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Based on observation, record review and interview the facility failed to meet the Condition of Participation to ensure patient health information was protected and a valid restraint order is in place prior to restraining a patient; and that restraints are not ordered on an "as needed" basis. This deficient practice would likely lead serious injury or death for all patients in this facility.

The findings are:

A. Refer to Tag A-0143, A-0168 and Tag A-0169

Based on record review, interviews and observations, the facility failed to maintain the personal privacy of patients, including but not limited to, the patient's location in the hospital; demographic information the hospital has collected on the patient, such as name, age, address; or information on the patient's medical condition. The Protected Health Information (PHI) was not protected for 20 (P (Patient) 9, P10, P14, P15, P16, P17, P18, P19, P20, P21, P22, P23, P24, P26, P27, P28, P29, P30, P33, and P34) of 35 (P1 - P35) patients. This failed practice can lead to direct inappropriate disclosure of PHI and is likely to lead to an increased risk of misuse and breach of PHI.

The findings are:

A. Record review of facility policy titled, "Safeguarding PHI" revision date 06/2023, stated, "B. SAFEGUARDS FOR WRITTEN PHI: All documents containing PHI should be stored appropriately to reduce the potential for incidental use or disclosure. Documents should not be easily accessible to any unauthorized staff or visitors. Active Records on Nursing Unit: 3. Active Medical Records shall not be left unattended on the nurses' station desk or other areas where patients, visitors and unauthorized individuals could easily view the records. 4. Medication Administration Records, Treatment Administration Records, report sheets and other documents containing PHI shall not be left open and/or unattended."

B. During an observation on 10/02/2023 at 10:07 am of open area nursing station the following patient's information was seen:
1) P9 Medical Administration Record (MAR) was laying on the desk revealed the following PHI: patient name, date of birth, admit date, room number, age, sex, height, weight, body mass index (BMI), hospital number, medical record number, medications prescribed by physician with doses and times to be administered.

2) P10, P22, P23, P24, P26, P27, P28, P29, P30, and P33 vitals record sheet was laid out on the desk and revealed the following PHI: patient name, room number, temperature, heart rate, blood pressure, respiratory rate, oxygen level, patients' blood sugar, patients 24 hour intake and 24 hour output.

C. During an observation on 10/03/2023 at 3:48 pm of the east wing hallway at the east end of hall showed the following PHI:

1) P14, P15, P16, P17, P18, P19, P20 and P34 charts were left unattended and unsecured on desk #1 in the hallway.

D. During an observation on 10/03/2023 at 3:53 pm of the east wing hallway at the west end of hall showed the following PHI:

1) P21's chart was opened in the hallway sitting out on a desk #2, unsecured with patient Ancillary Staffing Flowsheet showing the following PHI: patients name, date of birth, sex, age, medical record number, hospital account number, vital signs, intake and output, bath time, hair care, and nursing notes.

2) P17 chart was opened in the hallway sitting out on a desk #2, unsecured with the following PHI: Medical Administration Record (MAR) was opened and revealed the patient's name, date of birth, admit date, room number, age, sex, height, weight, body mass index (BMI), hospital number, medical record number, medications prescribed by physician with doses and times to be administered. The physician order sheet was laying in the open, next to the chart showing medications prescribed by the physician.

E. During an interview on 10/03/2023 at 3:53 pm with S8, Charge Nurse, when asked about charts being unsecured on desk, S8 answered, "Yes, they are because of the construction there isn't a nurse's station right now." When asked about the patient information being open on the desk for anyone to see, S8 answered, "Yeah they should be in the desk."







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Based on observation, interview, and record review, the facility failed to ensure there was a restraint order in place prior to restraining 1 (P (patient) P13) of 33 (P1-P33) patients. This deficient practice could likely lead to inappropriate restraint and seclusion, injury, or death of all patients in this facility.

A. During Record Review on 10/05/23 of policy "K.11.07 Restraints and Seclusion;" "Reviewed and Revision Date: 05/2023" 1. "G. Restraint use will only be imposed upon receipt of appropriate physician orders or other Licensed Independent Practice ..."

B. During Observation on 10/03/23 at 3:34 pm, P13 was laying in bed with soft white wrist restraints on both wrists which are secured in quick release type knot to loops on either side of the hospital bed.

