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Based on observation, interview, review of crash cart checklists, and policy review, the provider failed to ensure medications were securely stored in two (nursery and medical/surgical) of five crash carts. Findings include:

1. Observation and interview on 9/27/22 at 9:30 a.m. with registered nurse (RN) F in the nursery room revealed:
*Two separate locked doors were used to get into and out of that room.
-One of those doors had been propped open and led to an attached room where infant supplies like car seats were kept.
--The door into and out of that supply room was not locked and led to a hallway providing access to the nursery.
*There were no patients in the nursery at that time.
*The emergency medications inside the nursery crash cart (epinephrine, nalaxone, and sodium bicarbonate) were not secured in any manner to prevent unauthorized access to them.
*RN F agreed access to that nursery should have been secure at all times and confirmed the crash cart should have had a numbered seal in place to identify unauthorized access to the cart drawers.

2. Observation and interview on 9/27/22 at 10:30 a.m. with logistics technician G revealed:
*She entered a numbered combination to unlock room 254.
-Clean linen, medical supplies, and the medical/surgical crash cart were kept there.
*It was her responsibility to stock medical supplies in that room.
*She was not authorized to access the contents of the crash cart.

Continued observation of the medical/surgical crash cart in room 254 revealed:
*The plastic, numbered seal secured on the vertical metal strip that pressed against the cart drawers to keep them securely closed had been applied loosely.
-All of the cart drawers opened fully when pulled allowing unauthorized access to the emergency medications (diphenhydramine, lidocaine, epinephrine, amiodarone, atropine, naloxone, and sodium bicarbonate) that were kept inside.

Review at that same time of the Med/Surge (medical/surgical) Crash Cart Checklist binder on top of that crash cart revealed:
*A detailed list of tasks reviewed and checked off daily to ensure the safety and functionality of the crash cart in the event of a medical emergency.
-Tasks included ensuring the presence of a locked seal on that cart, locked cart drawers, and seal number documentation.
*Seal number 14584204 was first identified as being associated with that cart on 9/10/22.
-Between 9/10/22 and 9/26/22 checklist documentation indicated the tasks on the checklist referred to above had been met.

Interview on 9/27/22 at 11:00 a.m. with RN F in room 254 revealed:
*It was the responsibility of the floor nurse or charge nurse to inspect the cart each day for safety and security.
*She confirmed the "tag was not tightened enough" on the crash cart and allowed unauthorized access to the medications stored inside of it.

Observation on 9/27/22 at 11:10 a.m. of room 254 revealed laundry worker H entered a numbered combination to unlock that unoccupied room.

Interview on 9/28/22 at 10:30 a.m. and on 9/29/22 at 10:00 a.m. with director of nursing B regarding crash cart security revealed:
*She had thought no medications were kept in the nursery cart so it had not been routinely monitored for security.
-Staff had been expected to use the obstetrics crash cart in labor and delivery.
*Access to the nursery should have been restricted regardless of whether or not it had been occupied or not.
*The charge nurse or designee was expected to complete the Med/Surg Crash Cart Checklist on a daily basis to ensure the presence of a secure seal that prevented unauthorized access to medications inside that cart.
*She had not known the medical/surgical cart seal was improperly applied allowing the drawers to be fully opened and medications accessible to anyone.
-Logistics technician G and laundry worker H were not authorized to be unsupervised in that area.

Review of the revised 6/19/22 Security and Storage of Medications policy revealed:
*Medications in patient care areas will be safely handled, securely stored and will not be accessible to the public or unauthorized staff.
*"If unauthorized staff (housekeeping, maintenance, etc.) needs to be in an area where medications are present they will be under direct supervision of a staff member who has authorized access."

