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I. Based on review of the facility policy, random review of medical records from August 2022, and confirmed in interview, the facility failed to follow it's policy to support three of twenty patient's rights (Patient #R, #X, #BB) with regard to his/her informed decision for treatment.

Findings included:

1. Review of the facility policy Consent for Admission and Treatment (PolicyStat ID 12200258) state "Verbal consents: the following steps are taken if a patient admits to our facility voluntarily but is having difficulties signing the consents: the receptionist will speak with the voluntary patient regarding signing consents and have the patient attempt to sign. If the patient is having difficulty signing due to fatigue, tremors, visibility, they may then express their wishes to give verbal consent. The receptionist will call in a witness to hear the verbal consent given by the patient. The receptionist will then go over each consent and get the patient's verbal consent. The receptionist will write on the consents that the patient gave verbal consent and they, along with the witness will both sign on each form as witnesses to the consent."

2. Random review of medical records of inpatients from August 2022 revealed the following three of twenty patients whose 'verbal consent' did not include a witness.

Patient # R
Review of the medical record for Patient #R revealed she provided 'verbal consent' on 8/3/2022. Review of the consent forms revealed no signature of a witness to the consent per the facility policy.

Patient #X
Review of the medical record for Patient #X revealed he provided 'verbal consent' on 8/10/2022. Review of the consent forms revealed no signature of a witness to the consent per the facility policy.

Patient #BB
Review of the medical record for Patient #BB revealed he provided 'verbal consent' on 8/10/2022. Review of the consent forms revealed no signature of a witness to the consent per the facility policy.

3. An interview with the Corporate Chief Clinical Officer (Employee #14) on 8/12/2022 at 1330 hours in the conference room confirmed the above findings.

II. Based on review of the Health and Safety Code, facility policy, patient records from September 2021, July and August 2022, and confirmed in interview, the facility failed to support three of twenty patient's rights (Patient #D, Patient #AA, Patient M, and Patient #CC) in the informed decisions of treatment of his/her care. Patient #D was held without a voluntary consent or an EDO for 2 days. Patient #AA is a current inpatient and is held without voluntary consent or an Order of Protective Custody (OPC) for 10 days. Patient #M was held without voluntary consent or OPC for 11 days. Patient # CC was held without voluntary consent or an OPC for six days.

Findings included:

1. Review of the facility policy Consent for Admission and Treatment (PolicyStat ID 12200258) state "when a patient admits to the hospital without a power of attorney guardian and the psychiatrist declares they are incapacitated and unable to make decision regarding health care, the designated hospital staff will contact first the spouse (if applicable), parent adult child, then adult sibling to establish an in-hospital Health Care Representative. This Health Care Representative is only able to be utilized as long as the patient is not refusing care. Once a patient refuses care the psychiatrist will either discharge if the patient does not meet inpatient psychiatric criteria or the involuntary admission process (Emergency Detainment Order) will be utilized."

2. Random review of the inpatient medical records from August 2022 revealed the following one of twenty patients who 'refused' consent at admission and did not have an EDO until 48 hours after her admission.

Patient #D
Review of medical records for Patient#D was admitted to the facility on 8/3/2022. Review of the pre-admission Patient Screening dated 8/3/2022 revealed an intake status of 'voluntary' which included a psychiatric evaluation diagnosis of "unspecified dementia with behavioral disturbances, unspecified psychosis." Review of the Psychiatric Evaluation on 8/4/2022 stated "she does not know that she's is in the hospital. She cannot tell day, date, month or the name of the current president." Review of her records revealed a medical power of attorney given to her son dated 02/2019. Review of medical records for Patient#D revealed she 'refused' treatment and admission on 8/3/2022. No documentation was available for review to indicate her son, who was given power of attorney, was contacted regarding the patient's admission per the facility policy.

Further review of Patient #D revealed no application for an EDO was submitted until 8/8/2022, 48 hours AFTER admission (excluding weekend). Patient #D was held without a voluntary consent or an EDO for 2 days.

