HospitalInspections.org

Based on interview and record review, the Governing Body failed to ensure the Chief Executive Officer (CEO) was responsible for management of the entire hospital, including accountability for the effective oversite of staff to comply with the requirements under 42 CFR 482.23 Condition of Participation (CoP): Nursing Services, 42 CFR 482.13 CoP: Patient's Rights and 42 CFR 482.42 CoP: Infection Prevention and Control and Antibiotic Stewardship.

The hospital failed to:
- Ensure the Chief Executive Officer (CEO) was responsible for management of the entire hospital. (A-0057)
- Ensure the Nursing Vice President (VP) was responsible for nursing staff who provided patient care. (A-0395)
- Ensure designated continuous telemetry (remote observation of a person's heart rhythm, using signals that are transmitted from the patient to a computer screen) monitoring observation for all telemetry monitored patients;
- Ensure staff followed the suicide (to cause one's own death) risk assessment policy for one current patient (#28) of one suicidal patient record reviewed; and
- Prevent the elopement (when a patient makes an intentional, unauthorized departure from a medical facility), follow their policy for post elopement management and provide house-wide staff education for one Emergency Department (ED) suicidal patient (#47) of three ED left without treatment record reviews. (A-0144)
- Verify medication administration when insulin (medication that regulates the amount of sugar in the blood) was administered by scanning a bar coded label in a locked drawer outside of the patient's room for one current patient (#22) of one insulin medication observed. (A-0405)
- Follow their policy for restraint (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) orders for one discharged ED patient (#62) of two ED records reviewed. (A-0168)
- Follow their policy and complete a face-to-face (a qualified staff members evaluation of a patient in violent restraints [medical cuffs applied to both arms and both legs to prevent someone form causing harm to themselves or others]) assessment within one hour after violent restraints were placed on three discharged ED patients (#47, #62 and #63) of three discharged ED patients reviewed. (A-0178)
- Perform hand hygiene (washing hands with soap and water or alcohol-based hand sanitizer) when providing care for nine patients (#13, #15, #16, #19, #21, #22, #23, and #45) of nine patients observed;
- Ensure two staff (Staff K and Staff LL) of two staff observed followed the policy for nail care;
- Ensure three staff (Staff OO, PP, and EEE) of three staff observed wore eye protection during direct patient care in the operating room;
- Prepare a clean work surface prior to performing patient care for eight patients (#13, #15, #16, #19, #21, #22, #23, and #45) of eight patients observed;
- Cleanse a medication vial for two patients (#16 and #22) of two patients observed;
- Remove expired food on four patient care units and in the kitchen;
- Remove expired supplies on one unit;
- Clean workstation on wheels (WOW, a computer or supply and medication storage on a wheeled stand, that can be moved from patient to patient);
- Clean the surface of the crash cart (mobile cart which contains emergency medical supplies and medication); and
- Follow their Infection Prevention Plan to maintain a sanitary environment. (A-0749)
- Clean the anesthesia storage room;
- Clean the table in the decontamination room;
- Clean the kitchen floor in the dishwasher area;
- Clean the equipment in the kitchen area;
- Clean the microwave on one patient care unit; and
- Follow their Infection Prevention Plan to maintain a sanitary environment. (A-750)

These failures had the potential to adversely affect the quality of care and safety of all patients in the hospital.

Please refer to A-0057, A-0144, A-0168, A-0178, A-0395, A-0405, A-0749 and A-0750

Based on interview, policy review and record review, the Governing Body failed to ensure the Chief Executive Officer (CEO) was responsible for management of the entire hospital, including accountability for the effective oversite of staff to comply with the requirements under 42 CFR 482.23 Condition of Participation (CoP): Nursing Services, 42 CFR 482.13 CoP: Patient's Rights and 42 CFR 482.42 CoP: Infection Prevention and Control and Antibiotic Stewardship. These failures had the potential to affect the quality of care and safety of all patients.

Findings included:

Review of the hospital's document titled, "Organizational Chart," dated 01/2024, showed that all administrative leaders reported to Staff DDD, CEO.

During an interview on 08/29/24 at 9:49 AM, Staff DDD, CEO, stated that he had full oversight of the hospital.

Based on observation, interview, record review, policy review and video review, the hospital failed to:
- Ensure designated continuous telemetry (remote observation of a person's heart rhythm, using signals that are transmitted from the patient to a computer screen) monitoring observation for all telemetry monitored patients. (A-0144)
- Ensure staff followed the suicide (to cause one's own death) risk assessment policy for one current patient (#28) of one suicidal patient record reviewed. (A-0144)
- Prevent the elopement (when a patient makes an intentional, unauthorized departure from a medical facility), follow their policy for post elopement management and provide house-wide staff education for one ED suicidal patient (#47) of three ED left without treatment record reviews. (A-0144)
- Follow their policy for restraint (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) orders for one discharged Emergency Department (ED) patient (#62) of two ED records reviewed. (A-0168)
- Follow their policy and complete a face-to-face (a qualified staff members evaluation of a patient in violent restraints [medical cuffs applied to both arms and both legs to prevent someone form causing harm to themselves or others]) assessment within one hour after violent restraints were placed on three discharged Emergency Department (ED) patients (#47, #62 and #63) of three discharged ED patients reviewed. (A-0178)

These failures had the potential to adversely affect the quality of care and safety of all patients in the hospital.

The severity and cumulative effect of this practice had the potential to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ).

As of 08/27/24, the hospital provided an immediate action plan sufficient to remove IJ #one when the hospital implemented corrective actions that included educating all current and oncoming nursing staff on continuous telemetry monitoring. All remaining staff were education prior to the start of their next shift.

As of 08/28/24, the hospital provided an immediate action plan sufficient to remove IJ #three when the hospital staff implemented corrective actions that included educating all current and oncoming nursing staff on elopement and suicide precautions.


