HospitalInspections.org

Based on observation, interview and record review, the facility failed to ensure all licensed nurses adhered to the hospital's policies and procedures (P&P), when:

1. Licensed Nurses (LNs) did not adhere to the hospital's P&P "Pain Assessment and Management NCAL Regional Policy" for four of 13 patients (Pt), Pt 13, Pt 14, Pt 15, and Pt 32. LNs did not assess and/or reassess pain for Pt 14 and Pt 15. LNs did not reassess pain or sedation level after opioid medication administration for Pt 32. LNs did not administer pain medications for Pt 32 and Pt 14 while they were in pain. LNs did not administer pain medications per physician order for Pt 13 and Pt 15.

These failures placed Pt 13, Pt 14, Pt 15, and Pt 32 at risk for inadequate pain management or oversedation and could negatively affect the physical, emotional, and psychosocial (the influence of both physical and social factors on an individual) well-being of patients.

2. One of 10 sampled patients (Pt 13) did not have a Braden Scale risk assessment (A tool for predicting pressure sore risk) completed by LNs upon admission to the Telemetry unit, according to the hospitals P&P titled, "PC-042 Wound Management".

This failure placed Pt 13 at risk for developing pressure injuries.

3. Five boxes of cleft lip/cleft palate (birth defect when a baby's lip or top of mouth does not form properly, creating a space in the roof of the mouth or lip) nursers (special disposable bottles with nipples for babies) with the expiration date of 4/1/23 were observed in a storage room cupboard in the Labor and Delivery Recover Postpartum (LDRP) unit contrary to hospital P&P.

This failure may harm cleft lip/cleft palate babies by the expired bottles and nipples not working properly which may lead to poor feeding by the baby causing weight loss in an already vulnerable patient.


Findings:

1. During a review of Pt 13's "H&P", dated 7/18/24, indicated, Pt 13 had a past medical history of coronary artery (major blood vessel that supply the heart with blood) disease with a surgery to bypass a blocked or narrowed artery. Pt 13 was admitted to the hospital for a stroke (blood flow to the brain is cut off) on 7/18/24.

During a review of Pt 13's "Medication Order (MO 1)", dated 7/24/24, the "MO 1" indicated, " ... Acetaminophen Tablet 650 mg ... oral ... EVERY 6 HOURS AS NEEDED ... for mild pain (1-3) ...".

During a concurrent interview and record review on 7/25/24 at 3:25 p.m. with ANM 5, Pt 13's "PAF", dated 7/24/24 was reviewed. ANM 5 stated Pt 13's pain was assessed on 7/24/24 at 8:43 a.m. as a seven (severe). ANM 5 stated Pt 13's pain was assessed again on 7/24/24 at 9:38 a.m. as zero.

During a concurrent interview and record review on 7/25/24 at 3:30 p.m. with ANM 5, Pt 13's Medication Administration Record (MAR- a report detailing medications given to the patient)", dated 7/24/24, was reviewed, the "MAR" indicated acetaminophen 650 mg was administered at 8:43 a.m. ANM 5 stated acetaminophen was a medication for mild (1-3) pain and Pt 13 reported a pain score of 7 (severe) pain. ANM 5 stated Pt 13 did not have any other pain medications ordered for him. ANM 5 stated LNs should have contacted Pt 13s physician to ensure the medication for mild pain was indicated for reported pain in the severe range or, get an order for a medication indicated for severe pain. ANM 5 stated LNs must follow physician orders, and if they question the physician orders must contact the physician for clarification.

During a review of Pt 14's "History & Physical (H&P)", dated 7/20/24, indicated Pt 14 had a past medical history of cervical (neck) stenosis (bone narrowing) with end stage renal disease (kidney failure) admitted to the hospital for metabolic encephalopathy (brain disfunction caused by chemical imbalance in the blood) on 7/20/24.

During a review of Pt 14's "Medication Order (MO)1", dated 7/24/24, the "MO 1" indicated, " ... Acetaminophen [a pain reliever medication] Tablet 650 mg [milligrams, a unit of measure] ... oral ... EVERY 6 HOURS AS NEEDED ... mild pain (1-3) [on a scale of 0-10, zero being no pain, ten being the worst] ...".

During a concurrent interview and record review on 7/25/24 at 7:26 p.m. with Assistant Nurse Manager (ANM) 5, Pt 14's "Pain Assessment Flowsheet (PAF)" dated 7/24/24 was reviewed. ANM 5 stated Pt 14's pain was assessed on 7/24/24 at 3:39 p.m. as a 7 (severe). ANM 5 stated no pain medication was administered. The "PAF" indicated pain or sedation level (level of drug-induced sleep) was not assessed again until 11:52 p.m. and indicated a zero. ANM 5 stated her expectation was for LNs to assess patients for pain and administer pain medications when patients report pain.