3. Review of the HEALTH AND SAFETY CODE, TITLE 7. MENTAL HEALTH AND INTELLECTUAL, DISABILITY, SUBTITLE C. TEXAS MENTAL HEALTH CODE, CHAPTER 573. EMERGENCY DETENTIONSec. 573.021. PRELIMINARY EXAMINATION. (a) A facility shall temporarily accept a person for whom an application for detention is filed or for whom a peace officer or emergency medical services personnel of an emergency medical services provider transporting the person...A person accepted for a preliminary examination may be detained in custody for not longer than 48 hours after the time the person is presented to the facility unless a written order for protective custody is obtained."

4. Random review of the inpatient records from September 2021 and July to August 2022 revealed the following two patients (Patient #AA and Patient CC) who were held without a voluntary consent and/or order of protective custody.

Patient #AA
Review of patient chart #AA revealed there was an application for temporary Mental Health Services that was submitted on 7/28/2022 by another facility (LBJ) and was granted an EDO on 7/28/2022. Review of the Order of Protective Custody and notice of Hearing (No. 323131) revealed a Probable Cause hearing was set for 8/1/2022 and that a Hearing upon the application for Court-ordered Mental Health Services was set for 8/5/2022.

Review of the Protective Custody Transfer order revealed LBJ transferred the patient to this facility on 7/29/2022. Patient was admitted to the facility on 7/29/2022. Patient #AA remained an inpatient for 10 days after the EDO lapsed.


Patient #M
Review of Patient #M medical record revealed an Order of Protective Custody and Notice of Hearings (Case Number MH-5236) was filed on 8/1/2022. It stated that the Patient #M is presently confied in HCA Mainland Medical Center in Texas City, TX. It further states that 'the proposed patient (Patient #M) is hereby ordered to submit to said [medical] examination and that if the proposed patient is transferred to another inpatient mental health facility, then the physicians at that facility are appointed to examine the proposed patient." Review of the discharge records from HCA Mainland Medical Center confirmed that Patient #M was discharged to 'inpatient psych facility' with diagonses of 'suicidal ideation anemia transfusion alcohol intox.' No documentation was available for review for the transfer of the OPC to this facility.

Review of patient chart #M revealed he provided 'verbal' consent on 8/2/2022, despite meeting the criteria requiring court ordered temporary mental health services as deemed by his previous physician.

Patient #CC
Review of patient chart #CC revealed she consented voluntarily to treatment and admission on her admission date of 9/13/2021.
Review of the psychiatry progress note on 9/20/2021 revealed a chief complaint noted of "demanding to be discharged" by the nurse practitioner (personnel Roster #37). Review of the patient chart #CC revealed an Application for Emergency Detention was submitted on 9/22/2021. It was authorized by the presiding judge by Harris County the same day on 9/22/2021.

Review of the patient chart #CC revealed no documentation of the Order of Protective custody (OPC) after the EDO was warranted on 9/22/2021. She remained as an inpatient until 9/30/2021, when she voluntarily consented for treatment and care. She was then discharged on 10/1/2021.

An interview with the court liaison (personnel Roster #38) on 8/12/2022 at 1335 hours in the conference room confirmed the above findings. She verified that no OPC was submitted for the above patient.

5. An interview with the court liaison (personnel Roster #38) on 8/12/2022 at 1340 hours in the conference room confirmed the above findings.

Based on record review, observation, and interview the facility failed to provide adequate Nursing services that promoted patient rights, facility policy/procedure for infection control, nursing assessments and reassessment, documentation, medication administration, documentation, and oversight of non-licensed personnel.

Refer to A0392, A0396, A0405, A0454, A0467, A0750 for evidence of specific findings.

The cumulative effect of these deficient practices resulted in the facility's inability to meet the Condition of Participation for Nursing Services.

Based on record review, observation, and interview the facility failed to ensure that patients were receiving all care required by having an insufficient amount of RNs on to deliver care, complete dressing changes, patient assessments, supervision of unlicensed staff, medication administration, and infection control issues.