48359

Based on observation, interview, record review, policy review and video review, the hospital failed to:
- Ensure designated continuous telemetry (remote observation of a person's heart rhythm, using signals that are transmitted from the patient to a computer screen) monitoring observation for all telemetry monitored patients;
- Ensure staff followed the suicide (to cause one's own death) risk assessment policy for one current patient (#28) of one suicidal patient record reviewed; and
- Prevent the elopement (when a patient makes an intentional, unauthorized departure from a medical facility), follow their policy for post elopement management and provide house-wide staff education for one ED suicidal patient (#47) of three ED left without treatment record reviews.

Findings included:

1. Although requested, the hospital failed to provide a policy that directed staff to provide continuous observation of the telemetry monitor located at the nurse's station.

Observation on 08/26/24 at 4:15 PM, on the medical/surgical floor, showed seven patients (#12, #15, #16, #29, #30, #31 and #32) on the telemetry monitor with no staff present to observe the monitor.

Observation on 08/27/24 at 8:37 AM, on the medical/surgical floor, showed eight patients (#12, #15, #16, #21, #29, #30, #31, and #32) on the telemetry monitor with no staff present to observe the monitor.

Observation on 08/27/24 at 9:27 AM, on the telemetry floor, showed 16 patients (#17, #18, #19, #25, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43 and #44) on the telemetry monitor with no staff present to observe the monitor.

During an interview on 08/26/24 at 4:15 PM, Staff O, Registered Nurse (RN), stated that nurses at the desk were to watch the patients on the telemetry monitor.

During an interview on 08/27/24 at 9:27 AM, Staff P, Nurse Manager, stated that no one constantly watched the telemetry monitors.

During an interview on 08/27/24 at 2:03 PM, Staff V, Nursing Vice President (VP), stated that the telemetry monitors should be monitored at all times.

2. Review of the hospital's policy titled, "Close Observation/Suicide Assessment," reviewed 02/2024, directed staff to assess and document the patient's level of suicidality each shift.

Review of Patient #28's medical record, dated 06/22/24, showed:
- She was a 16-year-old female admitted to the Adolescent Behavior Health Unit (BHU) with Suicide Ideations (SI, thoughts of causing one's own death).
- Her initial suicide risk assessment screen showed she was a high risk for suicide.
- There was no time documented on the assessment.
- At 4:01 PM, a Columbia Suicide Severity Rating Scale (C-SSRS, scale to evaluate a person's risk to self-inflicted harm and desire to end one's life) showed she wished she was dead and had actual thoughts of killing herself.
-There were no additional suicide assessment screens completed.
- On 06/27/24 at 10:47 AM, she was discharged to home.

During an interview on 08/29/24 at 9:56 AM, Staff V, Nursing VP, stated that she expected staff to complete suicide risk assessment screens according to the policy.

During an interview on 08/26/24 at 3:35 PM, Staff E, BHU Director, stated that the C-SSRS was completed upon admission and every shift.

3. Review of the hospital's policy titled, "Close Observation/Suicide Assessment," reviewed 02/2024 showed:
- Close observation is the provision of a member of the hospital's staff to be in constant attendance and in close proximity to the patient, even during bathroom use. The staff member must have a clear and unobstructed view of the patient at all times.
- All patients assessed by the RN to be at risk for suicide or self-harm will have continuous one to one (1:1, continuous visual contact with close physical proximity) monitoring.
- Close monitoring is maintained until discontinued by the appropriate provider.
- A handoff of all pertinent information will occur, including information on stored personal belongings and level of risk.
- Patient clothing is to be removed and stored and patient placed in hospital attire.

Review of the hospital's Policy titled, "Post Elopement," reviewed 02/2024, showed:
- In the event of a patient elopement, the staff attempts to find the patient and notifies all concerned parties.
- Available staff looks throughout the unit as soon as the elopement is confirmed.
- The Charge Nurse or the patient's nurse immediately notifies security.
- The Charge Nurse or patient's nurse notifies the patient's family or responsible party as indicated on the Release of Information/Telephone Vising Consent form of the elopement unless the Physician chooses to talk with the family.
- The Charge Nurse or patient's nurse notifies the Program Director and Nurse Manager of the elopement within 30 minutes or as soon as possible.
- The Charge Nurse or patient's nurse accurately records the calls.
- The Charge Nurse or patient's nurse completes an Incident Report.
- A Root Cause Analysis (RCA, a tool to help study events where patient harm or undesired outcomes occurred in order to find the root cause) should be conducted.
- Document the time the absence was confirmed.
- List the individuals who were notified.
- Document efforts to locate the patient.
- Record the plan.
- If the patient does not return, document continuing effort to locate.

Review of the hospital's document titled, "Quality of Care Concern," dated 07/03/24, showed:
- The event was an ED elopement on a court ordered psychiatric (relating to mental illness) patient awaiting transfer to an inpatient facility.
- The problem statement was the patient was found not to be in room five. He was awaiting Department of Protective Services (DPS) transportation to Hospital B's psychiatric facility.
- There was a failure to maintain 1:1 observation.
- The sitter left her observation post for approximately two to three minutes and the patient was unsupervised.
- The patient was allowed to have his personal belongings by the sitter who thought the patient needed them for transfer.
- The Charge Nurse notified DPS but did not notify leadership of the elopement.
- The root cause was the ED Technician, who was assigned to the 1:1, left her observation post, leaving the patient unsupervised. The ED Technician who was assigned the 1:1 observation allowed the patient his personal belongings and a gap in observation allowed the patient time to elope.
- The corrective action plan was coaching completed with the ED Technician and Charge Nurse and department staff education on the proper process for 1:1 observation.

Review of the hospital's document titled, "Current Summary," dated 07/03/24, showed:
- Staff CCC, SW, reported that SW was notified via an electronic message (e-mail) from a Public Safety Officer that officers presented to transport Patient #47 to Hospital B at 8:45 PM and were notified Patient #47 "walked off premises".
- SW obtained a court order earlier in the day for Patient #47's SI and self-mutilating behavior.
- There was no documentation in the medical record regarding the elopement.
- The ED Manager was not notified.
- SW was unaware of how long Patient #47 was outside of the hospital.
- The patient's mother was contacted by police to assist with the search for Patient #47.
- Hospital B was not notified of Patient #47's elopement.