During a concurrent interview and record review on 7/29/24 at 3:15 with RN 4 Pt 14's "PAF" dated 7/24/24 was reviewed. RN 4 stated she was Pt 14's nurse on 7/24/24 from 3 p.m. to 10:30 p.m. RN 4 stated the Patient Care Technician (PCT - non licensed staff) took Pt 14's vital signs (VS) at 3:39 p.m. and VS included a pain score. RN 4 stated LNs were responsible for following up with all patient VS that the PCT's obtained. RN 4 verified no pain score was documented in Pt 14's "VSF" and no pain medication was administered for the pain score of seven that was obtained at 3:39 p.m. RN 4 stated according to Pt 14's documentation it appeared Pt 14's severe pain was not addressed. RN 14 stated she should have assessed and documented pain assessments for Pt 14. RN 14 stated she also should have administered pain medications if Pt 14 continued to report pain. RN 14 stated she should have validated the PCT's documentation for out of normal VS. RN 14 stated assessing pain was important because it affected the body and could cause a patient to become more agitated.

During an interview on 7/30/24 at 9 a.m. with the Clinical Adult Nursing Director (CAND), the CAND stated, her expectation was for LNs to do full assessments on patients to determine if the patient had pain and administer medications based on the reported pain score. The CAND stated her expectation was for PCT's to report all abnormal vital signs to the LN and for the LN to follow up with the patient.

During a review of Pt 15's "H&P", dated 6/9/24, indicated Pt 15 was a female with a history of Cerebral Vascular Accident (CVA-stroke), tracheostomy (a surgical created airway in neck through the windpipe) Pt 15 was admitted to the hospital for stroke on 6/9/24.

During a review of Pt 15's "Medication Order (MO 1)", dated 6/9/24, indicated, " ... acetaminophen oral soln [solution-liquid] ... 650 mg ... PEG [through tube in stomach] ... EVERY 4 HOURS AS NEEDED ... mild pain (1-3) ...".

During a review of Pt 15's "Medication Order (MO 2)", Dated 6/9/24, indicated, " ... End Date 7/16/24 ... oxycodone [a potent medication for pain] IR Tab 5mg ... EVERY 4 HOURS AS NEEDED for moderate pain (4-6), Severe Pain (7-10) ...".

During an interview and record review on 7/25/24 at 3:15 p.m. with ANM 5 Pt 15's "MAR", dated 7/6/24 to 7/7/24 and "PAF" dated 7/6/24/to 7/7/24 were reviewed. ANM 5 stated on 7/6/24 at 5:44 p.m. Pt 15 was administered acetaminophen 650 mg without documentation of a pain score. ANM 5 stated on 7/7/24 at 3:43 a.m. Pt 15 was administered acetaminophen 650 mg without documentation of a pain score. RNM 5 stated LNs must assess and document a pain score before administration of pain medications, to ensure the patient receives the right medication according to their reported pain score.

During an interview and record review on 7/25/24 at 3:30 p.m. with ANM 5, Pt 15's "MAR", dated 7/24/24, and "PAF", dated 7/24/22 were reviewed. ANM 5 stated Pt 15's pain was assessed as 5 (moderate) on 7/24/24 at 7:10 a.m., and Pt 15 was administered 650 mg acetaminophen (for mild pain). The "PAF" indicated Pt 15's pain was reassessed on 7/24/24 at 7:59 a.m. as zero. The ANM 5 stated LNs should have contacted Pt 15s physician to adjust the ordered medication's scoring scale or asked for an order for a different pain medication.

During an interview on 7/30/24 at 9:04 a.m. with the CAND, the CAND stated her expectation was for nursing staff to assess patients for pain and administer medications according to physician order. The CAND stated her expectation was for LNs to contact the physician if clinical judgment indicated adjusting the scale (such as administering acetaminophen for a score of 1-6) or asking for a different medication (when current medications were not helping pain).

During a review of Pt 32's "History & Physical (H&P)", dated 7/19/24, indicated Pt 32 was admitted after a colostomy closure (a surgical procedure that reconnects the two ends of the large bowel and closes the stoma [a surgical opening in the abdomen, connecting the bowel to the skin surface]) on 7/91/24.

During a review of Pt 32's "Medication Order (MO) 1", dated 7/19/24, the "MO 1" indicated, " ... oxyCODONE ... Tab [tablet] 2.5 mg [milligrams, a unit of measure] ... EVERY 6 HOURS AS NEEDED ... for moderate (4-6) [on a scale of 0-10, zero being no pain, ten being the worst] BREAKTHROUGH Pain. First line medication [medication to try first] ...".

During a review of Pt 32's "Medication Order (MO) 2", dated 7/19/24, the "MO 2" indicated, " ... oxyCODONE ... Tab 5 mg ... EVERY 6 HOURS AS NEEDED ... for severe (7-10) BREAKTHROUGH Pain. First line medication ...".

During a review of Pt 32's "Medication Order (MO) 3", dated 7/19/24, the "MO 3" indicated, " ... HYDROmorphone [a strong opioid for pain] Inj [injection] 0.1 mg EVERY 2 HOURS AS NEDED ... For moderate (4-6) BREAKTHROUGH Pain. Second line medication. Use only if first line medication (oxycodone) is not tolerated, not ordered, or if pain is still moderate (4-6) 60 minutes after administration of oxycodone. If 2 doses are administered within 8 hours, contact physician to re-evaluate pain medication order ...".