Based on observation, interview, record review, safety checklist review, and policy review, the provider failed to:
*Ensure three of three sampled patients (10, 11, and 13) at nutritional risk had been assessed.
*Identify interventions to improve safety in one of one monitoring room designated for use by patients at risk for self-harm and suicide.
Findings include:

1. Review of patient 10's electronic medical record (EMR) revealed:*She had been admitted on 9/22/22 with diagnoses that included: urinary tract infection, parotitis, acute (infection of saliva glands), chronic obstructive pulmonary disease, and failure to thrive.
*She had complained of nausea at times.
*Her weight was self-reported as 145 pounds.
*She had not been weighed since her hospital admission.
*A nutrition flowsheet completed on her hospital admission by the nursing staff revealed a score of three.
-The nutrition flowsheet reviewed the patients recent nutritional status per interview with the patient.
-If the score was two or higher the dietitian was to have been notified.
*There was no dietitian assessment completed until 9/28/22 after her admission to the swing bed program on 9/27/22.

Review of patient 10's 9/28/22 at 1:58 p.m. adult nutrition assessment completed by registered dietitian I revealed:
*She had a decline in her appetite.
*She needed dual-handle lidded cups to be independent with fluid intake.
*Was assisted with eating due to her "hands don't work like they should."
*Recommendations were to provide nutritional supplements 8 ounces twice daily until her appetite improved. Magic cup (a nutritional supplement) twice daily as an afternoon and bedtime snack.

Review of the provider's February 2022 Patient Nutrition Assessment and Screening policy revealed:
*"To assess and maximize nutrition care for the patient with poor nutrition status, or who is at nutrition risk as identified by a nutrition screening."
*"To establish a procedure for prioritizing all hospitalized patients according to nutritional needs or degree of nutritional risk."
*"To provide clinical dietetic services to patients who are in need of these services."
*"To identify patients who develop nutritional problems during extended hospitalization."
*"Nursing will screen patients within 24 hours of admission and record information in the EMR Navigator. Referral is made to the registered dietitian, licensed nutritionist via the System List and printed referral for any 'Yes' answer in the Nutrition Section."
*"A Registered Dietitian (RD) will assess the patient within 3 days as available after referral for inpatient and within 5 days as available after admit of Swing Bed patients."
-"If the RD determines there is no need for full assessment, a brief note may be made in the Clinical Team Notes."
*Nursing should consider diagnoses and any medical problems when completing the nutrition evaluations.


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2. Review of patient 13's EMR revealed:
*Patient 13 had been:
-Admitted for unresponsiveness, weakness and a urinary tract infection (UTI)
-Her diagnoses included hypertension, obesity, and diabetes.
*Her nursing nutitional evalutation had determined:
-She had lost weight without trying.
-She had been eating poorly due to a decreased appetite.
--She had scored a three on her malnutrition screening.

3. Review of patient 11's EMR revealed:
*She had a note from her provider which stated:
-"She did have vomiting 2 days ago but really hasn't been eating since then. She reports her abdomen is more distended and has not had a BM [bowel movement] except a very small one 2 days ago. She does have metastatic colon cancer and is doing chemo [chemotherapy].]
*Her nursing nutritional evaluation had determined she had been eating poorly because of a decreased appetite.

Interview on 9/29/22 at 10:00 a.m. with executive director A and director of nursing (DON) B revealed they:
*Expected nursing to refer patients to the dietitian to complete a comprehensive assessment.
*Stated patient 13 should have had a referral placed for the dietitian to complete her assessment.
*Agreed patient 11 would have benefited from an dietitian assessment due to her nausea, vomiting, and current cancer diagnosis.


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4. Observation on 9/27/22 at 2:00 p.m. revealed:
*A doorway from the nurses' station into a separate room with medical supplies, linen storage, handwashing sink, and a computer on wheels.
*On the east wall of that room was a door that led into a patient room.
-A blind hung on the inside of that room above the window on the door.
-With the blind pulled up, its cord hung down several feet.
*On that same wall was an approximately six-foot by three-foot window between those rooms.
-A vertical blind hung on the inside of that room above that window.
-With the blind pulled up, its cord hung down several feet.
*Beneath the window were unsecured cabinets with bedding, hospital gowns that had ties at the neckline and long-sleeved robes.
*Inside the shower stall of the private bathroom was a call light cord several feet in length.
*The bathroom door was locked from the inside only and there was no keyhole or other way to unlock that door from the outside.