Review of the hospital's document titled, "Department Updates," dated 07/03/24 and 07/24/24, showed staff education was isolated to ED RN's, Paramedics and ED Technicians.

Review of Patient #47's medical record dated 07/01/24 showed:
- He was a 31-year-old male who presented to the ED with self-inflicted cuts to his left hand and wrist and auditory hallucination (hearing things that are not heard by others, imaginary). He stated he was suicidal and wanted back on his psychiatric medications.
- His past medical history included schizophrenia (serious mental disorder that affects a person's ability to think, feel, and behave clearly), bipolar disorder (a mental disorder that causes unusual shifts in mood by alternating periods of emotional highs and lows), depression and anxiety.
- His symptoms were acute (sudden onset) and severe.
- His plan was admission to an inpatient BHU.
- A sitter was at his bedside. Security was required at times to redirect the patient to stay in his room.
- At 7:30 PM through 07/02/24 at 8:00 PM, Patient #47 was provided 1:1 observation. He eloped from the ED on 07/02/24 after 8:00 PM.
- At 7:42 PM, a C-SSRS placed him at a high risk for suicide. Suicide precautions (SP, precautions taken to ensure patients are safe and free of self-injury or self-harm) were ordered.
- On 07/02/24 at 1:07 AM, he was given Haldol (a medication used to treat mental disorders by decreasing excitement of the brain) intramuscularly (IM, in the muscle).
- At 1:15 AM, Patient #47 attempted to run through an open door at the entrance of the ED and was stopped by nurses. The police were notified. He was gently led back to his room and became upset that he was not able to see his girlfriend. The provider was notified.
- At 12:19 PM, a SW note showed a judge granted a court order which was faxed to hospital B.
- At 3:13 PM, a SW note showed transfer was accepted at Hospital B and was delayed until 6:30 PM.
- At 6:13 PM, DPS was contacted and planned to transport Patient #47 to Hospital B at 8:30 PM.
- At 9:30 PM, the Provider was notified, DPS presented to transport Patient #47. The patient was not in his room, it was assumed Patient #47 left the ED. DPS was searching for the patient. He had a saline lock (a thin flexible tube placed into a vein used for fluid or medication or nutrition administration) in place.
- On 07/03/24, Staff W, RN, entered a late nurse progress note that showed DPS was made aware Patient #47 eloped from the ED. Two addresses were given to the officers to assist with locating the patient. On 07/02/24 at 9:53 PM, DPS was notified Patient #47 had an intravenous (IV, in the vein) catheter in his left forearm. DPS reported no updates.
- On 07/04/24, Staff GGG, RN, entered a late nurse progress note that showed on 07/02/24 at 8:20 PM, she noticed the ED technicians were cleaning Patient #47's room, she assumed the patient was transported to Hospital B. The officers were initially scheduled to pick up the patient at approximately 8:30 PM. Later police officers arrived to pick up Patient #47. The police officers were informed the patient left one hour prior and were asked if different officers transported the patient. The nursing staff were notified that police officers did not transport Patient #47 to Hospital B. Staff W, RN, informed the officers of two addresses to assist with locating the patient. He was court ordered for an involuntary admission.
- There was no notification to Security, the Program Director or the Nurse Manager.
- There was no documentation of notification of the patient's family.
- The incident reports were not completed until the following day.
- There was no clear documentation of when the absence was confirmed.
- There was no documented plan or continued efforts to locate Patient #47.

During an interview on 08/29/24 at 9:56 AM, Staff V, Nursing VP, stated that she expected staff to follow all hospital policies. She expected notification to leadership, including the Administrator On-Call (AOC), DPS, to ensure "diligence" in the patient search and security, to search the entire hospital inside and out. She expected the operator to make an overhead announcement. The ED Director was to call the Chief of Police. This was a serious event; the patient had a court order for an involuntary admission. Officers went to his address and later he was found at his "girlfriends house."

During an interview on 08/29/24 at 9:49 AM, Staff DDD, President, stated that he expected staff to follow all hospital polices. He expected leadership to be notified of an elopement.

During an interview on 08/27/24 at 10:30 PM, Staff A, ED Director, stated that Patient #47 had a 96-hour hold (court-ordered evaluation by behavioral specialists to determine if a person is safe to themselves and others) and was waiting for DPS to transport him to Hospital B. Staff ZZ, ED Technician, placed Patient #47's clothing in his room, she believed he needed them for transfer. Staff ZZ went to the back hallway for an unknown reason. Staff A believed it was to make a personal phone call. Staff ZZ's behavior did not meet his expectations. Staff GGG, RN, who was Patient #47's primary nurse, transferred a patient out of the ED, upon her return she discovered Patient #47 was not in his room. Staff GGG informed Staff W, Charge Nurse, and Staff W believed Patient #47 was with DPS. Later, Staff ZZ returned to the patient's room and discovered he was gone, and she informed Staff FFF, Phlebotomist, his previous sitter. Staff A's expectations for an elopement were DPS, the House Manager and the AOC were notified. The notifications were not done. The following morning, he obtained a statement from Staff ZZ and provided coaching. She verbalized an understanding of the patient's belongings and blue scrub process to identify suicidal patients. He provided coaching to Staff WW regarding the communication escalation expectations for an elopement. The management of Patient #47's elopement did not meet his expectations. He sent two emails to the ED staff on 07/03/24 and 07/24/24 and provided education at the August ED staff meeting to discuss SI/homicidal ideation (HI, thoughts or attempts to cause another's death) and sitter precaution expectations. The time on the video footage was "off, because of daylights saving time."

During an interview on 08/27/24 at 2:07 PM, Staff Z, SW Director, stated that she was notified of the elopement by Staff CCC, SW, who was contacted by DPS via an email the morning after the patient eloped. Staff A, ED Director, was not aware of the patient's elopement. He believed the patient was at Hospital B. She contacted Risk Management and the AOC. She was involved in the RCA. The hospital planned to provide education related to the miscommunication between the sitters, personal belongings for SI patients and 1:1 sitter expectation. Staff A provided the staff education.

