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Based on record review and interview, the facility failed to ensure the patient advocate contacted the patient to determine satisfaction or dissatisfaction with the outcome. The facility resolved the complaint without any knowledge of the patient's conclusions. There was no further information if the grievance was reviewed by Quality, Grievance Committee, or peer review in 2 of 2( #5 and #16) patient charts reviewed.

Review of the Patient #5's chart revealed he was in the facility's emergency department on 4/16/22 at 1921 (7:21PM). The patient was triaged and seen by Staff #25 MD. Patient #5 was diagnosed with Covid-19 and discharged home. The patient was given 2 prescriptions. The first prescription was for Paxlovid and the second for Motrin 800mg. Review of the copied prescriptions revealed Staff #25 MD had written the prescriptions on Staff #32's MD prescription pad.

Review of the Grievance Details dated 4/19/22 stated, "Patient stated he came to the Emergency Room and was told he tested positive for COVID-19. Patient said Dr. ___ (Staff #25) wrote him a prescription but wrote it on Dr.___ (Staff #32) pad. His pharmacy did not have the medication in stock, but also questioned the wrong pad for the doctor. ___ (Staff #26) called the pharmacist, and the pharmacist agreed the patient could pick up the prescription and have it filled at another pharmacy who had the medication. Patient called and wanted the doctor who was on duty, Dr.___ (Staff #25) was off, to rewrite the prescription. which was Dr.___ (Staff # 27) and he refused to look at the chart? Patient was then upset because now he is wanting to come back to the ER to get a prescription again but upset his insurance might not pay for another visit for the same symptoms. ___ (Staff #26) tried to explain he could pick up the prescription at his pharmacy and take it somewhere else to get it filed but patient refused. Patient feels like we should have fixed the prescription since it was our fault it was written on the wrong pad, but the two pharmacies in his area did not carry the medication so he would have had to pick it up and take it to another pharmacy anyway. Patient was very upset and felt like no one was listening and no one cared about his concerns. ___ (Staff# 26) tried to explain if he came back to the emergency department that doctor may not write him a prescription for COVID, not all doctors do."

An interview with the Staff #26 and Staff #31 was conducted on 7/19/22. Staff #31 stated that she remembered the phone call the next morning from the complainant Patient #5. Staff #31 stated that she receives multiple calls the next morning concerning prescriptions and orders every time Staff #25 works the night shift. Staff #31 stated this was a common problem and she had reported it to her supervision but Staff #25 continues to forget to send in prescriptions, writes them on other physician's pads, writes the wrong prescriptions etc... Staff #31 was asked if she ever puts an occurrence/incident report in concerning these issues and she stated, "no." Staff #31 stated that when the patient called, she referred it to her charge nurse Staff #26. Staff #26 stated that she did remember this call and spoke to the complainant. Staff #26 stated that she told the patient that she had called the pharmacy and they stated that the patient could come pick up the prescription because they did not have the drug available anyway. Staff #26 stated that the pharmacist did say it was not written on Staff #25 prescription pad and that was also an issue. Staff #26 stated, "He didn't want to go get the prescription and try to fill it some where else. He had a choice." Staff #26 was asked if she felt the hospital could have corrected the problem by having the patient come back through the ER at no cost or have the prescribing physician correct the issue with the prescription pad or by a electronic prescription? Staff #26 stated, "He didn't want to go pick up the prescription because it was written on the wrong pad. He wanted a correct prescription and Staff #25 was off. There was nothing else I could do." Staff #26 was asked if she could have sent this issue up to her director if she was unable to assist the patient? Staff #26 stated, "We didn't have an ER director at that time and that was the best I could do. Staff #26 confirmed that she did not write an occurrence/incident report for this matter.

Review of the Grievance revealed, "ER Manager provided appropriate solution, client refused to comply with the plan."

Review of the Grievance letter that was sent out to Patient #5 dated 6/28/22 stated, "Please know we have given your grievance a careful consideration and as of June 28, 2022, now consider this matter closed.