During a review of Pt 32's "Medication Order (MO) 4", dated 7/19/24, the "MO 4" indicated, " ... HYDROmorphone Inj [injection] 0.1 mg EVERY 2 HOURS AS NEDED ... For severe (7-10) BREAKTHROUGH Pain. Second line medication. Use only if first line medication (oxycodone) is not tolerated, not ordered, or if pain is still severe (7-10) 60 minutes after administration of oxycodone. If 2 doses are administered within 8 hours, contact physician to re-evaluate pain medication order ...".

During a concurrent interview and review on 7/25/24 at 2:50 p.m. with Nurse Manager (NM) 1 and Registered Nurse (RN) 6, Pt 32's Pain Assessment Flowsheet (PAF) was reviewed. NM 1 stated Pt 32's pain was assessed on 7/21/24 at 12:03 p.m. as a 7 (severe). NM1 stated Pt 32's pain on 7/21/24 at 3:22 p.m. was rated as a 6 and at 5:55 p.m. as a 5. The "PAF" indicated pain or sedation level (level of drug -induced sleep) was not assessed again until 10:35 p.m. and indicated Pt 32 was sleeping.

During a concurrent interview and review on 7/25/24 at 2:52 p.m. with Nurse Manager (NM) 1 and Registered Nurse (RN) 6, Pt 32's "Medication Administration Record (MAR)", dated 7/19/24 to 7/21/24, the "MAR" indicated hydromorphone 0.2 mg was administered at 12:03 p.m. The "MAR" indicated the first line drug, oxycodone was not given on 7/21/24. The "MAR" indicated no pain medication was administered to Pt 23 on 7/21/24 after 12:03 p.m.

During an interview on 7/30/24 at 11:15 a.m. with the Interim Chief Nursing Officer (ICNO), the ICNO stated it was her expectation for Licensed Nurses (LN) follow physicians' orders for pain medication as written and pain should be assessed/reassessed per the hospital P&P. the ICNO stated nurses have the autonomy to call and question the physician to meet a plan of care for patients. The ICNO stated on medical/surgical units LN should ask the patient about their pain during hourly rounding (checking on patients hourly).

During a review of the facility's P&P titled, "Pain Assessment and Management (PAM)", dated 3/15/23, the "PAM" indicated, " ... Procedures ... All patients will be assessed for pain ... Upon admission ... At least once each shift ... prior to, during and following any known pain-producing procedure ... With each new report of pain ... RN may use clinical judgement to determine the analgesic and dose to administer in accordance with the pain management orders ... Assess and document sedation level prior to and following the administration of opioids and routinely thereafter with each pain assessment ... Implement pharmacologic pain management interventions as needed to achieve patient comfort ... Reassess pain ... 60 minutes or less of the intervention as needed; to evaluate the effectiveness of pain management interventions ...".

During a professional reference review titled, "Pain management in hospitals: patients' satisfaction and related barriers," dated 9/25/18, (found at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6207353/) indicated, " ... Suboptimal pain control has been frequently reported in healthcare settings and documented to negatively impact patients' health. Patients' perception regarding pain management may influence their satisfaction regarding treatment ...".

During a professional reference review titled, "Acute Pain Management Pearls: A Focused Review for the Hospital Clinician," dated 12/22/22, (found at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9818465/) indicated, " ... Uncontrolled pain worsens patient outcomes ... Uncontrolled acute pain triggers a complex neurohormonal cascade that is toxic to nearly every organ system, as evidenced by increased rates of renal [kidney] and gastrointestinal [stomach and intestine] dysfunction, infection, cardiopulmonary [heart and lungs] and thrombotic [blood clot] complications, impaired wound healing, adverse psychological effects, and poorer functional recovery and quality of life ... Acute pain management in hospitalized patients should therefore be a clinician and intuitional priority as a key driver of patient outcomes ...".

2. During a review of Pt 13's "H&P", dated 7/18/24, indicated, Pt 13 with past medical history of coronary artery (major blood vessel that supply the heart with blood) disease with a surgery to bypass a blocked or narrowed artery. Pt 13 was admitted to the hospital for a stroke (blood flow to the brain is cut off) on 7/18/24.

During a concurrent interview and record review on at with ANM 5 and the CAND, Pt 13's "Admission Assessment Flowsheet (AAF)", dated 7/18/24, was reviewed. ANM 5 stated Pt 13's "Braden Score for Predicting Pressure Sore Risk [tool to predict the risk of pressure injuries based on 6 things, sensing, moisture, activity, mobility, nutrition, and friction]" was not completed for his admission to the unit on 7/18/24. ANM 5 stated the score was used for LNs to plan care and begin pressure injury prevention strategies for patients when they are admitted to the hospital or transferred into a different unit. ANM 5 stated prevention strategies were pressure reduction mattresses, a turn schedule, or pressure offloading devices. ANM 5 stated when patients had a low Braden score, they were at a higher risk for pressure injury. ANM 5 stated Pt 13 should have had a Braden assessment score completed, to assess his risk for pressure injury. ANM 5 stated Pt 13 had mobility issues and was at a higher risk than some patients for pressure injuries.

During an interview on 7/30/24 at 9:04 a.m. with the CAND, the CAND stated a head-to-toe assessment included skin to ensure it was intact (had no breaks) and check all pressure points to know where there could be skin breakdown. The CAND stated her expectation was for LNs to give each patient a Braden Score, because it identified the risk of skin breakdown and risk to a patient's skin integrity.