During an interview on 08/27/24 at 2:32 PM, Staff CCC, SW, stated that she met Patient #47 in the ED and completed the 96-hour hold application. He was expected to transfer to Hospital B. The next morning, she received an email from DPS stating that Patient #47 was not at Hospital B. He was not at the ED when DPS arrived for transport. She reviewed the medical record and informed Staff Z, SW Director, of the event because "nothing made sense." She was "nauseated and very upset," he eloped from the ED with a 96-hour hold court order in place. He was located approximately 24-hours later at his father's home after he eloped. He was taken to Hospital B. No leadership staff were aware the patient eloped prior to the email she received from DPS. Patient #47 was a risk of harm to himself. She completed an incident report. She could not remember if she was questioned during the RCA or if any house-wide education was provided. The hospital's psychiatric protocols were "not strong." Staff ZZ was not given report. Staff A, ED Director, stated that he was not aware of the elopement.

During an interview on 08/28/24 at 9:14 AM, Staff FFF, Phlebotomist (a health worker trained in drawing venous blood for testing or donation), stated that he provided 1:1 observation for Patient #47 for most of the day. Patient #47 was irritated. Staff FFF was called away for a blood draw and asked Staff ZZ, ED Technician, to watch Patient #47. He told Staff ZZ Patient #47 was expecting transport, was a suicide risk and "really wanted to leave." Staff ZZ sat down outside of room eight. Staff ZZ placed Patient #47's clothing in his room, she did not want him to leave them behind. He returned 15 to 20 minutes later, the patient was gone, and Staff ZZ was "freaking out." Staff W, Charge Nurse, was notified and believed Patient #47 was picked up by DPS, he started to clean the room. Staff A, ED Director, called him the following day. The ED staff were aware of the elopement approximately an hour after Patient #47 left the ED. When providing 1:1 observation, continuous line of sight was expected as well as documentation of every 15-minute observations.

During a telephone interview on 08/27/24 at 1:30 PM, Staff ZZ, ED Technician, stated that she did not have any interaction with Patient #47 she expected him to be transferred five minutes after she was asked to sit with him. Staff FFF, Phlebotomist, was asked to draw labs on another patient, he asked her to watch Patient #47. She set his belongings inside his door and "walked around the corner." She spoke with Staff A, ED Director, regarding protocols, SI belongings, every 15-minute observations and not leaving her post when assigned 1:1 observation. She was not aware Patient #47 was on SP, she did not receive report from Staff FFF. One-to-one observation required her to sit in a patient's room, within walking distance and maintain the patient in her line of sight.


48359

Based on interview, record review and policy review, the hospital failed to follow their policy for restraint (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) orders for one discharged Emergency Department (ED) patient (#62) of two ED records reviewed.

Review of the hospital's policy titled, "Restraints," revised 05/2024 showed:
- A restraint is the use of a manual method, physical or mechanical device, medication, material or equipment attached or adjacent to the patient's body that he/she cannot easily remove, that restricts freedom of movement or normal access to one's body.
- Drugs used as restraints are medication used in addition to or in replacement of the patient's regular medication regimen to control extreme behavior or restrict patient movement in an emergency and is not part of standard treatment for the patient's medical or psychiatric condition.
- Initiation of restraints requires the order of a provider.

Review of Patient #62's medical record dated 06/28/23, showed:
- At 10:12 PM, he was an 18-year-old male who presented to the ED with agitated or violent behavior and altered mental status (any change in a person's mood, behavior, psychomotor skills, and/or cognition).
- The patient was brought to the ED by Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) escorted by a police officer due to the EMS request for assistance in transporting the patient.
- At 11:46 PM, he left his room and would not come back, he disturbed other patients and was redirected to his room.
- On 06/29/24 at 12:10 AM, he refused "the shot," became very distressed, grabbed a chair, jumped on the bed and threatened staff. The Police Department (PD) were called, he ripped his shirt and wrapped it around his fist. He threatened to harm staff if they entered his room. He was physically restrained, Zyprexa (medication used to treat mental disorders), Haldol (a medication used to treat mental disorders by decreasing excitement of the brain), Diphenhydramine (medication used to treat itching, insomnia, allergic reactions and decrease excitement in the brain) and Ativan (a medication used to treat anxiety or sleep difficulty) were given intramuscularly (IM, in the muscle).
- At 12:55 AM, the restraints were removed, and he was able to move all extremities.
- No order was written for restraints.
- At 2:09 AM, the juvenile officer left without telling anyone.
- He was discharged to an inpatient Behavioral Health Unit.

During a telephone interview on 09/03/24 at 8:33 AM, Staff CC, ED Manager, stated that he expected an order was written for all restraints. He was unable to determine if the patient was placed in handcuffs or violent restraints. No order was written for restraints for Patient #62.

During a telephone interview on 09/03/24 at 9:03 AM, Staff V, Nursing Vice President VP), stated that she expected orders to be written for violent restraints. The police were called for Patient #62 because he was violent. It was unclear if he was placed in violent restraints or handcuffs. He was not in the custody of the police.

During a telephone interview on 09/03/24 at 2:20 PM, Staff HHH, RN, stated that Patient #62 arrived with a police officer. The officer left the ED, and the patient became violent. The PD were called because he jumped on the bed, grabbed a chair and threatened to hurt the staff. He was not certain if the patient was placed in handcuffs or violent restraints. He could not recall if the police officer was present during the patient's entire restraint episode. The patient was also chemically restrained.

Based on interview, record review and policy review, the hospital failed to follow their policy and complete a face-to-face (a qualified staff members evaluation of a patient in violent restraints [medical cuffs applied to both arms and both legs to prevent someone form causing harm to themselves or others]) assessment within one hour after violent restraints were placed on three discharged Emergency Department (ED) patients (#47, #62 and #63) of three discharged ED patients reviewed.