Review of the policy and procedure "Patient Complaint and Grievance Management" stated, "Resolved Grievance - A Grievance is considered resolved when the patient or patient's representative is satisfied with the actions taken on their behalf. There may be situations where the hospital has taken appropriate and reasonable actions on the patient's behalf in order to resolve the patient's Grievance and the patient or the patient's representative remains unsatisfied with the hospital's actions. In these situations, the hospital may consider the Grievance closed for the purposes of these requirements." There was written documentation that the patient was called and was only given the option to pick up a prescription from the pharmacy with the wrong doctor's name on it. The patient wanted a new prescription with the correct physician or electronically sent into a participating pharmacy. There was no documentation found that the patient received any correspondence from the patient advocate to see if the patient was satisfied or dissatisfied with the outcome. The facility resolved the complaint without any knowledge of the patient's conclusions. There was no further information if the grievance was reviewed by Quality, Grievance Committee or peer review.

Patient #16
Review of Patient #16 revealed she was a 12-year-old that came into the ER on 3/10/22 with a missing tooth from accident. The chart revealed the patient arrived at 8:13PM, triaged at 8:27PM but was not seen by the Physician Assistant (PA) until 10:09PM. The PA saw the patient and told her there was nothing they could do for her and that she needed to see the dentist. The PA signed the note out at 10:13PM.

A grievance was found for the patient dated 3/11/22. The grievance stated, "Grievance Summary Patient's mother stated she brought her daughter into the emergency department because she had a tooth knocked out. The mother stated the triage nurse assured her that their dental emergency could be taken care of here at CHI. The mother stated they waited 2 hours in the waiting room before they were sent to the back. The mother stated ____ (Staff #34) came in, asked what was wrong, spent maybe 3 seconds then commented there is nothing I can do. The mother told ___ (Staff #34) that is not what we were told by the triage nurse, that is why we waited so long in the waiting room. The mother stated then ___ (Staff #34) offered to super glue the tooth back in, which shocked the mother and told Jeff she did not feel like that was sound medical advice. The mother refused to sign any paperwork and stated she does not feel like any care was provided and does not think she should be billed for the visit. Patient Expectation Does not want to receive a bill."

The grievance stated that the actions were "discussed with the provider" but no information if the chart was reviewed, or what the provider conclusion was. The facility resolved the complaint without any knowledge of the patient's conclusions. There was no further information if the grievance was reviewed by Quality, Grievance Committee or peer review.

Based on review and interview nursing failed to provide ongoing assessments and reassessments of patient needs and changes during the hospital stay. Nursing failed to assess patient care needs or response to interventions by documenting patient assessment, pain scale, vital signs, medication instructions,provide safe practices related to intravenous access insertion, care and maintenance, and disposition of the patient in 2 of 2(#3 and #4) patient charts reviewed.

Patient #3

Review of the Patient #3's, chart revealed she arrived at the ER on 6/2/21 at 8:52AM with abdominal pain. The patient was seen by the ER physician and ordered IV Dilaudid for pain and Zofran for nausea. The nurse documented the medications were administered, the pain scale was at a 6 out of 10, and the patient had pain relief.

The patient had lab work done and an EKG. The ER physician documented that the patient was to be admitted for biliary colic and an abnormal ekg. The patient was seen by the Hospitalist on 6/2/22 at 13:09 (1:09PM). There were no rooms in the hospital so the patient was being held in the ER until she could be moved onto the floors.

Review of Patient #3's ER record revealed there was no vital signs found after 8:55AM on 6/2/22. The nurse documented that the she gave report to the oncoming Staff #37 RN at 11:57AM. There was no nursing documentation of an assessment from the RN assuming care. The last nursing documentation found was at 10:23AM. There were no vital signs documented or any pain scale documented.

Staff #38 MD documented at 2035 8:35PM, "per nursing patient tearful and anxious ...Fioricet (Analgesic) and Reglan(Antiemetic and Gut motility stimulator) added to the chart." Staff #39 RN documented in the Medication Administration Record (MAR) that the medications were administered at 8:35PM. There was no nursing documentation of a patient assessment, pain scale, vital signs, or medication instructions.