Record review of the policy titled, "Staffing Precaution Plan", dated 8/22 showed the following:

Patient Precaution - levels of intensity of the patients on the unit. The precaution level aligns nursing resources and professional practice standards as part of the patient's treatment plan taking into consideration the complexity of care needs requiring the skill and care of a licensed nurse.

Variance - an event or circumstance inconsistent with the standard routine operations of the hospital and / or staff or patients. A staffing variance is a deviation from the total number of skill hours required to the number of hours actually used. Procedure:
1. The hospital will take reasonable steps to ensure that there are sufficient numbers of qualified and competent staff members available to meet the precaution level and needs of the patients.
2. Scheduled core staffing for a predetermined average daily census shall establish a minimum number of nursing staff to ensure nursing care needs of each patient.
a. There will be a minimum of one registered nurse in hospital at all times if the
hospital has one patient.
b. Under no circumstances shall there be less than one registered nurse in the hospital, if the hospital has more than one patient.
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Record review of staffing 08/10/22 revealed 19 patients on unit 400 with 1 RN and 1 LVN, and 2 Certified Nursing Assistants (CNA), 2 other CNAs were on 1:1s.

Record review of staffing on 08/10/22 revealed 20 patients on unit 100 with 1 RN and 1 LVN, and 3 Certified Nursing Assistants (CNA). The Registered nurse on unit 1 was also assigned new admissions.

Record review of staffing on 08/10/22 revealed 5 patients on unit 200 this unit is assigned the Covid Patients with 1 RN and 1 LVN, and 2 Certified Nursing Assistants (CNA) that were assigned to 1:1s . Both nurses the LVN and the RN were assigned to codes, leaving no nurse to supervise or care for the other high acutiy patients with Covid.

Record review of patient Patient #P dated on 08/11/22 (unknown time) written by unknown person, total fluids 16 ounces, no meals documented on the patient's intake and output located on the 15-minute round sheet only 1 snack 100% was documented. Breakfast, lunch and dinner were left blank.

Interview with Employee #2 on 08/10/22 at 1400 revealed that administration is aware there are problems with documentation of assessments and medications. She said she just started six weeks ago and is the process of trying to capture all the problems that need addressing.

Interview with Employee #14 on 08/11/22 at 15:00 revealed that Employee #14 recently re-educated staff on documentation.

Interview with Employee ##17 on 08/12/22 at 0820 am revealed that she has done multiple employee educations on how and where to document food and fluid intake.

Interview with Employee #14 on 8/12/22 at 13:30 revealed the following statement:
"ideally we would have 1 one RN to eight patients.

I. Based on observation, record review, and interview the facility failed to have a nursing care plan that reflects the patient's goals and needs for 1 of 1 patient (#K) with healing fractures on unit one.

Patient #K was admitted 8/8/22 from a hospital where she first arrived in critical condition. Diagnoses include depression, suicidal ideation with jump from a 15-foot bridge, 8/3/22, causing a pelvic fracture, splenic laceration, right sacral fracture, and soft tissue injuries including a muscle tear. She was unable to ambulate and used a wheelchair for mobility.

Nursing Admission Assessment dated 8/8/22 at 0100 indicated patient #K arrived via wheelchair (WC). It documented cause of admission as "pt. attempted suicide by jumping off a 15 ft Bridge."
Skin assessment portion indicated multiple bruises and "surgical wound" on right buttocks. No measurement or description was documented. Musculo-Skeletal portion was check marked "No Abnormal Findings." Fall risk was assessed as "High."

Nursing Narrative note 8/8/22 at 1500 read if patient medication and meal compliant. No suicidal or homicidal ideations observed or reporting. No behaviors during shift; End of note

Nursing Narrative note 8/8/22 timed as 0430 (but documented below the 1500 note and not marked as a late entry) read patient is calm complaint and cooperative, experiencing significant pain from injury/pelvic fracture. Patient is tolerating Tramodol < (sic) [Tramadol], ibuprofen, Tylenol around the clock per doctor's orders. Patient reports her appetite is there in she sleeps well. Has no problems with fluid intake or elimination. We will continue to monitor and follow up PRN.

Daily nursing assessment sheet dated 8/8/22 at 2240 has skins section left blank.