Findings included:

Review of the hospital's policy titled, "Restraints," revised 05/2024 showed:
- When restraint or seclusion is used to manage violent or self-destructive behavior, a Provider, Registered Nurse (RN) or Physician Assistant (PA) must see the patient face-to-face within one hour after the initiation of the intervention.
- This requirement also applies when a drug or medication is used as a restraint to manage violent or self-destructive behavior.
- Drugs used as restraints are medication used in addition to or in replacement of the patient's regular medication regimen to control extreme behavior or restrict patient movement in an emergency and is not part of standard treatment for the patient's medical or psychiatric condition.
- When the one-hour face-to-face evaluation is conducted by a qualified RN or PA, they must consult the attending provider or other provider who is responsible for the patient's care as soon as possible after completing the one-hour evaluation. If a patient who is restrained for aggressiveness or violence quality recovers and restraints are removed, a face¿to-face assessment must still occur.

1. Review of Patient #47's medical record, dated 07/01/24 showed:
- He was a 31-year-old male who presented to the ED with self-inflicted cuts to his left hand and wrist and auditory hallucination (hearing things that are not heard by others, imaginary). He stated he was suicidal (thoughts of causing one's own death) and wanted back on his psychiatric (relating to mental illness) medications.
- Security was required at times to redirect the patient to stay in his room.
- On 07/02/24 at 1:07 AM, he was given Haldol IM.
- At 1:15 AM, Patient #47 attempted to run through an open door at the entrance of the ED and was stopped by nurses. The police were notified. He was gently led back to his room and became upset that he was not able to see his girlfriend. The provider was notified.
- No face-to-face assessment was performed.

2. Review of Patient #62's medical record, dated 06/28/23, showed:
- At 10:12 PM, he was an 18-year-old male who presented to the ED with agitated or violent behavior and altered mental status (any change in a person's mood, behavior, psychomotor skills, and/or cognition).
- The patient was brought to the ED by Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.).
- On 06/29/24 at 12:10 AM, he refused "the shot," became very distressed, grabbed a chair, jumped on the bed and threatened staff. The Police Department (PD) were called, he ripped his shirt and wrapped it around his fist. He threatened to harm staff if they entered his room. He was physically restrained, Zyprexa (medication used to treat mental disorders), Haldol (a medication used to treat mental disorders by decreasing excitement of the brain), Diphenhydramine (medication used to treat itching, insomnia, allergic reactions and decrease excitement in the brain) and Ativan (a medication used to treat anxiety or sleep difficulty) were given intramuscularly (IM, in the muscle).
- At 12:55 AM, the restraints were removed, and he was able to move all extremities.
- No face-to-face assessment was performed.

During a telephone interview on 09/03/24 at 2:20 PM, Staff HHH, RN, stated that Patient #62 arrived with a police officer. The officer left the ED, and the patient became violent. The PD were called because he jumped on the bed, grabbed a chair and threatened to hurt the staff. He was not certain if the patient was placed in handcuffs or violent restraints. He could not recall if the police officer was present during the patient's entire restraint episode. The patient was also chemically restrained. He "hoped" he completed the face-to-face assessment.

3. Review of Patient #63's medical record, dated 06/13/23 showed:
- She was a 39-year-old female who presented to the ED via EMS.
- At 10:30 AM, she attempted to fight and bite staff, was verbally aggressive, and an order was written for, and she was placed in violent restraints.
- No face-to-face assessment was performed.

During a telephone interview on 09/03/24 at 9:03 AM, Staff V, Nursing Vice President (VP), stated that medication given for behavior management were chemical restraints and she expected a face-to-face assessment was completed. She expected a face-to-face assessment was completed for all violent restraints.

During an interview on 08/29/24 at 10:20 AM, Staff C, ED Manager, stated that he expected a face-to-face assessment for violent restraints. Providers were expected to complete the face-to-face assessment. The failed face-to-face assessments did not meet his expectations.

Based on interview, record review and policy review, the hospital failed to ensure that the Nursing Vice President (VP) provided adequate oversight and supervision of nursing personnel when the staff failed to verify medication administration when insulin (medication that regulates the amount of sugar in the blood) was administered by scanning a bar coded label in a locked drawer outside of the patient's room for one current patient (#22) of one insulin medication observed.

The severity and cumulative effect of this practice had the potential to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ).

As of 08/27/24, the hospital provided an immediate action plan sufficient to remove the IJ when the hospital implemented corrective actions that included educating all current and oncoming nursing staff on medication administration verification. All remaining staff were education prior to the start of their next shift.

Please refer to A-0405.

Based on interview, record review and policy review, the hospital failed to ensure that the Nursing Vice President (VP) provided adequate oversight and supervision of nursing personnel when the staff failed to verify medication administration when insulin (medication that regulates the amount of sugar in the blood) was administered by scanning a bar coded label in a locked drawer outside of the patient's room for one current patient (#22) of one insulin medication observed.
These failures had the potential to affect the quality of care and safety of all patients.

Findings included:

Review of the hospital's document titled, "Organizational Chart," dated 01/2024, showed that all nursing leaders reported to Staff V, Nursing VP.

During an interview on 08/29/24 at 9:56 AM, Staff V, Nursing VP, stated that she had full oversight of the nursing staff.

Based on observation, interview, record review and policy review, the hospital failed to verify medication administration when insulin (medication that regulates the amount of sugar in the blood) was administered by scanning a bar coded label in a locked drawer outside of the patient's room for one current patient (#22) of one insulin medication observed.

Findings included:

Review of the hospital's policy titled, "Medication Administration," reviewed 02/2024, showed:
- Medications are administered to diagnose, to prevent and assist in the cure of disease, and to heal the injured. Medications ordered by a physician may be administered by appropriately licensed Nurses, Certified Registered Nurse Anesthetists (CRNA, registered nurses who have obtained graduate-level education and board certification in anesthesia), Paramedics, Respiratory Therapists and Radiology Technicians.
- Take medicine to the patient's bedside with any needed supplies, including the barcode scanner.
- Verify the correct medication by scanning the medication package barcode.