Review of the Record revealed on 6/3/22 at 8:32AM the hospitalist documented that the patient left during the night Against Medical Device (AMA). There was no nursing or ER physician documentation when the patient left, how the patient left, why the patient left, what condition the patient was in, no assessment, or vital signs. There was no AMA paperwork signed.

Review of the patient's complaint revealed she left the ER around 8:00PM AMA because she was not getting any communication or care from the hospital staff. The patient was in the ER bed for a total of 12 hours. The face sheet stated the patient discharged on 6/2/22 at 8:55PM.

An interview was conducted with Staff #6 on 7/18/22. Staff #6 was assisting this surveyor in navigating through the record. Staff #6 confirmed there was no nursing documentation after 10:23AM. Staff #6 stated there should have been an AMA form filled out along with nursing assessments. Staff #2 provided the surveyor with a blank AMA form. The form is titled, "Release from Responsibility for Discharge." The form stated the patient was agreeing to be discharged against the advice of the attending physician. However, the form was missing a place for the patient's signature, date, and time. Staff #2 and #6 confirmed the form was incomplete.

Patient #4

Review of Patient # 4 chart revealed 1/6/2022 the patient entered the emergency room with altered mental status (AMS), review of the clinical notes reflected the patient received intravenous (IV) fluids and IV antibiotics through an IV line; however, there was no order for an IV or "hep-lock." On visit 1/6/22 left antecubital space (LAC) 18g short peripheral catheter (SPC) and 20g right antecubital space (RAC) SPC. There was no found nursing documentation related to attempts, or how procedure performed (aseptic). Electronic medical record (EMR) system includes an area to clearly define whether an IV was started, how many attempts, and if the procedure was successful or unsuccessful.

Review of the policy and procedure "Vascular Access Device Management," states under 1. B. Vascular access devices require a physician's order prior to placement or removal. Due to no nursing documentation found related to the complaint of multiple IV attempts, infiltration (fluid leakage under the skin around the IV as it has become displaced from the vein) of the IV, as well as multiple existing access simultaneously with no orders. The surveyor was unable to confirm findings related to facility not displaying any nursing documentation regarding insertion, removal, or adverse events with IV accesses.

Review of patient #4 chart on 2/1/2022, patient entered the emergency room related to unresponsive requiring intubation (tube placed in the airway to provide oxygenation) post aspiration (swallowing fluids into their lungs). According to MR patient #4 on 2/1/22 had a 20g SPC top RAC, at 2033 had a 22g SPC to left hand, 2110 Right triple lumen catheter (TLC) jugular. Upon review of nursing documentation, noted no documentation of IV site assessments. Noted use of Right Internal jugular in the medication administration record (MAR) for IV fluids and IV medication administration. The surveyor was unable to confirm findings related to facility not displaying any nursing documentation regarding insertion, removal, or adverse events with IV accesses.

No discoverable policy or procedure for a vein finder or ultrasound guided technology (USGT) utilization for SPC.
According to Policy: Vascular Access Device Management revised 4/2021, III. A. 2. The IV site should be changed immediately if the site scores 2 or greater on the phlebitis scale. The physician should be notified when the IV site scores 3 or greater on the Phlebitis scale. The policy does not define the number of attempts for IV insertion. The policy does not clarify the infiltration scale or phlebitis scale as established for National Standards of care for best practice: Infusion Nursing Society and Association of Vascular access.

Review of the Texas Board of Nurses standard practice of care refers to the leaders for evidence-based practice in the industry related to vascular access, Infusion Nursing Society (INS) and Association of Vascular Access. The review of INS practice guidelines in April 2022 release that attempts for intravenous access by a competent provider should not exceed 2 unless it is a life or limb emergency.

An interview was conducted on 7/19/2022 with staff #14, #15, # 16, and # 17. During the interview staff was asked how many attempts does one person have to start a short peripheral catheter (SPC). Staff # 14 stated 3 attempts. Staff # 15 stated at least 3 attempts. Staff # 16 and # 17 stated 2 attempts. Review of the policy does not reflect the number of attempts a competent person has to initiate an SPC.