During a review of the facility's P&P titled, "PC-042Wound Management", dated 8/17/22, indicated. " ... The Braden Scale for Predicting Pressure Score Risk is a clinically validated tool that allows nurses and other health care providers to reliably score a patient/client's level of risk for developing pressure injuries/pressure injuries. Specific risk factors include alteration in sensory perception, moisture, activity, mobility, nutrition, and friction and shear ... A risk assessment (e.g. Braden Scale) shall be performed and documented upon admission ... A through full body skin assessment shall be performed upon all patients upon admission ...".

During a review of Braden Scale for Predicting Pressure Sore Risk referenced in facility's policy and procedure (P&P) titled, ""PC-042Wound Management", dated 8/17/22, indicated, " ... Patient's with a total score of less than nine are severe risk, 10-12, high risk, 13-14 moderate risk and 15-18 a moderate risk, 19-23 no risk ..." for pressure injury. Each assessment category was scored one through four, with six categories. Category one sensory perception, two moisture, three activity, four mobility, five nutrition, and category six friction and shear.

During a professional reference review titled, "Use of the Braden Scale for pressure ulcer risk assessment in a community hospital setting: the role of total score and individual subscale scores in triggering preventive interventions", dated 11/2014, (found at https://pubmed.ncbi.nlm.nih.gov/25377103/) indicated, " ... Routine use of a pressure ulcer risk assessment tool is considered necessary for a comprehensive pressure ulcer prevention program. Planning preventive care according to the subscale scores of the Braden Scale may be more effective for prevention of HAPUs [Hospital Acquired Pressure Ulcers] in some cases ...".

3. During an observation and interview on 7/24/24 at 10:20 a.m. with NM 4in the LDRP unit's Postpartum (after baby delivery) clean storage room five expired boxes of cleft/lip palate nursers were observed in a cupboard. The expiration date on the boxes was 4/1/23. The NM 4 stated the nursers were special bottles with nipples used to feed babies born with the birth defect cleft lip or cleft palate. The NM 4 stated many cleft lip babies and most cleft palate (roof of the mouth) babies were not able to breastfeed, so they required special bottles and nipples for feeding. NM 4 stated central supply and LNs were responsible to ensure no expired supplies were in the supply room. NM 4 stated expired supplies must not be used for patients because the integrity (wholeness) of the materials may be affected. NM 4 stated sterilization (elimination of germs) of the supplies may be affected in expired supplies.

During an interview on 7/30/24 at 11:20 a.m. with the ICNO, the ICNO stated expired devices should never be used on patients. The ICNO stated industry standard was no use of expired items in a medical setting. The ICNO stated the packaging of an expired product may not have the same integrity as an unexpired device and so the product inside the package may not work the same or could even harm the patient.

During a review of the facility's P&P titled, "STOREROOM OPERATIONAL READINESS PLAYBOOK", dated 8/2023, indicated, " ... Check for any expired or damaged items and report to supervisor to take appropriate action ...".

During a professional reference review titled, "Managing packaged sterile supplies and devices", dated 6/2022, (found at https://www.jointcommission.org/-/media/tjc/newsletters/quick-safety-65-packaged-sterile-devices-6-20-22-final.pdf) indicated, " ...Managing commercially prepared sterile supplies and devices can be challenging for healthcare organizations. In order to protect patients from infection and other potential harm from expired or compromised supplies and devices, organizations must identify the best location to store the supplies so that staff can readily access them, ensure the supplies are being stocked to the most optimal par levels, and that items have not passed their expiration dates ...".

During a professional reference review titled, "Cleft Palate: Feeding your Baby", dated 8/19, (found at https://www.nationwidechildrens.org/family-resources-education/health-wellness-and-safety-resources/helping-hands/cleft-palate-feeding-your-baby) indicated, " ... The palate, more commonly referred to as the roof of the mouth, separates the mouth from the nose. The palate is important for feeding ... A cleft is an opening or split in the palate. This cleft can make feeding hard for your baby. Most babies with a cleft of the palate are not able to use standard bottles or solely breast feed because they cannot create the suction needed to draw the milk out of the nipple. Special bottles and nipples are available to help infants with cleft palate feed and grow. These bottles may be used with formula or breast milk ...".

Based on observations, interviews and record review, the facility failed to maintain a clean and sanitary environment to avoid sources and transmission of infection in accordance with hospital policy and professional standards when:

1. Three of four clean linen storage carts did not have the protective cloth cover over the clean patient linen in the Labor and Delivery, Recovery Postpartum (LDRP) unit and two of six clean linen storage carts did not have the protective cover closed on the 2nd and 4th floor Telemetry (heart monitoring) Units, contrary (opposite) to hospital Policies and Procedures (P&P).

2. One of two sharps containers (containers used for the safe disposal of needles and other sharp medical instruments) on the 4th floor Telemetry Unit in the medication preparation storage area was overfilled past the fill line marked on the side of the container, contrary to facility P&P.

3. Seven of 30 storage bins observed in the clean patient supply rooms in the LDRP Unit contained flaky white and brown debris and dust. The bins contained respiratory (breathing) supplies for nebulizer (device that changes liquid medicine into mist) treatments, breast milk storage bottles, nipples for bottles, Intravenous (IV-into the vein) Start Kits, patient hygiene supplies, cold packs, and pacifiers, contrary to hospital P&P.