Review of the hospital's policy titled, "Medication Storage," reviewed 02/2024, showed all medications are stored in accordance with established standards.

Observation on 07/27/24 at 11:10 AM, showed:
- Staff U, Registered Nurse (RN), removed insulin from the medication dispensing machine, withdrew the insulin into a syringe and returned the insulin vial to the medication dispensing machine.
- Staff U entered Patient #22's room, scanned her identification bracelet, returned to the computer outside of the room, opened a locked drawer next to the computer and scanned a barcode taped inside of the drawer to complete the medication administration documentation. He did not scan the barcode on the insulin vial.
- Five different types of insulin barcodes were taped inside the drawer next to the computer.

Review of Patient # 22's medical record, showed on 08/27/24 at 11:46 AM, Staff U, RN, administered two units of insulin.

Based on observation, interview and policy review, the hospital failed to:
- Perform hand hygiene (washing hands with soap and water or alcohol-based hand sanitizer) when providing care for nine patients (#13, #15, #16, #19, #21, #22, #23, #29 and #45) of nine patients observed;
- Ensure two staff (Staff K and Staff LL) of two staff observed followed the policy for nail care;
- Ensure three staff (Staff OO, PP, and EEE) of three staff observed wore eye protection during direct patient care in the operating room;
- Prepare a clean work surface prior to performing patient care for eight patients (#13, #15, #16, #19, #21, #22, #23, and #45) of eight patients observed;
- Cleanse a medication vial for two patients (#16 and #22) of two patients observed;
- Remove expired food on four patient care units and in the kitchen;
- Remove expired supplies on one unit;
- Clean workstation on wheels (WOW, a computer or supply and medication storage on a wheeled stand, that can be moved from patient to patient);
- Clean a medication scanner for one patient (#22) when entering and exiting the room of five patients observed;
- Clean a stethoscope for one patient (#22) after performing a physical assessment on one patient observed;
- Clean the surface of the crash cart (mobile cart which contains emergency medical supplies and medication);
- Clean the anesthesia storage room;
- Clean the table in the decontamination room;
- Clean the kitchen floor in the dishwasher area;
- Clean the equipment in the kitchen area;
- Clean the microwave on one patient care unit; and
- Follow their Infection Prevention Plan to maintain a sanitary environment.

Based on observation, interview and policy review, the hospital failed to:
- Perform hand hygiene (washing hands with soap and water or alcohol-based hand sanitizer) when providing care for nine patients (#13, #15, #16, #19, #21, #22, #23, #29, and #45) of nine patients observed;
- Ensure two staff (Staff K and Staff LL) of two staff observed followed the policy for nail care;
- Ensure three staff (Staff OO, PP, and EEE) of three staff observed wore eye protection during direct patient care in the operating room;
- Prepare a clean work surface prior to performing patient care for eight patients (#13, #15, #16, #19, #21, #22, #23, and #45) of eight patients observed;
- Cleanse a medication vial for two patients (#16 and #22) of two patients observed;
- Remove expired food on four patient care units and in the kitchen;
- Remove expired supplies on one unit;
- Clean workstation on wheels (WOW, a computer or supply and medication storage on a wheeled stand, that can be moved from patient to patient);
- Clean a medication scanner for one patient (#22) when entering and exiting the room of five patients observed;
- Clean a stethoscope for one patient (#22) after performing a physical assessment on one patient observed;
- Clean the surface of the crash cart (mobile cart which contains emergency medical supplies and medication); and
- Follow their Infection Prevention Plan to maintain a sanitary environment.

Findings included:

1. Review of the hospital's policy titled, "Hand Hygiene, Hand and Nail Care," dated 01/2024, showed staff were to perform hand hygiene before donning gloves and after removing gloves, before clean or aseptic procedures, before administering medication, after touching a patient, and after touching patient surroundings.

Observation on 08/27/24 at 9:00 AM, showed Staff N, Registered Nurse (RN), failed to perform hand hygiene prior to putting on his gloves while administering medication to Patient #13.

Observation on 08/27/24 at 11:10 AM, showed Staff U, RN, failed to perform hand hygiene between glove changes while he performed a point of care blood sugar test on Patient #13.

Observation on 08/27/24 at 8:42 AM, showed Staff O, RN, failed to perform hand hygiene between glove changes while administering medications to Patient #15.

Observation on 08/27/24 at 11:05 AM, showed Staff O, RN, failed to perform hand hygiene after removing her gloves when she performed a point of care blood sugar test on Patient #15.

Observation on 08/27/24 at 9:07 AM, showed Staff K, RN, failed to change her gloves after administering a subcutaneous medication and prior to administering a topical medication to Patient #16. She also failed to perform hand hygiene after removing her gloves.

Observation on 08/27/24 at 9:50 AM, showed Staff R, Licensed Practical Nurse (LPN), failed to perform hand hygiene prior to putting on her gloves and after removing her gloves while administering medication to Patient #19.

Observation on 08/27/24 at 9:50 AM, showed Staff S, RN, failed to perform hand hygiene after removing her gloves while administering medication to Patient #19.

Observation on 08/27/24 at 11:09 AM, showed Staff O, RN, failed to remove her soiled gloves prior to reaching into her pocket after she performed a point of care blood sugar test on Patient #21.

Observation on 08/27/24 at 11:15 AM, Showed Staff III, RN, failed to perform hand hygiene after removing her gloves while performing a physical assessment on Patient #22.

Observation on 08/27/24 at 11:05 AM, showed Staff X, RN, failed to perform hand hygiene between gloves changes during insertion of a midline catheter (a catheter that is inserted into a vein near the bend of the arm and advanced three to 12 inches into the upper arm) for Patient #23.

Observation on 08/27/24 at 1:50 PM, showed Staff O, RN, failed to perform hand hygiene prior to putting on her gloves and between glove changes. She also failed to remove her soiled gloves prior to reaching into her pocket after removing a catheter for Patient #29.

Observation on 08/27/24 at 2:05 PM, showed Staff Y, RN, failed to perform hand hygiene prior to medication administration for Patient #45.