Interview on 9/27/22 at 2:05 p.m. with DON B regarding the use of the room referred to above revealed:
*It was formerly an intensive care patient room and was now used for patients at risk for self-harm and suicide or patients in need of close staff monitoring.
*The door of that room was kept open when occupied by a patient at risk for self-harm and suicide.
-Staff provided one-on-one monitoring sitting just inside the door entry.
*Staff either kept the bathroom door open for observation or stayed inside the bathroom with the door closed when it was used by a patient.
*That room was used on a regular basis with patients at risk for self-harm and suicide.

Interview on 9/27/22 at 2:35 p.m. with registered nurse (RN) F regarding patients at risk for self-harm and suicide revealed:
*She had been trained on the care of patients at risk for self-harm and suicide by shadowing a nurse caring for that type of patient and through provider-based on-line training.
*Prior to being transferred from the emergency department to the monitoring room, the charge nurse, admitting nurse, or other designated nurse completed, signed, and dated a Safety Checklist for patients at risk for self-harm and suicide.
-It included individual lists for the following:
--General precautions to ensure staff and patient safety.
--Removable room hazards that were not required or needed to be kept out of reach of the patient.
--Items unable to be removed from the room that were required for care.
--Items in the room where potential contraband may be stored.
--Dietary/food service hazards.
-Staff responsibilities for patient monitoring.
*Checkmarks were placed beside those interventions pertinent to each individual patient.
*It was a working tool expected to be discussed between nurses at shift change and updated as needed based on the patient's needs.

Interview on 9/28/22 at 4:45 p.m. with RN F regarding the care of patients at risk for self-harm and suicide revealed she:
*Knew those patients were expected to wear a hospital gown in that monitoring room.
-Had not considered the potential of the hospital gowns with ties around the neckline or the long sleeved robes stored inside the patient room to be used by a patient to cause self-harm.
*Had not considered the pull cords on the door and window blinds could have been used by a patient to cause self-harm.
*Either yelled for help, used a walkie talkie, activated a "panic button", or pressed an emergency call button at the head of the patient's bed to summons emergency assistance if needed.
-Agreed there may not always be staff close enough to hear her yell.
-A second staff person carrying a walkie talkie may not be immediately available to assist.
-The "panic button" was located outside of the monitoring room and around the corner from the nurses' station and alerted the local police department.
*Had not known the bathroom door locked from the inside of the bathroom and was unable to be unlocked from outside of the bathroom.
-Agreed the call light cord in the shower could have been used by a patient in that instance to cause self-harm.

Continued interview at that same time and review of a copy of the Safety Checklist referred to above with RN F revealed:
*General Precautions:
-"Staff members to have a panic/duress device [personal alarm system] on them."
*She had not ever seen or heard of such devices.
*That checklist had identified the following cords be considered for removal if they had not been required or to keep them out of the patient's reach: "suction tubing, IV [intravenous] tubing, power cords, O2 [oxygen] tubing, blood pressure cuff, call lights, phone, etc."
-It had not listed the door and window blind cords.
*That checklist had identified "extra linen" be considered for removal if it was not required or to keep it out of the patient's reach.
-It had not specifically defined what linen was appropriate for use with a patient at risk for self-harm.
-She had gotten needed linen from storage cabinets immediately outside of and in front of the patient window and was unsure why it was also stored inside that room.
*The checklist had not indicated the bathroom door locked from the inside of the bathroom and was unable to be unlocked from outside of the bathroom.

Interview on 9/28/22 at 5:30 p.m. with DON B revealed:
*Panic/duress devices had been used for about two years and were available at the nurses' station.
-She was uncertain why RN F would not have known about them.
*She was unaware the bathroom door of the monitoring room locked from the inside and was unable to be unlocked from the outside.
-Agreed there was potential for a negative outcome for a patient at risk for self-harm and suicide who had locked themselves inside that bathroom.
*Linens and blinds inside that monitoring room created an unnecessary hazard to patients at risk for self-harm and suicide.

Review of the revised 12/16/21 Suicide policy revealed:
*"Purpose: To increase patient safety through identification and intervention for patients at risk for self-harm and suicide."
*Inpatient services suicide precautions at a minimum included:
-"Completion of the environmental risk assessment using the Safety Checklist."
-"All objects that pose a risk for self-harm that can be removed without adversely affecting the ability to deliver medical care will be removed.
-Patient will be placed into designated hospital attire as applicable."