4. Unused items were stored in the Emergency department (ED) dirty utility room (a room where used items are placed to be cleaned or disposed of) contrary to professional standards.

5. Multiple commodes (a reusable portable toilet) were stored in the Perioperative (Pre-Op) dirty utility room and not cleaned to Manufacturer's Instructions for Use.

These failures had the potential for cross contamination (the process by which bacteria [microscopic living organisms that cause infections] are unintentionally transferred from one object or to another object or person with a harmful effect) and transmission of infection.

Findings:

1. During a concurrent observation and interview on 7/24/24 at 10:05 a.m. with Nurse Manager (NM) 4 on the Labor and Delivery area of the LDRP Unit, two different clean patient linen carts were observed without the protective cover down and closed. NM 4 stated facility staff restocking or removing linens should close the protective cover. NM4 stated uncovered linen could cause the linens to become dirty. NM4 stated dirty linens could cause infection in patients. NM 4 stated her expectation was for facility staff to close and secure the protective cover on the linen carts after stocking or removing patient linens, so linens remained clean and contaminant free.

During a concurrent observation and interview on 7/24/24 at 10:30 a.m. with NM 4 in a clean storage room in the Postpartum side of the LDRP unit, a linen cart was observed without the protective cover down and closed. NM 4 stated facility staff should make sure linen carts remained covered.

During a concurrent observation and interview on 7/24/24 at 10:40 a.m., in the 2nd floor telemetry unit supply room with Nurse Manager (NM) 3, the drape over the linen cart was left pulled open and clean linen exposed. NM 3 stated the linen should be covered to avoid cross contamination (the process by which microorganisms are unintentionally transferred from one object to another of person with a harmful effect) of clean linen.

During a concurrent observation and interview on 7/24/24 at 10:41 a.m. with Assistant Nurse Manager (ANM) 5 and the Clinical Adult Nursing Director (CAND) in the clean storage room on the fourth floor Telemetry Unit, a clean patient linen cart was observed without the protective cover down and closed. The CAND stated an uncovered patient linen cart can lead to patient infection by linens becoming dirty and contaminated. The CAND stated her expectation was for facility staff to close the protective cover on the linen carts.

During an interview on 7/29/24 at 4:10 p.m. with the Director of Risk Management, Patient Safety and Infection Prevention (DIP), the DIP stated clean linen should be covered to protect from dust and cross-contamination.

During an interview on 7/30/24 at 11: 30 a.m. with the Interim Chief Nurse Executive (ICNE), the ICNE stated Linen carts are to be covered all the time if you are not gathering the linen, and if there is damaged linen, it must be taken out. The ICNE stated linen was covered to avoid dust because cross contamination can occur with dust and can create dust mites (microscopic relatives of ticks and spiders, invisible to the naked eye and live in materials and house dust) which could get on clean supplies and be carried to patient areas.

During a review of the facility's P&P titled, "Handling of Linen", dated 11/16/22, indicated, " ... Clean linen are transported and stored in a manner that ensures cleanliness and protection from dust and soil ... to prevent transmission of infection via contaminated linen ... Clean linen storage carts must be covered in a manner to protect linen from dust, debris, and other contaminants ... Carts that are going to be used to store linens ... must have covers during transportation and storage time ... The covers shall protect the linens at all time during storage ...".

2. During a concurrent observation and interview on 7/24/24 at 10:50 a.m. with the ANM 4 and the CAND on 4th floor Telemetry Unit in the medication preparation room, the sharps container on the wall was filled past the fill line (a line indicating when to stop filling the container for safe closure) marked on the side of the container. ANM 4 stated Environmental Services (EVS) were supposed to exchange them out when full. ANM 4 stated EVS would not know the container was full unless nursing staff informed them. The CAND stated staff could accidentally get stuck by a sharp themselves with a potentially contaminated needle if they tried to push down the things in the container to fill past the fill line. The CAND stated staff could also poke themselves if sharps were on top of the many paper wrappers that were placed in a sharp's container. The ANM 4 stated an over filled sharps container could cause injury due to a needle or other sharp sticking out of the top.

During an interview on 7/29/24 at 4:10 p.m. with DIP, the DIP stated sharps containers should have been filled only to the fill line and then disposed of appropriately because when it was over filled one could not dispose of sharps properly and there is a risk of a unintentional needle stick and cross-contamination.

During an interview on 7/30/24 at 11:30 a.m. with the ICNE, the ICNE stated, sharps containers must be emptied when the contents reach the fill line. The ICNE stated contents placed in the containers must be free to drop without staff taking a chance of pushing down the container contents and potentially causing a needlestick injury. The ICNE stated the EVS staff could also have been affected by an over filled container due to sharps bouncing out of the over filled container and causing a needlestick injury. The ICNE stated a sharp or needle may have an infectious bloodborne material (bacteria in human blood that can cause disease) on it and could be a source of cross-contamination.

During a review of the facility's P&P titled, "Blood Borne Pathogen Exposure Control Plan, EOC-SM-052, dated 10/18/2022, indicated " ...At all times during the use of sharps, containers for contaminated sharps must be ... replaced when no more than ¾ full ...".