Review of the complaint revealed the complainant stated patient was stuck over 12 times in the ER and ICU for IV access, states, "finally someone brought the ultrasound to stick an external jugular (EJ) in her neck before the doctors put in a different line." The complainant states the nurses continued to push medications into the patients infiltrated IV in her hand, "hand was hot and swollen (twice the size of other arm.)." Review of the chart revealed the physician procedure note on 2/1/2022 for the insertion of the right internal jugular triple lumen catheter. Internal jugular in the MAR for IV fluids and IV medication administration. According to the policy and procedure, Vascular Access Device Management, IV. A. 3) IV sites should be changed at least every 96 hours and as needed .... Documentation should include acknowledgement that the site is greater than 96 hours old. Review of the chart did not reveal any of the sites were documented as successful or unsuccessful or patent.

Based on record review and interview, the facility failed to;

A. ensure policy and procedures were written to ensure safe prescription pad ordering, use, storage, monitoring, and destruction as needed for 2 of 2 (ER and ICU) patient care areas. The facility failed to ensure prescription pads were kept in locked storage or be otherwise not accessible to patients, visitors, and unauthorized staff in 40 out of 40 prescription pads found and failed to account for 2 out of 40 pads found.

Refer to Tag A0491

Based on review and interview the facility failed to ensure policy and procedures were written to ensure safe prescription pad ordering, use, storage, monitoring, and destruction as needed for 2 of 2 (ER and ICU) patient care areas. The facility failed to ensure prescription pads were kept in locked storage or be otherwise not accessible to patients, visitors, and unauthorized staff in 40 out of 40 prescription pads found and failed to account for 2 out of 40 pads found.

Review of the Patient #5's chart revealed he was in the facility's emergency department on 4/16/22 at 1921 (7:21PM). The patient was triaged and seen by Staff #25 MD. Patient #5 was diagnosed with Covid-19 and discharged home. The patient was given 2 prescriptions. The first prescription was for Paxlovid and the second for Motrin 800mg. Review of the copied prescriptions reveled Staff #25 MD had written the prescriptions on Staff #32's MD prescription pad.

Review of the Grievance Details dated 4/19/22 stated, "Patient stated he came to the Emergency Room and was told he tested positive for COVID-19. Patient said Dr. ___ (Staff #25) wrote him a prescription but wrote it on Dr.___ (Staff #32) pad. His pharmacy did not have the medication in stock, but also questioned the wrong pad for the doctor. ___ (Staff #26) called the pharmacist, and the pharmacist agreed the patient could pick up the prescription and have it filled at another pharmacy who had the medication. Patient called and wanted the doctor who was on duty, Dr.___ (Staff #25) was off, to rewrite the prescription. which was Dr.___ (Staff # 27) and he refused to look at the chart. Patient was then upset because now he is wanting to come back to the ER to get a prescription again but upset his insurance might not pay for another visit for the same symptoms. ___ (Staff #26) tried to explain he could pick up the prescription at his pharmacy and take it somewhere else to get it filled but patient refused. Patient feels like we should have fixed the prescription since it was our fault it was written on the wrong pad, but the two pharmacies in his area did not carry the medication so he would have had to pick it up and lake it to another pharmacy anyway. Patient was very upset and felt like no one was listening and no one cared about his concerns. ___ (Staff# 26) tried to explain if he came back to the emergency department that doctor may not write him a prescription for COVID, not all doctors do."

During a tour of the ER the surveyor noticed physician prescription pads lying out on the ER desk unattended. The pads were out in full view and were available for anyone to pick up and use. The pads had the physician's information, DEA (Drug Enforcement Administration) numbers, and NPI (National Provider Identifier) numbers on them.