During an interview on 08/29/24 at 1:40 PM, Staff S, Nursing Manager, stated that hand hygiene should be performed prior to putting on gloves, between glove changes, and after removing gloves.

During an interview on 08/29/24 at 10:18 AM, Staff RR, Infection Prevention, Safety and Emergency Preparedness Supervisor, stated that all staff should follow the policy for hand hygiene.

During an interview on 08/28/24 at 9:55 AM, Staff V, Nursing Vice President (VP), stated that staff should perform hand hygiene when entering and exiting a patient room, before and after medication administration, between glove changes, and when they touch anything that is unclean.

2. Review of the hospital's policy titled, "Hand Hygiene, Hand and Nail Care," dated 01/2024, showed all artificial nail enhancements, including but not limited to nail tips/extenders, artificial nails, nail jewelry or adornments, and wraps are prohibited for employees performing direct patient care.

Observation on 08/26/24 at 4:15 PM, showed Staff K, RN, had red dipped nails and was assigned to patient care.

Observation on 08/27/24 at 3:40 PM, showed Staff LL, RN, had pink dipped nails and was assigned to patient care.

During an interview on 08/26/24 at 4:18 PM, Staff G, Nurse Manager, stated that patient care staff were not supposed to have artificial nails.

During an interview on 08/29/24 at 10:18 PM, Staff RR, Infection Prevention, Safety and Emergency Preparedness Supervisor, stated that staff should follow the policy on nails and should not be worn when providing patient care.

During an interview on 08/29/24 at 9:55 AM, Staff V, Nursing VP, stated that she would not expect patient care staff to have artificial nails or any nail art.

3. Review of the hospital's policy titled, "Exposure Control Plan," dated 01/2024, directed staff to wear eyewear during surgical procedures.

Observation on 08/28/24 at 9:25 AM, in the operating room, showed Staff OO, Certified Registered Nurse Anesthetist (CRNA, registered nurses who have obtained graduate-level education and board certification in anesthesia); Staff PP, CRNA; and Staff EEE, CRNA Student, failed to have protective eyewear in place during the intubation (process where a healthcare provider inserts a tube through a person's mouth or nose down into their windpipe when a person is not breathing on their own) of surgical patients.

During an interview on 08/28/24 at 9:27 AM, Staff C, Surgical Services Director, stated that all staff should have eye protection while in the operating room.

During an interview on 08/28/24 at 9:30 AM, Staff RR, Infection Prevention, Safety and Emergency Preparedness Supervisor, stated that he expected all operating room staff to wear eye protection when in the operating room providing patient care.

During an interview on 08/29/24 at 9:55 AM, Staff V, Nursing VP, stated that she expected operating room staff to wear eye protection during intubation.

4. Although requested, the hospital failed to provide a policy that addressed preparing a clean work surface prior to performing patient care.

Observation on 08/27/24 at 9:00 AM, showed Staff N, RN, placed medications on Patient #13's bedside table prior to administering medications and failed clean the bedside table or place a barrier.

Observation on 08/27/24 at 8:42 AM, showed Staff O, RN, placed medications on Patient #15's bedside table prior to administering medication and failed to clean the bedside table or place a barrier.

Observation on 08/27/24 at 11:01 AM, showed Staff K, RN, placed supplies in Patient #16's bed prior to removing the intravenous (IV, in the vein) catheter and failed to place a barrier.

Observation on 08/27/24 at 9:50 AM, showed Staff R, LPN, placed Patient #19's medication on the bedside table prior to administration and failed to clean the bedside table or place a barrier.

Observation on 08/27/24 at 11:09 AM, showed Staff O, RN, placed supplies in Patient #21's bed before she performed a point of care blood sugar test and failed to place a barrier.

Observation on 08/27/24 at 11:10 AM, showed Staff U, RN, placed medications on Patient #22's bed prior to administering medications and failed to place a barrier.

Observation on 08/27/24 at 11:05 AM, showed Staff X, RN, failed to place a barrier or clean an area to place supplies prior to insertion of a midline catheter (a catheter that is inserted into a vein near the bend of the arm and advanced three to 12 inches into the upper arm) for Patient #23.

Observation on 08/27/24 at 2:05 PM, showed Staff Y, RN, failed to clean the bedside table or place a barrier prior to medication administration for Patient #45.

During an interview on 08/28/24 at 9:30 AM, Staff RR, Infection Prevention, Safety and Emergency Preparedness Supervisor, stated that he expected staff to have a clean work surface prior to placing any supplies that were to be used on a patient but there was no specific policy.

During an interview on 08/29/24 at 9:55 AM, Staff V, Nursing VP, stated that although there was no policy that specifically addressed using a barrier, she expected staff to have a clean work surface during patient care.

5. Although requested, the hospital failed to provide a policy that addressed cleaning of the medication vial prior to administration.

Observation on 08/27/24 at 9:07 AM, showed Staff K, RN, failed to clean the medication vial prior to removing the solution when administering medications to Patient #16.

Observation on 08/27/24 at 9:00 AM, showed Staff N, RN, failed to clean the medication vial prior to removing the solution when administering medications to Patient #13.

During an interview on 08/28/24 at 9:30 AM, Staff RR, Infection Prevention, Safety and Emergency Preparedness Supervisor, stated that he expected staff to clean the hub of the medication vial prior to medication administration.

During an interview on 08/29/24 at 9:55 AM, Staff V, Nursing VP, stated that she expected staff to clean the medication vial prior to medication administration.

6. Review of the hospital's policy titled, "Food and Supply Storage," dated 01/2024, showed foods past the use by date should be discarded. Open packages should be covered, labeled and dated.

Review of the hospital's policy titled, "Expired Items, Disposal of Assets/Property and Other Items," dated 02/2024, showed departments are to assure that no expired items or supplies are in use or available within their departments.

Observation on 08/26/24 at 3:00 PM, showed one sandwich with an expiration date of 08/25/24, and 12 packages of coffee creamer in a bag with a placed date of 06/06/24 and no expiration date on the bag or on the product in the Intensive Care Unit (ICU, a unit where critically ill patients are cared for) nutrition area.