During a review of professional reference titled, "Sharps Safety Guidelines," dated 12/26/22, (found at https://www.infectioncontroltoday.com/view/sharps-safety-guidelines) the professional reference indicated, " ... Punctures and cuts can introduce bloodborne pathogens into the body, such as hepatitis B virus (HPV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV) ... Most sharps-related injuries can be prevented and occur during or immediately after use it is important to understand safe sharps waste disposal ... Containers should also be marked with a line to indicate when the container is three-fourths full. Once the container reaches that point, do not place any more sharps in the container-this line is to prevent injuries. One of the leading causes of sharps injuries is overfilled containers. Never force items into the sharps container ...".


3. During a concurrent observation and interview on 7/24/24 at 10:10 a.m. with NM 4 in the LDRP Labor and Delivery (L&D) clean supply room, three plastic bins containing new patient supplies were observed with white and brown dust and debris on the bottom of each bin. The supply bins held individually packaged items such as nebulizer masks (masks to administer breathing treatments), cold packs (ice packs), and patient hygiene supplies (mouthwash, body soap, lip balm). NM 4 stated environmental services (EVS) were responsible for cleaning the bins, but unit staff should report to EVS when the bins needed cleaning. NM4 stated, the bins should be clean to prevent infection in patients.

During a concurrent observation and interview on 7/24/24 at 10:20 a.m. with NM 4 in the LDRP Postpartum (PP) clean supply room, six plastic bins containing new patient supplies were observed with white and brown dust and debris on the bottom of each bin. The supply bins held individually packaged items such as, breastmilk storage bottles, nipples (for babies), pacifiers, and disposable feeding bottles. NM 4 verified the dirt and dust in the supply bins and stated the bins should not be dusty and dirty, for reasons of infection control.

During an interview on 7/30/24 at 11:17 with the Interim Chief Nurse Executive (ICNE), the ICNE stated the supply bins should be cleaned like all areas of the hospital, to prevent infections in patients.

During a review of the facility's policy and procedure titled, "Cleaning and Disinfection of Reusable Equipment, medical devices, and surgical instruments (C&D)", dated 11/15/23, the "C&D" indicated, " ... The cleaning of storage areas, containers, racks, cabinets and shelves used to store clean equipment and supplies must be assigned and schedules to prevent cross-contamination from dust and any residue ... Infection Control staff will provide consultation regarding equipment supplies, and procedures used for sterilization, disinfection and decontamination purposes ...".

4. During a concurrent observation and interview on 7/24/24 at 9:50 a.m. with the ED Manager (EDM) in the ED dirty utility room there was unused Spill Kit (an organized set of equipment designed to deal with hazardous spills) in the cabinet of the room. The EDM stated everything in the dirty utility room is dirty and they are dirty when taken out of the room.

During an interview on 7/29/24 at 4:10 p.m. with the DIP, the DIP stated there should be a separation between clean and dirty items to avoid cross-contamination. The DIP stated it was her expectation that clean supplies should be kept in a clean area to avoid contamination.

During a review of a professional reference from the Agency for Healthcare Research and Quality (AHRQ) titled, "Infection Prevention (IP)" (undated), "IP" indicated, " ... Providing a sanitary environment ... There is a clear separation of clean and dirty work areas. Clean areas are used for storage and preparation of medications and unused supplies; dirty areas are used for contaminated equipment ...".

5. During a concurrent observation and interview on 7/24/24 at 10:15 a.m. with Nurse Manager (NM) 5 and Assistant Nurse Manager (ANM) 7 in Pre-Op Unit, multiple commodes were stored in the dirty utility room. NM 5 stated commodes were used for patients and have been storing them in the dirty utility room " ... forever ...". NM 5 and ANM 7 stated everything in the dirty utility room was dirty and should not be used for patients.

During an interview on 7/29/24 at 2:30 p.m. with ANM 7, ANM 7 stated nothing should be removed from the dirty utility room and used for patients. ANM 7 stated the commodes were cleaned by wiping with cleaning Sani (a type of pre-moistened wipe that can be used for cleaning) wipes. ANM7 stated reusable equipment like commodes should be cleaned according to manufacturer's instructions and stored in the clean utility room. ANM 7 stated policy was not followed for cleaning and storing of the commodes.

During an interview on 7/29/24 at 2:45 p.m. with NM 5, NM 5 stated nothing should be removed from the dirty utility room and used for patients. NM 5 stated reusable equipment like commodes should be cleaned according to manufacturer's instructions after patient use and stored in the clean utility room. NM 5 stated commodes were cleaned before patient use and not after patient use. NM 5 stated policy was not followed for cleaning and storing of the commodes.

During a review of the "Instructions For Use (IFU)", undated, the IFU indicated, " ... Use a mild soap and water solution, rinse with clean water then dry with a soft cloth. Ensure the product is well rinsed before using ...".

During an interview on 7/29/24 at 4:10 p.m. with the DIP, the DIP stated there should be a separation between clean and dirty items to avoid cross-contamination. The DIP stated it was her expectation that clean supplies should be kept in a clean area to avoid contamination. The DIP stated she expected staff to follow manufacturer's instructions for cleaning reusable patient care items, reusable items should be clean immediately after use, and stored in the clean room.