During an observation tour of the ED on 7/19/2022 at 9:20 AM with Staff #1 RN, the surveyor observed a prescription tablet on the desk where Staff #10 MD was working. Staff #10 was asked how often he was handwriting prescriptions for patients. Staff #10 replied, "I rarely use them. Most all prescriptions are escribed (electronically submitted to a pharmacy of patient choice). I have it here just in case I need them." Staff #10 was asked if the prescription pad was secured when he was away from the desk. Staff #10 stated, "Well, it is covered up with papers but no, it is not locked up when I am away from this area."

An interview was conducted with Staff # 7 Contracted Interim Director ER and Staff #2 on 7/19/22. Upon request the facility was asked for an employee file on Staff #7. Staff #2 confirmed Staff #7 had an incomplete employee file and there was no signed job description. Staff #7 was asked about the prescription pads. Staff #7 stated that he had a box of multiple prescription pads in a box in his office he had ordered for the physicians and PA in the ER. Staff #7 confirmed he had ordered the pads on his own without the knowledge of the Pharmacist. The pads were stacked in an open box just sitting in the ER director's office. Staff #7 stated that he felt it would make it easier on the physicians if they did not want to use the electronic prescription method. Staff #7 stated he ordered them from Kwik Kopy Business Solutions and had them delivered to him.

According to www.cdc.gov/phlp/docs/menu-prescriptionform.pdf
Similarly, Texas law provides that "[e]ffective April 1, 2008, prescriptions for covered pharmaceuticals submitted to a pharmacy in written form will be eligible for payment only if the prescription is executed on tamper resistant prescription paper, as required by § 1903(i)(23) of the Social Security Act . . . ."11."

According to www.pharmacy.texas.gov/files_pdf/Tamper_Resistant.pdf Tamper-Resistant Prescriptions,
"Obtaining Prescription Pads
Prescribers may select their supplier of CMS-compliant prescription pads. Information on available vendors may be obtained online by using a keyword search of "secure prescription pads."
There are many compliant features available from security prescription vendors. The National Council for Prescription Drug Programs (NCPDP) has developed a guide to many of the available features. Prescribers should refer to the guide (Appendix B) before ordering tamper-resistant prescription pads or paper.

Pharmacists have voiced concerns about how to identify a tamper-resistant prescription. HHSC encourages pharmacists to call the prescriber every time they have a question. HHSC strongly encourages all prescribers to order tamper-resistant prescription pads that clearly list the security features. This will reduce the number of calls and cause the least workflow disruption for both pharmacists and prescribers.

Prescribers are encouraged to check with their current suppliers of prescription pads. Providers may also obtain information on vendors of tamper-resistant prescription pads online by using a keyword search of "secure prescription pads." ... The Texas Medical Association has published a list of vendors approved for other states at the link below. These printers meet the baseline requirements set by CMS.www.texmed.org/Template.aspx?id=6495 ...

...Only hand-written prescriptions provided directly to the patient are required to be executed on tamper-resistant prescription pads. Prescriptions for patients in nursing homes and other facilities, where the patient does not handle the prescription directly, are exempt from this requirement. However, if the facility provides a written prescription to be filled by the client directly, it must be written on a tamper-resistant prescription pad... This applies to all prescribed outpatient drugs, including over-the-counter drugs.

In the question section of the article the question was asked, "Can I use another doctor's official prescription forms?" the answer was, "No. The official prescription forms are not transferable."

Review of the list of approved vendors revealed Kwik Kopy was not on the approved list.

Review of the purchase order receipts from the printer revealed Staff #27 MD, Staff #33 MD, Staff #10 MD, and Staff #34 PA were ordered 10 prescription pads each for use in the ER. The pads had the physicians name, facility address, TX license number, DEA number and NPI number. The pads came in a plastic wrapped package of 10. Staff #10 MD and Staff #33 MD packages were unwrapped, and a pad was missing from each order. There was no information on how many prescriptions were in a pad. The surveyor was unable to account for how many prescriptions were missing. The facility failed to provide the surveyor with information on where the two prescription pads were. The facility failed to provide to the surveyor a process, contract, or any other information concerning the ability of the printer to create the pads and what tamper-resistant techniques were used. There was no information provided upon request of the printer's ability to maintain and protect the physicians TX License number, DEA Number and NPI number.