Nursing Narrative note 8/9/22 1500 read No behaviors. Med & meal compliant. No suicidal or homicidal ideations (SI/HI) observed or reported.
Nursing Narrative note 8/9/22 2320 read Patient observed in room. No behaviors. No acute distress. Patient asked to move rooms due to aggressive patient currently housed with patient. Patient moved to another room. Patient denies SI/HI Patient monitored by staff to ensure safety.

There was no nursing assessment of the patient wounds/injuries. No measurements, descriptions or detail as to areas.
There was no treatment nursing assessment of the patient's need for assistance with mobility, or Activities of Daily Living (ADLs) - dressing, grooming, bathing, toileting, eating.

Interdisciplinary Treatment Plan dated 8/8/22 listed three problems: Depression, SI and Pain. The plan for pain
Short term goals:
1. Verbalize expectations of pain relief. Have no nonverbal indicators of pain.
2. Report pain management satisfactorily releases pain.
Provider Interventions:
Assess daily the need for increased or decreased precaution level.
Nursing Interventions:
1. On admission assess patient's current use of medications
2. Document Every shift - Pain assessment, interventions for pain and reassessment of any intervention.
3. Vital Signs (no frequency indicated)
4. Provide patient with a quiet environment when experiencing pain
5. Provide alternative treatments to pain medications when possible (i.e. relaxation exercises, breathing exercises, music, distraction, guided imagery, warm or cold compress per order.
There was no correlation in the treatment plan(s) to injuries/wounds.
There was no treatment plan for the patient's injuries, wounds, lack of mobility, or need for assistance with Activities of Daily Living (ADLs) - dressing, grooming, bathing, toileting, eating.

When Interviewed 8/11/22 at 1520 Employee #14 Corporate Chief Clinical Officer stated he thought the facility care plans were adequate.


II. Based on record review and Interview the facility failed to keep nursing care plans that reflect the patients current condition, with goals and nursing care to be provided to meet the patients needs in 1 of 3 patient with wounds.

Texas Board of Nursing RN Scope of practice. Rule 217.11. Standard of Nursing Practice.
Assessment: "The comprehensive assessment is the first step and lays the foundation for the nursing process. The comprehensive assessment is the initial and ongoing, extensive collection, analysis and interpretation of data. Nursing judgment is based on the assessment findings. The RN uses clinical reasoning and knowledge, evidence- based outcomes, and research as the basis for decision-making and comprehensive care. Based upon the comprehensive assessment the RN determines the physical and mental health status, needs, and preferences of culturally, ethnically, and socially diverse patients and their families using evidence-based health data and a synthesis of knowledge. Surveillance is an essential step in the comprehensive assessment process. The RN must anticipate and recognize changes in patient conditions and determines when reassessments are needed."
Evaluation and Re-assessment:
"A critical and fourth step in the nursing process is evaluation. The RN evaluates and reports patient outcomes and responses to therapeutic interventions in comparison to benchmarks from evidence-based practice and research findings and plans any follow-up care and referrals to appropriate resources that may be needed. The evaluation phase is one of the times when the RN reassesses patient conditions and determines if interventions were effective and if any modifications to the plan of care are necessary."

Record review of Patient Letter BB revealed that patient was admitted with a stage 2 decubi. An MD order by Employee #33 dated 08/11/22. Cleanse Stage Two ulcer to right buttock every other day and as necessary with normal saline or wound cleanser. skin prep to peri wound cover with thin hydroalloid until healed.

Nursing Care plan dated 08/10/22 reflects Depression, Hypertension, High cholesterol, and fall risk. Documentation on the Nursing Care Plan did not reflect altered skin integrity.

Interview with Employee #2 on 08/10/22 at 1400 revealed that administration is aware there are problems with documentation of assessments and medications. She said she just started six weeks ago and is the process of trying to capture all the problems that need addressing.

Interview with Employee #14 on 08/11/22 at 15:00 revealed that Employee #14 recently re-educated staff on documentation.

Based on Record Review and Interview the facility failed to ensure the proper administration and documentation of medications on there Medication Administered Record, leaving the chart incomplete.