Based on interview, record review, and policy review, the provider failed to ensure five of five sampled patients' (10, 11, 12, 19, and 20) care plans had been comprehensive to ensure consistent care was provided. Findings Include:

1. Review of patient 11, 12, and 19's care plans revealed:
*Patient 11 had been marked as a fall risk, but fall risk had not been added to her care plan.
*Patient 12 had a heel ulcer and had been receiving daily dressing changes.
-Skin integrity had not been added to his care plan.
*Patient 19 received hemodialysis and there was no mention of a fluid restriction or dialysis on her care plan.

Interview on 9/28/22 at 3:00 p.m. with director of nursing B revealed she would have expected:
*Patient 11 to have fall risk or a fall related intervention on her care plan.
*Patient 12 to have skin integrity placed on his care plan.
*Patient 19 to have an intervention for monitoring fluid on her care plan.

Interview on 9/29/22 at 10:00 a.m. with director of nursing B and executive director A revealed:
*The items with patients 11, 12, and 19 should have been addressed on the nursing care plans.
*They do not always put dialysis on a patient's care plans but could understand how it would be beneficial.
*They would expect staff to have placed a fluid monitoring intervention on patient 19's care plan.
*They agree the issues patients were being treated for should be interventions on their care plans.
*She agreed that interdisciplinary team (IDT) discharge planning had not been initiated upon admission.
*She stated that discharge planning should be documented frequently and after the completion of care conferences.
*Typically, the nursing care coordinator or social worker would enter care notes into the patient's electronic medical record (EMR)regarding discharge planning.
*She agreed that no notes from the nursing care coordinator or the social worker had been found in the patient's EMR.


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2. Record review of patient 20's EMR regarding discharge planning revealed:
*He had been admitted to the skilled swing bed program from 3/22/22 through 4/8/22.
*His admission questions completed upon admission noted his discharge plan was to return home.
*He did not have any other documentation regarding his discharge planning other than his discharge instructions given upon discharge.


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3. Review of patient 10's EMR revealed:*She had been admitted on 9/22/22.
*Her admission status had changed from inpatient to having been admitted to the swing bed program on 9/27/22.
*She had diagnoses that included: urinary tract infection, parotitis (infection of the saliva glands), chronic obstructive pulmonary disease, and failure to thrive.

Review of patient 10's:
*9/22/22 admission care plan included: ineffective health management, impaired gas exchange, and impaired physical ability.
*9/27/22 swing bed care plan included: physical comfort, impaired gas exchange, and impaired physical mobility.
*Her urinary tract infection, parotitis, and failure to thrive had not been included in those care plans.

Review of the provider's September 2020 Plan of Care policy revealed:
*"Synonymous with "care plan." A plan of care may refer to various types of entries, or the culmination of numerous entries into the medical record such as but not limited to:"
-"Formal Care Plan Activity."
-"Longitudinal Plan of Care."
-"Plan documented with a note."
-"Treatment Plan."
-"Interdisciplinary Plan of Care/Interdisciplinary Treatment Plan"
-"After Visit Summary Plan of Care."
*"Also known as a nursing care plan. A subcategory of a patient's plan of care. A plan is developed by assessing the patient's nursing care needs and treatment goals. The plan develops appropriate nursing interventions in response to the identified nursing care needs. In most instances, the nursing plan of care will be developed utilizing the Care Plan Activity."

Based on observation, interview, and record review, the provider failed to ensure:
*One of one emergency department (ED) trauma room had been thoroughly disinfected by one of one housekeeper (E) after a trauma patient had been treated in the room.
*The patient care supplies and linens had been stored in four of four patient room pod cupboards and cabinets that had uncleanable surfaces and dust on the shelves.
*Laboratory (lab) technician J had not potentially contaminated clean supplies by reaching into clean supplies with soiled gloves.
Findings include:

1. Observation and interview on 9/27/22 at 10:24 a.m. with registered nurse (RN) I revealed:
*Their trauma room had received a motor-vehicle accident (MVA) patient about three hours prior.
*The patient had been involved in an MVA and had been found on the side of a dirt road.
*They were waiting on their flight team to arrive to transfer the patient to another hospital.