An interview with the pharmacist, Staff #35, was conducted on 7/19/22. Staff #35 was asked about prescription pads and how does the pharmacy ensure the pads are available and accounted for? Staff #35 stated that generic pads were ordered and stocked in the locked drug cabinet for physician use. Staff #35 provided the policy and procedure, "Security: Staff, and Drugs" the policy stated, "Prescription Pads- Prescription pads/blanks shall be kept in locked storage or be otherwise not accessible to patients, visitors, and unauthorized staff." Staff #35 confirmed there was no other policy or process she was aware of in policy form.

A tour was conducted in the ER medication room with Staff #35, Staff #1, and Staff #26 on 7/19/22. Inside the medication room the pharmacy technician Staff #29 was filling the locked medication storage cabinet with medications. Staff #29 was asked to open the cabinet and show the surveyor where the prescription pads were stored. The cabinet showed, "out of stock" as she was attempting to open the drawer. The drawer was empty. Staff #29 and Staff #35 confirmed the drawer was empty. Staff #26 stated that she had worked in the ER for three years and she never has seen a pad in the cabinet. Staff #29 confirmed that she had never put pads in the locked cabinet. Staff #35 stated that she had just started as the pharmacist in that facility and the protocol will need to be revised.

An interview was conducted with Staff #2 on 7/19/22. Staff #2 stated that the prescriptions should have never been ordered by Staff #7 and the pharmacy should be in control of the prescription pads. Staff #2 stated that the pads that were ordered were taken to the pharmacy and the pharmacist would take responsibility of the pads. There was no further information if the pharmacy reported the missing pads to the Texas PMP.

According to www.pharmacy.texas.gov/files_pdf/Tamper_Resistant.pdf Tamper-Resistant Prescriptions, " ...the completed theft or loss of an official prescription form (Lost/Stolen Form) must be reported to Texas PMP by fax (512) 305-8085, or email."

Based on observation, document review, and interview the facility failed to;

1. provide a clean and sanitary environment to mitigate the risks of possible hospital acquired infections in 6 (Emergency Department, Intensive Care Unit, K3 Floor, K5 Floor, Central Supply, and Post Anesthesia Care Unit) of 6 areas observed.

Refer to Tag A0749

Based on observation, document review, and interview the facility failed to provide a clean and sanitary environment to mitigate the risks of possible hospital acquired infections in 6 (Emergency Department, Intensive Care Unit, K3 Floor, K5 Floor, Central Supply, and Post Anesthesia Care Unit) of 6 areas observed.


Findings include:


Observation tours were conducted from 7/18/2022-7/19/2022 with multiple staff members. The following was observed.


Emergency Department


Trauma 2

An IV Pole is noted to have a white dried liquid on the base. In the lower cabinets, heavy dirt and dust was noted on both upper and lower shelves. In the upper cabinet an Arctic gel pad (a gel pad placed on a patient to reduce a temperature) was readily available for patient use was expired. The gel pad expired 11/30/2021. On top of the gel pad was a 5.0 mm endotracheal tube that expired 4/11/2021. A hard plastic basket attached to the pole of a Glide scope (a video laryngoscope used to assist with intubation) was soiled with dirt and dust. Inside the basket were two stylets (an instrument that is placed inside an intubation tube for more stability). One was sealed and stored in a sterile peel pack, and another was just placed in the basket ready for patient use. Staff #12 could not confirm if the stylet was clean or dirty. The base of the pole was heavily soiled with dirt and dust. The drawers were soiled with dirt, dust, and debris.


Exam A1

The bowl of the sink and the drain was heavily soiled with a black substance. Between the wall and the Exam table trash, dirt, dust, and a lens from a pair of glasses was observed.


Exam Room #16

A sharps container (a container used to dispose of used needles, blades, and glass items) was noted in ED Room #16. The container was grossly overfilled. A sticky unknown white substance on computer in patient room. Surveyor attempted used a wipe to clean the keyboard and the substance was removed along woth dust and hair.