Findings:

22 Texas administrative Code 217.1(A)(B)(C)(i)(ii)(iii)(iv)(v)(vi)

(1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall:

(A) Know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice;
(B) Implement measures to promote a safe environment for clients and others;
(C) Know the rationale for and the effects of medications and treatments and shall correctly administer the same;
(D) Accurately and completely report and document:
(i) the client's status including signs and symptoms;
(ii) nursing care rendered;
(iii) physician, dentist or podiatrist orders;
(iv) administration of medications and treatments;
(v) client response(s); and
(vi) contacts with other health care team members concerning significant events regarding client's status;
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Record review of education for Nurses named, " Medication Administration Record", dated 01/25/22, revealed the following information:

Medication Errors:

Any medication administration errors, or adverse reactions will be reported to the physician and an incident report shall be completed along with any information pertinent to the error.

All medications will be administered within one hour (before or after) of administration time or physician will be notified with reason medication not administered and an incident report will be completed if needed.
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Record review of current incident report for August 2022 did not reflect any medication errors.
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Record review of Patient letter P, medication administration record (MAR) dated 08/07/22 revealed that Buspar 5 Milligrams (mg) twice a day (BID) at 0900 was not given to patient as prescribed by Employee #33 on admission. No documentation in the nursing note indicated MD was made aware that the prescribed medication was not given and why.

Record review of Patient Letter P, medication administration record (MAR) dated 08/06/22 for Synthroid 25 micrograms (mcg) every day written by Employee #33. At 0600 on 08/10/22 Synthroid 0.25 mcg (left blank) was indicated as not given. No documentation in the nursing note indicated MD was made aware that the prescribed medication was not given and why.

Based on reivew of facility policies, record review, and Interview the facility failed to ensure that assessments and reassessments were performed by an RN and documented in patients charts for two of twenty patient records reviewed (Patient #C and Patient #P).

Findings:

Record review of the policy titled, "Assessment and Reassessment", dated 8/2022, showed the following:

Nursing staff completes the admission nursing database upon admission. All other nursing documentation will be placed in the medical record within 12 hours.
Upon admission each patient's physical, psychological and social status are assessed by nursing. The primary care needs for each patient are determined by initial assessment as documented on the Nursing Care Record. The scope and intensity of further assessment performed is dependent upon the patient's diagnosis, care setting, desire for care, and response to any previous care.

Further assessments consider such factors as functional, nutritional, psychosocial, and environmental/safety needs,. The information generated through the analysis of assessment data is integrated to identify and prioritize the patient's needs for care. Assessment is ongoing as appropriate throughout the hospital stay and continues through discharge from the facility.
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Record review of education for Nurses named, " Daily Medical Nursing Assessment", dated 01/25/22, revealed the following information:

The first item for each assessment is the value that is "Within Normal Limits" (WLN)
If WNL is selected, you will move to the next assessment.
lf the finding is anything except WNL you should document further about the finding either within the daily nursing assessment or in the nursing narrative.
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Record review of the policy titled, "Vital Signs and Weight", dated 8/2022, showed the following:
To monitor patient's physical status.
All patients will have their vital signs, weight and height, taken on admission. Vital signs will be taken a minimum of once per shift, unless the provider orders a more frequent schedule.

Nurses will notify the provider of findings outside patient's normal range.
Record vital signs on Patient Observation Form.
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Record review of education for Nurses named, "Reporting Vital Signs", dated 01/25/22, revealed the following information:
· Any vital sign that has changed significantly from the previous measurement
· When vital signs are ABOVE or BELOW the normal range

Temperature- 97.8 degrees Fahrenheit to 99.1 degrees Fahrenheit
Blood Pressure- 90/60 mmHg to 120/80 mmHg
Heart Rate- 60 beats per minute(BPM) to 100 BPM
Respirations- 12-18 respirations per minute