C. Record Review of P13 medical chart for day of 10/03/23 revealed no signed restraint order.

D. During interview on 10/03/23 at 3:40 pm with Staff (S)7 Registered Nurse (RN), S7 was asked if there were restraint orders for P13? S7 confirmed there were no restraint orders. When asked if there should be orders when a patient is restrained, and S7 stated "yes definitely".

E. During interview on 10/04/23 at 1:10 pm with S5 RN Case Manager, S5 was asked, Are you required to have a physician order for restraints? S5 stated "Yes."

F. During interview on 10/05/23 at 1:25 pm with S8 RN Charge Nurse, S8 was asked if an order is required prior to initiating restraints? S8 confirmed that a restraint order is required prior to initiating restraints.

Based on observation, interview, and record review, the facility failed to ensure that restraint orders were not written as needed basis for 1 (P(patient) P13) of 33 (P1-P33) patients. This deficient practice could likely lead to serious injury or death for all patients in the facility.

A. During observation on 10/05/23 at 9:30 am, P13 was seated in a wheelchair in front of nurse station and was not restrained.

B. During Record Review of P13 medical chart of "Daily Nursing Assessment" dated 10/04/23 "Special Precautions" the box next to "Fall" was checked indicating P13 is a Fall Risk. The box next to "Restraints" was checked and written in was "wrist x (times) 2" indicating restraints on both wrists.

B. During Record Review of P13 medical chart on 10/05/23 revealed a completed "Restraint Order Sheet."
1. "RN [Registered Nurse] Assessment completed by: [signed by Staff (S)7 RN] Date 10/05/23; Time 06:10 [am]"
2. "LIP [Licensed Independent Practioner] Signature: [signed but illegible] Date: 10/05/23 Time: 0902 [09:02 am]"

C. During Interview with S7 on 10/05/23 at 9:30 am, S7 was asked if P13 had been restrained today on 10/05/23, S7 stated "no". When asked why there was a signed restraint order in the patient's (P13) chart, S7 stated "I just got the order in case I needed it." When asked if it is policy to get "PRN" [or as needed] restraint order, S7 stated "we get the orders if we think the patient might need them [the restraints] later in the day so they're ready."

D. During Record Review of policy "K.11.07 Restraints and Seclusion"; "Reviewed and Revision Date: 05/2023"
1. "J. Restraint orders will not be written or accepted as a PRN or standing order."

Based on observation, record review and interview the facility failed to label and administer medications safely in accordance with Federal and State laws. This failed practice can lead to medication errors resulting in harm to all patients.

Findings are.

A. Record review of facility policy titled, "MM.28 Administration of Medications" dated 09/2023. Policy stated, "All medications must be properly stored /secured at all times prior to administration. Prepared medications must never be left unattended" and "The individual administering the medication (s) must document all medications immediately after administration in the patient's Medication Administration Record (MAR)."

B. Record review of facility policy titled, "K.11.3 Administration of Medications" dated 05/2023. Policy stated, "All medications must be properly stored /secured at all times prior to administration. Prepared medications must never be left unattended."

C. During an observation on 10/04/2023 at 10:00 AM, the medication room door was left open, four syringes (two normal saline flushes (an aqueous solution of electrolytes and other hydrophilic molecules), one Enoxaparin (helps prevent the formation of blood clots) injection and one unlabeled prefilled syringe with a needle attached) and a cup filled with unknown liquid was left unattended on top of counter. At 10:05 am S4, RN (Registered Nurse) walked in and began gathering the syringes and cup that was left unattended on the counter.

D. During an interview on 10/04/2023 at 10:05 AM with S4, when asked what the medications on the counter were, S4 stated that the unlabeled medication was Reglan (medication used to prevent nausea and vomiting) in the syringe. S4 stated I was going to give all the medications really quick but had to step away.

E. Record review of patients Medication Administration Record (MAR) indicated that medications were administered at 9:30 am on 10/04/2023, the five medications were observed on the counter at 10:03 am and had not been administered to the patient.