During a review of the facility's policy and procedure titled, "Cleaning and Disinfection of Reusable Equipment, medical devices, and surgical instruments (C&D)", dated 11/15/23, the "C&D" indicated, " ... Reusable patient care equipment, medical devices and surgical instruments will be cleaned, disinfected and/or sterilized following manufacturer's instructions to decrease the risk of transmission of infection to patients and staff ... All staff must be trained in the use, cleaning, disinfection and/or sterilization and storage following manufacturer's instruction for use (IFU) prior to use ... Purpose ... To provide guidance on how to effectively and safely clean and store reusable instruments and equipment to help prevent the transmission of infections ... Definitions ... Cleaning is the physical removal or organic material, lubricant or soil form objects by using water and detergents or soap and is required before any further processing ... Disinfection is the elimination of many, or all, pathologic microorganisms ... on inanimate objects and is done with liquid chemicals ... Reprocessing- is a detailed multistep process to clean, and then disinfect or sterilize reusable devices according to manufacturer's IFUs ... Reusable medical devices- are devices that can be reprocessed following manufacturer's IFUs and reused on multiple patients ...Dirty or contaminated equipment will be separated from equipment that is clean or sterile ... Patient care equipment will be cleaned on a regular basis, after each use ..."

Based on interviews and record review, the facility failed to immediately make available the full extent of its patient care resources when a patient (Patient 1) was not triaged (preliminary assessed patient needs in order to determine the urgency of their need for treatment) in the Emergency Department (ED) appropriately in accordance with standard pain scale and hospital triage policy & procedure.

This failure resulted in a delay in a medical screening exam (an initial exam by a qualified medical professional performed when a patient requests care in an emergency department) and care for Patient (PT) 1.

Findings:

During a review of Pt 1's "Ambulance Run Sheet (RS, a form documenting the patient status from pick up to deliver to hospital ED)", dated 5/13/24, the "RS" indicated Pt 1 was a 55-year-old male. The "RS" indicated, " ... CC [chief complaint] shoulder pain with nausea ... AOS [arrived on scene] to pt [patient] sitting on his couch. Pt appears in some obvious distress. (-) [negative for] chest pain, sob [shortness of breath], weakness, dizziness, v/d [vomiting/diarrhea]. (+) [positive for] shoulder blade pain with intermittent [come and goes] nausea. Pt denies recent illmess [sic] or trauma [injury]. Pt states he has a hx [history] of bilateral shoulder pain but elevated a few days ago. Today while at work, pain between shoulder blades came back worse than normal. Pt also complains of intermittent nausea. Pt is ambulatory [walks] without assistance ...". The "RS" indicated Pt 1's blood pressure (BP) was 164/103 at 2;11 p.m.; 198/88 at 2:15 p.m.; 187/118 at 2:19 p.m.; and 164/105 at 234 p.m. (normal adult BP was less than 120/80 mmHg (millimeters of mercury, a unit of measure). The "RS" indicated, " ... Protocol: Nausea/Vomiting ..." and Pt 1 was given ondansetron (a medication to treat nausea) 4 milligrams (mg, a unit of measure) at 2:28 p.m. and arrived at the facility's ED at 3:06 p.m. The "RS" indicated, " ... Note: Times listed may be estimates entered at a later time ...".

During a review of Pt 1's "ED Timeline (EDT)", dated, 5/13/24, the "EDT" indicated Pt 1 arrived in the ED at 2:43 p.m. as entered by Clerk (CL) 1. The "EDT" indicated CL1 documented, " ... Chief Complaints ... BACK PAIN ..." The "EDT" indicated triage was started by Registered Nurse (RN) 7 at 2:49 p.m. The "EDT" indicated, " ... General Appearance-Distress Level: MILD ... Information provided by: Patient; Paramedic/Emergency Medical Technician ... BP: 174/104 ... Pain Scale Type: Numeric 0-10(per patient) ... Pain Score: 8 ... Acceptable Level (Pain): 1 ... Location: Shoulder; Back ... Chief Complaints Updated ... BACK PAIN (BIBA [brought in by ambulance] from home, c/o [complaint of] pain between shoulder blades; nontraumatic [non-injury]; hx of shoulder pain.) ... Priority ...How many resources are needed? ... One, assign Level 4 ... ESI [Emergency Severity Index, a five-level emergency department triage algorithm, based on the severity of a patient's medical condition and the number of resources their care is anticipated to require, 1 being the highest severity and 5 the lowest] ... Priority: 4NonUrg [non-urgent] ... 2:52 p.m. ...". The "EDT" indicated Pt 1 received oral pain medication, laboratory specimens, an electrocardiogram (EKG, electrical activity of the heart), and a chest x-ray.

During a concurrent interview and record review on 7/17/24 at 11:16 a.m. with RN 7, Pt 1's "EDT" was reviewed. RN 7 stated he triaged Pt 1 and stated the Pt arrived at 2:43 p.m. by ambulance with a complaint of pain between the shoulder blades. Pt 1 stated Pt 1's pain level was 8/10 and BP was 174/104. RN 7 stated he assigned Pt 1 an ESI Priority Level 4. RN 7 stated Level 1 was for an emergency patient needing resuscitation; Level 2 was for a high priority patient needing to start actions, abnormal vital signs. RN 7 stated he though Pt 1's elevated BP due to the shoulder pain. RN 7 stated, " ... I was not told or informed of him being diaphoretic and nauseated prior to his arrival to the ER [Emergency Room]. It was later stated. ... After triage patient went back to the lobby ...".