"VITAL SIGNS MUST BE MEASURED AND RECORDED ACCURATELY
IF YOU ARE NOT SURE OF A MEASUREMENT, RECHECK IT
NURSES ALL VS NOT WLN MUST BE ACTED ON! !!!"
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Medical record review of Patient Letter C, Nursing Admission revealed the patient was admitted 08/09/22 Date of Birth: 04/05/1950, on O2 2L nasal canula (NC) (oxygen dependent) with a history of Chronic Obstructive Pulmonary Disease (COPD) and Asthma the following information for a daily assessment ,Oxygen, and pulse rate were found:

Medical record review of patient Patient Letter C, on 08/09/22 at 7 am- 7 pm revealed patient with a pulse of 96 and an O2 saturation level of 98%. The proceeding heart rate on 7pm to 7 am was 99 with an oxygen saturation level of 91%, change in patient's condition. No further evaluation was completed on patient even with a downward trend of 7%. Per chart patient refused to have respiration rate taken. Documentation in the nursing note did not indicate if the MD was made aware that the patient's Oxygen Saturation level went down with a slightly elevated heart rate.

On 08/09/22 (7pm-7am), Patient Letter C, had a heart rate of 105, no pulse oxygen was taken. A patient reassessment and a repeat heart rate was not completed to assess for further cardiac problems. Documentation in the nursing note did not indicate if the MD was made aware that the patient's heart rate was elevated.

Record review of Patient letter C, dated 08/10/22 7 am to 7 pm, indicated Patient Letter C, had a heart rate of 100, no further assessments or heart rates for that day were taken to evaluate if patient's heart rate went down or up.
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Record review of Patient Letter P, born 06/15/1942 admitted on 08/08/22 (unknown time) written by Nursing Assistant (unknown Illegible) patient keeps having constant diarrhea, no RN re-assessment completed. Documentation in the nursing note did not indicate if the MD was made aware that the patient was having diarrhea.

Record review of Patient Letter P, born 06/15/1942 admitted on 08/08/22 (unknown time) written by Nursing Assistant (unknown Illegible) patient keeps having constant diarrhea, no RN re-assessment completed. Documentation in the nursing note did not indicate if the MD was made aware that the patient was having diarrhea., or that the registered nurse reviewed the documentation by the nursing assistant.

Record review of Patient Letter P, on 08/09/22 (unknown time) written by Employee #35, CNA, patient been (sic) throwing up and not eating or drinking. Heart Rate 101. No RN assessment for patient throwing up, no amount, color, or type of emesis noted. On 8/9/22 at 15:00 Employee #36, writes patient medication and meal compliant. On 8/09/22 at 22:40 RN (illegible) no acute distress noted. Documentation does not indicate if MD was notified of vomiting.

Interview with Employee #2 on 08/10/22 at 1400 revealed that she is aware there are problems with documentation of assessments and medications. She said she just started six weeks ago and is the process of trying to capture all the problems that need addressing.

Interview with Employee #14 on 08/11/22 at 15:00 revealed that Employee #14 recently re-educated staff on documentation.

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Based on observation and interview, the facility failed by to ensure that the hospital environment was maintained in a manner to ensure the well-being of patients.

During the initial tour on 8/10/22 at 1025 of Unit 1 with 2 surveyors and the CEO #1 numerous patients were observed huddled in blankets in the day room and their personal rooms. The unit felt cold upon entering. Most patients and all staff except 1 CNA wore long sleeves, sweaters, or both.
Patients five patients (#R, J, K, CC & DD) approached the surveyors during the tour and complained about the cold temperature. They stated it was always cold on the unit and their reports and complaints to staff and nursing were ignored.

CEO #1 was quired about the temperature and said he would call maintenance and check. Minutes later after speaking to someone on his cell he said the thermometer read it was 72 degrees on the unit.