F. During an interview on 10/05/2023 at 11:03 AM, with S5, RN (Registered Nurse) Case Manager S5 confirmed that the medication room door was not to be left open. S5 stated that medication should be marked with a sharpie of what they are and how many milligrams. S5 confirmed that medication should not be left unattended on the counter and that staff is educated that if not administered immediately they need to be placed in patient's bin or drug buster. S5 confirmed that the time on the MAR is when medications are administered.

Based on observation, record review and interview the facility failed to ensure daily patient nourishment refrigerator temperature log was completed and all food was labeled and dated and expired food was disposed of. This failed practice can lead to bacterial or viral food borne infection of all patients.

The findings are:

A. Record review of facility policy title "General Refrigerator Cleaning" dated 10/2021 stated: "Procedure: Objective: Medications, food and nutrition products, and laboratory specimens will be stored under proper conditions of sanitation, temperature, light, moisture, ventilation, and security to maintain product stability. Steps for Achieving Basic Principles: Cleaning Frequency: Monthly, and as needed. Temperature logs are to be maintained and monitored by specific units with the corresponding temperature logs. Each month a new temperature log will be taped to the outside of the refrigerator by the day shift change nurse. All refrigerator logs are to be forwarded to the COO [Chief Operating Officer] or filing (except for Pharmacy). All refrigerators require dates and names placed on each item.

B. During an observation on 10/02/2023 at 10:09 am of the nutrition area and refrigerator, revealed the following:

1) There was not a refrigerator temperature log. In the refrigerator there were nine Styrofoam cups without a label or date, there was an expired snack pack consisting of carrots, broccoli, almonds, cheddar cheese and ranch dip, and there was an opened carton of Silk Almond milk with no label or date of opening.
2) On a shelving unit there were two bins of cereal with no labels or dates. An unsterile cup was being used to scoop the contents out of the bin.
3) A bin of individual serving size Jif peanut butter with no expiration dates. On the counter there were two serving containers of cereal with no labels or expiration dates.

C. During an observation on 10/02/2023 at 10:19 am of the patient refrigerator in the nursing station, revealed the following:
1) An individual container of cottage cheese with no patient name, label or date.
2) An individual container of yogurt with no patient name, label or date.
3) A bottle of aloe vera juice with no patient name, label or date.
4) A bottle of Sparkling beverage with no patient name, label or date.
5) A container of food with a date of 09/21/2023 and a note stated: "informed it will be thrown in 3 days."
6) A bag of food from Burger King with no date.
7) A bottle of milk with no patient name, label or date that expired on August 2, 2023.
8) A container of Rocky Road Ice Cream with no patient name, label or date.
9) A contain of Chocolate Fudge Brownie ice cream with a label and no date.
10) An individual container of Blue Bunny ice cream with no patient name, label or date.
11) An unlabeled container, contents unknown, with no patient name, label or date.

D. During an interview on 10/03/2023 at 3:41 pm with S1, Chief Executive Officer, when asked if all food should be labeled and have expiration dates on it, S1 answered, "yes." When asked who is responsible for the temperature log and cleaning of the refrigerators, S1 stated housekeeping is responsible for cleaning out the refrigerators and the charge nurse is responsible for the temperature logs. When asked who is ultimately responsible for making sure it is done, S1 answered, "Ultimately I am in charge of making sure everybody is doing their job."

Based on observation and interview the facility failed to maintain medical supplies in a clean and sanitary manner. This deficient practice is likely to result in infections, injury, or death to all patients in this facility.

The findings are:

A. During observation on 10/02/23 at 10:04 am of the East Unit Medication Room storage closet, the following items were on the floor: One open box of white plastic forks; and one open box of 10 cubic centimeter pre-filled normal saline (a solution used for injection into a vein by itself or mixed with other medications) syringes (a device used to inject fluids into or withdraw them from something such as a vein).

B. During observation on 10/03/23 at 10:00 am of the Supply Room, the following items were on the floor: One box of Y-type Blood/Solution Set with Standard Blood Filter (tubing used to administer blood and blood products into a vein) in an open storage container and five boxes of Nebulizer Adapters (connect respiratory tubing to a nebulizer which is used to give medications directly to the lungs).

C. During an interview on 10/03/23 at 10:00 am, S12 Central Supply Coordinator confirmed the supplies were on the floor; and that no medical supplies should be stored on the floor.