During a concurrent interview and record review on 7/30/24 at 9:20 a.m. with the Emergency Department Director (EDD), Pt 1's "RS" was reviewed. The EDD stated the "RS" was not entered in the electronic medical record in real time, but the triage nurse should have received a report from the paramedic who brought Pt 1 to the ED. The EDD stated the report would include Pt 1's history and any protocols or medications given in route. The EDD stated depending on the nature of the patient's complaint, more questions could be warranted. The EDD stated since Pt 1 came in by ambulance with a history of shoulder pain, the triage nurse should ask what was different about it today that made you call an ambulance? The EDD stated RN 7 signed the "RS" meaning RN 7 got report and would have known about the Pt 1's nausea and the ondansetron given. The EDD stated it was her expectation for RN 7 to ask appropriate questions.

During a review of Pt 1's ED Progress Note (EDPN), dated 5/13/24 at 3:39 p.m., the "EDPN" indicated, 55 y/o male presents to the emergency room complaining of shoulder pain to upper back. No hx of sustaining an injury or fall. He states that earlier today he felt diaphoretic and nausea: pt spouse call ambulance, concerned about possible heart attack sx [symptoms]. No CP [chest pain] and no SOB at this time. Will do a cardiac work up. Pt states that the shoulder pain has been off and on for 2 months ...".

During a review of Pt 1's "History & Physical (H&P)", date /13/24 at 8:04 p.m., the "H&P" indicated, " ... around 11:15, started experience this constant 8/10 intense sharp pain in between his shoulder blades that radiates up to his neck causing him nausea without vomiting ... pain did not go away and therefore caused him to go to the ED as urged by wife ... 2 months ago that he would have it on and off, intermittent pain in between his shoulder blades ... but this occurrence was different as it never went away ... notable labs include troponin 36 followed by 96 [troponin, a proteins found in the cells of the heart muscle, as heart muscle is damaged, troponin leaks into the bloodstream and levels will rise] ... Assessment and Plan ... ACS [Acute coronary syndrome, a medical emergency that occurs when blood flow to the heart is suddenly reduced or stopped] ....hypertensive urgency [severe elevation in blood pressure without signs or symptoms of organ damage] ...".

During a review of Pt 1's "Rapid Response (RR)", date 5/14/24, the "RR" indicated, " ... Patient BIBA for C/C [chief complaint] of shoulder pain that radiate to neck which caused him to have nausea. Arrived in ED hypertensive. Patient was transferred to telemetry floor [patient care unit that monitors the heart] around 2300 [11:00 p.m.]. Code Blue {patient requiring resuscitation] announced overhead at 0022 [12:22 a.m.] Writer arrived at bedside with patient unresponsive and ongoing CPR [cardiopulmonary resuscitation] ... OUTCOME: Expired [died] ...".

During a review of Pt 1's "Death Note (DN)", dated 5/14/24, the "DN" indicated, " ... Immediate Cause of Death: Cardiopulmonary arrest ... Due to: Chest pain ... Due to: Elevated troponins ...".

During a review of the facility's policy and procedure titled, "Triage", dated 11/20/19, "Triage" indicated, " ... Purpose ... patients presenting to the Emergency Department are treated in order of priority based upon acuity utilizing the Emergency Severity Index (ESI) ... A RN will triage all patients arriving to the Emergency Department to identify life-threatening conditions and prioritize patients according to acuity ... The following steps should occur ... Determine chief complaint; vital signs are not required during the initial triage unless the information is necessary to determine acuity ... ESI ED resources are as follows ... below are considered individual resources ... Labs ... ...ABGs [arterial blood gases, measure ] ... Respiratory treatments ... EKG ... x-rays ... CT/MRI/Ultrasound/Angiography [imaging services] ... IV Fluids ...IV IM [intermuscular, injection in the muscle] ... Specialty consultations ... Simple Procedures ... Level I Presentation ... Unresponsive ... Apneic [not breathing] ... Pulseless ... Level II Presentation ... When Level II condition is identified, the triage process stops, the patient is taken directly to a room and immediate physician intervention is requested ... High risk situations ... New onset confusion ... Severe pain/distress ... Level III presentation ... Patients requiring two or more resources with vital signs not in danger zone ... Level IV Presentation ...Patients requiring 1 resource only ... Level V Presentation ... Patients requiring no resources ...".

During a review of a professional reference titled, "Pain Levels (PL)" (undated), "PL" indicated, " ... The pain scale actually has standard explanations which divides pain into three categories ranging from mild for lower numbers, moderate to cover the middle numbers, and severe for numbers above seven ... Severe Pain is that which is disabling, preventing you performing normal activities during the day or night. At level 7, pain stops you sleeping. Either you can't get to sleep at all or it will wake you during the night, and keeping up with social relationships is very difficult. When it intensifies to level 8, pain makes even holding a conversation extremely difficult and your physical activity is severely impaired ..."