At surveyor request, a revisit to Unit 1 08/10/22 at 1217 with CEO #1 and the Director of Plant Operations #10, was made to recheck the temperature. The unit still felt cold, and patients remained bundled in blankets and staff in long sleeves and sweaters. Employee was asked to recheck the temperature. He brought a surveyor to the nursing station on unit 2 to see a row of thermometers on a wall. He pointed to one and said this is Unit 1's. It read 78 degrees. Staff #10 was asked of that was correct and he stated he would check the air temperature himself. Surveyor was escorted back to Unit 1 CEO. Staff #10 returned with a handheld infrared laser thermometer. Air temperature in the dayroom was checked and registered 64 degrees at 1220, aimed at the floor it registered 67 degrees. Room 101 was checked, and it registered 65 degrees. Employee #10 then stated he would look at the system and adjust the temperature.

Unit 1 was revisited 08/11/22 at 1545. Patient #H complained to this surveyor "It's freezing in here." She was wearing long sleeves and a blanket. She also complained there was no hot water in her shower. Her shower was turned on and it run for several minutes. It got slightly warm, and she was invited to feel the water. She then stated "Well, when it's this old in here that still feels cold, and nobody wants to get naked to shower when it's freezing."
Observation of other patients on the unit reveled most covered with blankets in the dayroom.

Staff #1, CEO on 8/12/22 at 1045 Staff #1, CEO presented a review of Unit 1 incident film from 8/7/22 with this surveyor. The patients on the unit were wearing blankets and staff were in long sleeves and sweaters. When asked what people were wearing in the film, Staff #10 chuckled and replied, "They're wearing clothes." When asked what else he noticed he responded "They look cold."

Based on record review, observation, and interview the facility failed to ensure that infection control was maintained by having dirty equipment, expired supplies, and dirty bins with sterile supplies were not available for use in the patient care area:

Findings:

1) Record review of the policy titled, "Cleaning Central Supply", dated January 2020, showed the following:
The Environmental Services (ES) personnel will clean the Central Supply Department on a daily basis.
Empty all waste containers. The waste containers will be wiped out with a hospital approved germicidal solution and bag liners replaced. Emptied waste will be deposited in the appropriate container, red waste bags will be placed in biohazardous waste receptacles and clear bags will be placed in regular waste receptacles.
Damp dust counters, furniture, telephones, and receivers, etc., with a hospital approved germicidal solution. Do not clean equipment or workspaces unless instructed to do so.
Spot clean walls, doors and partitions as needed.
Clean mirrors, glass doors and partitions with glass cleaner.
Dust mop floor.
Mop floors using a hospital approved germicidal solution according to procedure. Place wet floor signs prior to mopping.

At 10:30 am on 08/10/22 a tour was started with Employee #3, in the clean/sterile storage Room. Multiple items found that should not be in the clean supply room due to infection control issue.

o Dirty Medicine Ball from physical therapy being stored in clean utility room with clean and sterile supplies.
o A Gomco machine (Serial #H41737) with used tubing and yankaur.
o A chuck was sitting on the 3rd that appeared to be used and have old blood on it.
o Two utility ladders made by Louisville were used with obvious paint and other debris.
o There was a toilet plunger the was wet and in a bag on the floor.
o Dirty used individual use pair of crutches.
o A shop Vacuum with obvious dirt and debris. The handle of the shop vac was leaning against the clean supply cart.
o 2 open foley catheter sets were open and in foley bin.
o 6 bins that hold sterile and clean supplies were soiled with debris and dust.
o Open Kangaroo Tube feeding bag in sterile package open and in left for patient use.

Interview with Employee #3 on 08/10/22 at 12:30 revealed that, no one is assigned to the Central Supply that she knows of. When stock comes in, we will assign a CNA to put it away. We do not have a policy of what can go into the central supply room.

Interview with Employee #14 on 08/11/12 at 15:30 revealed that the do not have a policy on expired supplies that describes where and when they should be disposed of. We do not have a List of what can and can not be in the Central Supply.


2) At 11:15 am on 08/10/22 while going out of unit 300 on our tour with Employee #3, in hallway on unit not in use. A 12 lead EKG machine (McKesson AM-12) with heavily soiled leads. The leads also had blackened tape residue on them.

Interview with Employee #3 on 8/10/22 at 11:35 am revealed, she concurred with the fact that machine was dirty and had tape residue on leads and top of machine. She indicated that the EKG operator sometimes tape down the leads to get a better reading.