Observation and interview on 9/27/22 at 10:32 with housekeeper E revealed she:
*Was going to begin cleaning the trauma room since the MVA patient had been transferred out.
*Removed the bed sheet from the trauma bed and there was what appeared to be black electrical tape covering a hole in the bed.
*Cleaned the inside of the trauma room hand-washing sink with her rag that had "Nurtra-Quat" on it.
*Then continued to use the same rag and the same soiled gloves to clean the following items.
-The sharps container.
-The pediatric crash cart, cleaning around opened supplies.
--Saline, tape, and gauze.
-The intravenous (IV) pole.
-Suction Tubing, touching an opened Yankauer suction attachment with the soiled gloves and soiled rag.
-The back cabinets, not cleaning the handles.
-The blood pressure cuff and vitals tower.
-The adult crash cart, cleaning around used tape and supplies.
-The computer, cleaning around a needle package on the keyboard.
-The trauma room bed, and cart.
*Wiped around used supplies but had not thrown them away or cleaned underneath them.

Further observation and interview on 9/27/22 at 10:40 a.m. with housekeeper E revealed:
*Surveyor pointed out an area on the bed, about the size of a dollar bill that appeared to be blood
-Housekeeper E agreed it was blood after she wiped the blood with her white rag.
*Surveyor then continued to point out two other bloody spots on the trauma bed which had what appeared to be blood.
-Housekeeper E agreed she had missed the three areas of blood until the surveyor had pointed them out to her.
*The only personal protective equipment (PPE) she wore to clean up the blood was a surgical mask and gloves.

Interview on 9/28/22 at 3:00 p.m. with maintenance director D revealed he:
*Had overseen housekeeping staff.
*Agreed the process housekeeper E used to disinfect a trauma room was not the cleaning process that staff should be following.
*Was unsure of the process without looking at the sheet.
*Had been unware there was a hole in the trauma bed that had been covered by a piece of tape.
-Surveyor had asked for a copy of this sheet, and he was going to look and see if he could find their process.
--By the end of survey he had been unable to find a sheet documenting their process.

Interview on 9/29/22 at 9:56 a.m. with infection preventionist K revealed:
*After trauma cases, everything should be disinfected.
*Staff were expected to wear appropriate PPE.

2. Observation and interview on 9/27/22 at 2:35 p.m. of lab technician J revealed she:
*Was going into an emergency department (ED) room to obtain labs on a newly assessed patient.
*A venipuncture (lab draw) was initiated and then she reached outside of the door to her clean cart with her soiled gloves.
-Using the soiled gloves, she reached in the clean lab supplies to grab certain lab tubes that she needed.
*Agreed she used the same soiled gloves to obtain clean supplies.
*Agreed this was not the practice that was to be completed by lab technicians.

Interview on 9/29/22 at 9:56 a.m. with infection preventionist K revealed:
*Staff are expected to change gloves, and perform hand hygiene after touching a soiled surface.
*Lab staff were not to be touching clean supplies with soiled gloves.
*Staff were expected to wear appropriate PPE.

Review of the provider's March 2022 Cleaning Blood and Body Fluid Spill policy revealed:
*"To prevent the spread of infections from blood and body fluids. This procedure is used for cleaning blood spills as well as other potentially infectious material (OPIM) such as cerebrospinal, synovial, pericardial, peritoneal and amniotic fluids, semen, vaginal secretions, or any body fluid contaminated with blood..."
*"For Hard Surfaces:"
-"1. Don [put on] PPE."
-"2. Contain the spill."
-"3. Wipe up body fluid using a dry cloth or paper towels and dispose of cloth/towels in red biohazard garbage bag. Use a wet cloth to remove all visible soil/organic material."
-"Disinfect the area using an EPA [environmental protection agency] registered disinfectant solution or wipe. Leave the area undisturbed to dry for the contact time stated on the label. Dispose of cloth/towels/wipes and PPE in a red biohazard bag. Perform hand hygiene."

