open excision. Patient seen and examined in holding area. Preop H&P from clinic reviewed. No changes in medical or surgical history since clinic visit. Risks, benefits, alternatives of procedure discussed with patient, and she wants to proceed." The remainder of the information identified as history of present illness, medications, past surgical history, current medications, health maintenance, allergies, social history, family history, review of systems, vital signs, and physical exam is identified with a date of 11/21/24, but electronically signed on 01/28/25. The history and physical referenced in the surgery preop note was greater than 30 days prior to this surgery date. An updated history and physical was not completed by the surgeon per their medical staff bylaws prior to the patient's surgery.


Patient 31


Review of Patient 31's medical record showed a 68-year-old male admitted on 03/04/25 for a laparoscopic cholecystectomy (surgical procedure to remove the gallbladder). Surgery preop H&P dated 03/04/25 at 8:45 AM showed "Patient with symptomatic cholelithiasis here for laparoscopic cholecystectomy. Patient seen and examined in holding area. Preop H&P from clinic reviewed. No changes in medical or surgical history since clinic visit. Risks, benefits, alternatives of procedure discussed with patient, and he wants to proceed." The remainder of the information identified as history of present illness, medications, past surgical history, current medications, health maintenance, allergies, social history, family history, review of systems, vital signs, and physical exam is identified with a date of 01/27/25, but electronically signed on 03/04/25. The history and physical in the surgery preop note was greater than 30 days prior to this surgery date. The blood pressure identified in the surgeon ' s preop H&P was 192/116 dated 01/27/25. An updated history and physical was not completed by the surgeon per their medical staff bylaws prior to the patient's surgery. Nurses preop notes identified elevated blood pressure of 183/114 (Normal 120/80) at 8:35 AM.


Review of Patient 31 clinic records received on 03/13/25, showed documentation from a cardiac clinic visit on 02/17/25, which identified blood pressures of 150/90 on 02/17/25; 166/92 on 02/10/25; and 166/111 on 02/04/25. An echocardiogram (detailed imaging of the heart) was reviewed. The cardiac clinic nurse practitioner cleared the patient for surgery from a cardiac status. A progress note from the patient's family nurse practitioner dated 02/20/25 reviewed a Chest x-ray from 12/12/24 which was completed during an emergency room visit; ordered an additional chest x-ray; referenced blood pressure medication adjustments and instructions since her last visit with the patient; documented last three clinic blood pressures as 166/92 on 02/10/25, 150/90 on 02/17/25, and 145/82 on 02/20/25. The summation of these clinic notes was not part of Patient 31's chart provided by the facility. It is unclear which documentation the surgeon reviewed or its source other than a date of 01/27/25.


During observation on 03/04/25 of Patient 31 from admission to preop at 8:20 AM through discharge at 12:31 PM. The patient did receive a visit from Staff B2, surgeon, at 8:37 AM. There was a brief conversation regarding proceeding with the planned surgery with interpreter assistance. The surgeon did not perform a physical exam. At 8:45 AM, Staff B2, Certified Registered Nurse Anesthetist (CRNA) observed outside patient room and discussing patient's elevated blood pressure with another CRNA. Staff B2 then joined the conversation, and they ultimately agreed to proceed with surgery. There was no reference in the surgery preop to the patient's elevated blood pressure.