Hallway

An alcove in the hallway was observed storing patient equipment. A portable vein scanner and a portable thermometer was covered by a plastic bag. In the same alcove, a mayo stand (a portable table), and a portable video monitor (used for telemed or translation line) was left uncovered. Staff #12 could not confirm nor deny if the equipment was clean or dirty.

An interview was conducted with Staff #8 on 7/19/2022 at 10:25 AM. Staff #8 was asked how well the housekeeping staff was completing their tasks. Staff #8 stated, "We have 1 housekeeper that has to clean all 24 rooms and the lobby. There is really no way for them to keep up if we have a busy day." Staff #8 was asked if any of the staff was assigned to clean rooms or patient equipment. Staff #8 replied, "We have tried several things. We have new staff all the time, new directors, no one will take responsibility, and there is no one checking to make sure it gets done. We can barely keep the day going sometimes when we get busy. We can wipe the beds down before we get a new patient in the room but, most of the time that is all we have time to do."

An interview was conducted with Staff #12 on 7/18/2022 after 11:00 AM. Staff #12 was asked if Infection Control Rounds were made on a regular basis throughout the facility. Staff #12 replied, "The EOC makes rounds twice a year in each clinical area." Staff #12 was then asked if routine rounds were made for infection control outside the scheduled EOC rounds. Staff #12 stated, "No."

Staff #1 and Staff #12 confirmed the findings.


Medication Room

In the medication Room, a hard plastic container used to dispose of used medication vials and used medication bags was overfilled.

An interview was conducted with Staff #13 on 7/19/2022 at 1:30 PM. Staff #13 was asked how long it takes to do a terminal clean on rooms between patients. Staff #13 replied, "I am allotted 15 minutes for a regular room turnover (or one that is not heavily contaminated), 30 minutes for an isolation room that requires heavier disinfection, 30 to 45 minutes for a trauma or code." Staff #13 was then asked how many isolation rooms she must turnover in an 8-hour shift. Staff #13 replied, "3-4 depending on if COVID is increasing. I complete about 3 Trauma or code rooms on a shift." Staff #13 confirmed the nurses, or the doctors would change the bed linen to be able to place a patient in a room. Staff #13 informed this surveyor that it was stressful and frustrating when her job duties were not completed because there was not enough time in the shift. Staff #13 also confirmed that one Environmental Services (EVS) staff was assigned to 24 ED Rooms, the nurses station, the physician area, the triage area, and the ED lobby.

Staff #22 stated that if the EVS staff in ICU was busy we would pull from the ED EVS staff and if the EVS staff in the ED was busy, we would pull EVS staff from the ICU. This would leave the two busiest units with no EVS staff for an undetermined amount of time.


Intensive Care Unit

A tour was conducted on 7/19/2022 after 10:00 AM with Staff #4. The patient in Room 11 was having a femoral line (an IV placed in the femoral vein) placed by the physician. Staff #18, #19, #20, and #21 were observed entering and exiting the patient's room with contaminated gloves. The staff did not perform hand hygiene upon entering or exiting the patient's room on multiple entrances and exits. Staff #18, #20, and #21 were observed touching surfaces outside the patient's room which contained supplies for the unit resulting in contaminated items and then re-entering the patients room wearing the same contaminated gloves. Without proper hand hygiene the patient was placed at great risk for a hospital acquired infections (HAIs).


K3 Floor

Patient Room #301 was identified as clean. This room was ready for a new admit. In the trash can was multiples forms of trash and a cola can. A torn blue fingertip of a non-latex glove was noted between the patient bed and the chair. The bathroom was soiled with dust and stains to the sink and countertop. The toilet was soiled and stained but contained a clean strip indicating the toilet had been cleaned and ready for a new admission. Outside of the room, in the hallway where a computer was once placed, was heavily soiled with dirt and dust.


K5 Floor

Three temporal artery thermometers (thermometers that scan across the patient's forehead for temperatures) were held together with copious amounts of clear tape. The tape was dirty and unable to be properly sanitized to prevent the spread of infectious diseases between patients.