Review of the provider's March 2022 Venipuncture Collection policy revealed:
*"To provide a procedure for the proper technique for venipuncture collections of samples for laboratory testing..."
*"...Careful attention to the recommended collection protocols is extremely important."
*Supplies were supposed to be assembled at the patient's bedside.

Interview on 9/29/22 at 10:00 a.m. with executive director A and director of nursing B revealed they:
*Expected staff to thoroughly disinfect trauma rooms.
*Expected staff to wear PPE when disinfecting areas, especially when cleaning up the blood.
*Agreed staff should remove any used supplies.
*Agreed unused supplies taken out of the cabinet should be discarded to ensure there was no risk for cross-contamination.
*Agreed a written process would be beneficial for staff to be aware of the steps to take to thoroughly disinfect rooms after trauma cases.


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3. Observation on 9/27/22 from 10:00 a.m. through 12:30 p.m. and again on 9/28/22 at 1:00 p.m. of the four patient pods:
*In the pod by rooms 239, 240, 241, and 242 revealed there were dead moths and spiders on the floor and the desk area.
-The floor had a white substance on the floor in front of room 242.
-Rooms 239 and 242 were used for the storage of patient care equipment. There were dead bugs on the floor and spider webs were noted.
-The patient care supply cabinets shelves had missing laminate edges, which made them uncleanable.
-The patient linen supply cupboards had areas of missing paint which revealed bare wood. This made those areas uncleanable. There was also a light layer of dust along the front edges of the cupboard frame.
*In the rest of the pods by rooms 235, 236, 237, 238, 247, 248, 249, 250, 251, 252, and 254 the patient care supply cabinet shelves and linen supply cabinets had uncleanable surfaces identified above.
*During the observations of the patient rooms missing areas of laminate along the edges of the patient room bathroom sinks was noted.

Review of the provider's undated cleaning check list guides revealed:
*The patient side weekly checklist revealed areas and items to be cleaned daily included:
-Pods-dust mop, trash, clean computer stations daily.
-Rooms-empty trash, clean sink and toilet, refill sharps, and mop floor.

Review of the provider's 12/03/21 Infection Prevention, Nursing - Chamberlain policy revealed the:
*Purpose included:
-"To define Infection Prevention and Control Standards for cleaning, storage and handling of equipment and supplies and maintenance of a sanitary environment."
-"To identify department-specific techniques for Infection Prevention and Control."
*Policy included:
-"There will be established cleaning protocols for the general department environment and equipment, and for safe storage and handling of equipment and supplies."
*Cleaning and disinfecting procedures included:
-"Daily and terminal cleaning of patient-related areas will be done by Environmental Services."
-"Environmental Services will thoroughly clean walls, lights, and floors per their routine."


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4. Observation on 9/27/22 at 11:30 a.m. of the nursery revealed the cabinets had missing laminate on the edges making the surfaces uncleanable.

5. Observation on 9/27/22 at 2:35 p.m. of the facilities front entrance vestibule and the window sills in the lobby revealed:
*Spider webs and dead bugs in the corners of the widows.
*Dead bugs on the floor in the entry vestibule and in the hallway of the hospital.

Interview on 9/28/22 at 8:15 a.m. with housekeeper E regarding cleaning on the first floor revealed she:
*Had been working on the second floor in the patient care areas.
*Stated they are short-staffed and only cleaned the bathrooms on the first floor.

Interview on 9/28/22 at 2:10 p.m. with maintenance director D regarding the cleanliness of the facility revealed he:
*Stated that maintenance had been helping with cleaning, but had not helped out for a while.
*Agreed there were was a lot of dead bugs and spider webs in the window sills near the front entrance.
*Had been aware of the missing laminate on the cabinets in the nursery and had ordered some to cover the areas.
*Agreed that cabinets had some uncleanable surfaces due to missing laminate.
*Agreed the pod cabinets had uncleanable surfaces and had a layer of dust around the frame edges.
*Was not aware of the amount of dead bugs and spider webs in rooms 239 and 242 and the pod outside of those rooms.