Disposable Curtains

Multiple disposable curtains were noted in the ED utilized for privacy. The curtains in ED Room #9, #11 had outdated tags. Multiple curtains were noted without a due date for exchange or a date when the curtains were hung.

The disposable curtain in ICU Room #3 was expired by one month. Also, in ICU Room #23, the curtain was expired.

The disposable curtain in the Post Anesthesia Care Unit, Room #16 was expired by 2 months.

An interview was conducted with Staff #13 and Staff #22 on 7/19/2022 after 2:00 PM. Staff #13 and Staff #14 were asked how long the curtains hang before they must be replaced. Staff #13 and Staff # 22 stated, "90 days or if they are contaminated."


A review of the policy titled, "Environmental Infection Prevention, Revised March 2018" was as follows:

" ...11) Privacy curtain maintenance: Should be routinely changed once a quarter, when visibly soiled, or after use in an isolation (i.e., contact, droplet) room. Curtains that are torn or ripped should be replaced immediately as well. Label with month and year when changed ..."

Staff #1, #4, #9, #12, #13, and #22 confirmed the findings.







32143

Findings:
Room 13 (used for psych patient observation)
The nurse stated the room was ready for a new patient. The room was found to have soiled floors. The surveyor cleaned a section of the floor to reveal it was not black marks but soiled with dirt, dust, and hair.
A stretcher was soiled with dust, rusted, and had a hard sticky substance on the rail.
The windowsills and countertops were heavily soiled with dirt, dust and hair.

ER Room 11
was confirmed to be terminally cleaned and ready for a patient. The commode area was found to be soiled with dirt, dust and hair. A door was opened next to the toilet and the doors were soiled with dust and dried urine.
The sink was soiled and a dirty used ear probe was lying in the sink.
The stretcher was soiled with dust and hair.

ER Public Bathroom
was soiled with dirt, dust and hair on the floor and sink. The commode was soiled with urine and stool.

ER Clean Equipment Room
An interview with Staff #26 on 7/18/22 stated the equipment was to be cleaned and covered in plastic. That's how they know if the equipment has been cleaned and ready for patient use.
Found to have one beside commode chair wrapped in plastic and two that were not. They were stacked on top of each other. The commode chairs were all soiled with dust, hair and rust.
Was found to have a beside rail cover, cords, and IV pump uncovered. The bedside rail cushion was found on the floor and soiled with dust and hair.
The room was found to have a three- tiered wire rack. Blood pressure cuff, a suction machine, and an air mattress were found unwrapped and covered in dust. There was no information found if the items were clean or dirty.
2-rolling monitors with missing paint on the handles. The handles were rusted and unable to be cleaned properly. The monitors were covered in plastic.
5 corrugated shipping boxes were found sitting on the floor and next to sterile supplies.

ER Medication Room
IV refrigerator was heavily soiled with trash, dust, hair, and a moldy substance in the door.
The sink had no splash guard. When washing hands water is splattered all over the work counter.
A large, uncovered box was pulled out of the cabinet. The contents had expired items of opened crackers and peanut butter.


Outside of the loading dock an alcove was found to have piles of medical supply trash (masks, booties, paper) and leaves.

Central Supply
In the clean patient medical supply area of the central supply room revealed an open package of cloth halter monitors. The monitors were on the top shelf under the air condition vent. The vent was blowing on the uncovered supplies.

An interview was conducted on 7/18/22 with Staff #22. Staff #22 stated that the facility had started taking care of its own housekeeping needs in the last year. Previously the facility had a contracted service. Staff #22 stated there was only one housekeeper in the ER but there was three shifts. The housekeeper was responsible to keep all the patient rooms (23) clean and turned over, clean all bathrooms in public ER area, nurses station, medication room, all clean supply rooms, soiled rooms, 2 large lobbies, and 1 triage area. Staff #22 stated that the numbers show it can be done but in reality its not workable. Staff #22 confirmed the above findings and stated he was aware it was not clean.