Observation on 08/26/24 at 4:00 PM, showed a bowl of undated food in the refrigerator and 11 Chicken broth packets with an expiration date of 04/06/24 on unit Three F in the nutrition area.

Observation on 08/27/24 at 8:30 AM, showed one opened bottle of barbeque sauce in the cabinet with no open date and no expiration date and eight single use bags of coffee grounds without expiration dates in the Emergency Department (ED) nutrition room.

Observation on 08/27/24 at 8:50 AM, showed four single use pepper, five salt and seven ketchup packets without expiration dates in the Labor and Delivery Unit nutrition room.

During an interview on 08/29/24 at 1:40 PM, Staff P, Nursing Manager, stated that all patient food in the refrigerators should be labeled with a patient sticker and an expiration date, and there should be no expired supplies in the nutrition area.

During an interview on 08/29/24 at 9:55 AM, Staff V, Nursing VP, stated that dietary staff were responsible for the food items in the kitchen of patient care areas and no expired food items should be available for patients.

Observation on 08/28/24 at 10:25 AM, showed, in cooler four in the kitchen:
- Five packages of molded strawberries;
- Two bags of spinach with an expiration date of 08/25/24;
- Two opened bottles of barbeque sauce and one opened bottle of hot sauce with no open date and no expiration date; and
- Two opened packages of shredded cheese with no open date and no expiration date.

Observation on 08/28/24 at 10:45 AM, showed, in the dry storage area of the kitchen:
- One opened package of quinoa with no expiration date;
- One opened waffle mix with an expiration date of 03/19/24;
- One opened bag of rice with no expiration date;
- Two opened bags of pasta with no expiration date;
- One container of liquid smooth with an expiration date of 12/18/23;
- 47 packages of individual cookies with an expiration date of 06/15/24; and
- 19 packages of individual cereal bars with an expiration date of 06/24/24.

During an interview on 08/28/24 at 10:15 AM, Staff TT, Food Services Director, stated that expired food items were unacceptable and should not be available for staff or patients.

During an interview on 08/29/24 at 10:18 AM, Staff RR, Infection Prevention, Safety and Emergency Preparedness Supervisor, stated that expired food items should not be available for patients.

During an interview on 08/29/24 at 9:50 AM, Staff DDD, President, stated that dietary staff were responsible for the rotation of food and dating food items.

7. Review of the hospital's policy titled, "Expired Items, Disposal of Assets/Property and Other Items," dated 02/2024, showed departments are to assure that no expired items or supplies are in use or available within their departments.

Observation on 08/28/24 at 9:20 AM, in the Labor and Delivery Operating Room, showed:
- One expired bottle of open scrub soap with an open date of 03/12/23;
- Three nasopharyngeal (the upper part of the throat behind the nose) suction tubes with expiration dates of 08/05/24;
- One newborn endotracheal tube (a tube inserted through the mouth or nose, that extends into the lungs, to maintain an open passageway for oxygen) with an expiration date of 11/28/23;
- One newborn umbilical artery catheterization (a thin, flexible tube that is placed in a blood vessel located in the stump of a newborn's umbilical) kit with an expiration date of 07/2024;
- One bag of Intravenous (IV, in the vein) fluids with an expiration date of 06/2024;
- Two carbon dioxide (CO2, a gas produced by exhaling) detectors with expiration dates of 07/11/24;
- One newborn laryngeal blade (a device used to visualize the vocal cords to assist with intubation [a process where a healthcare provider inserts a tube through a person's mouth or nose down into their windpipe when a person is not breathing on their own) with an expiration date of 05/31/24; and
- One uterine hemorrhage balloon (a device to control uterine [hollow, pear-shaped organ in a woman's pelvis] hemorrhage [excessive bleeding]) with an expiration date of 07/29/24.

During an interview on 08/29/24 at 9:56 AM, Staff V, Nursing VP, stated that she expected expired supplies were removed from patient care areas. The expired umbilical artery catheterization tray was significant and would become a Quality Assurance and Performance Improvement Program (QAPI, process for reporting and/or identifying adverse events, near misses or review of high risk, problem prone areas for patient safety) item.

8. Although requested, the hospital failed to provide a policy related to the cleaning of the WOW.

Observation on 08/27/24 at 8:37 AM, on unit Three F, showed four WOWs with dirty keyboards, dusty and dirty bases, and dirty wheels.

Observation on 08/27/24 at 9:33 AM, on unit Two F, showed three WOWs with dirty keyboards, dusty and dirty bases, and dirty wheels.

Observation on 08/27/24 at 9:00 AM, showed Staff N, RN, failed to clean the WOW before entering and exiting Patient #13's room.

During an interview on 08/27/24 at 10:02 AM, Staff P, Nursing Manager, stated that the WOW was to be cleaned by nursing staff when they went in and out of patient rooms. He also stated that he was not sure who cleaned the wheels.

During an interview on 08/28/24 at 9:30 AM, Staff RR, Infection Prevention, Safety and Emergency Preparedness Supervisor, stated that he expected the WOWs to be cleaned by nursing staff before going into a patient's room and after coming out of a patient's room. He also stated that he expected the WOW to be free of dust and debris.

During an interview on 08/29/24 at 9:55 AM, Staff V, Nursing VP, stated that she expected nursing staff to keep the WOW clean.

9. Review of the hospital's policy titled, "Cleaning and Disinfectant Policy," reviewed 01/2024, showed the surfaces of non-critical patient-care equipment should be wiped with a cloth saturated, but not dripped, with a detergent-disinfectant.

Observation on 08/27/24 at 11:10 AM, showed Staff U, RN, failed to clean the medication scanner before entering and exiting Patient #22's room.

During an interview on 08/27/24 at 11:50 AM, Staff W, ICU Director, stated that she expected the medication scanners to be cleansed prior to entering and exiting a patient's room.

Observation on 08/27/24 at 11:15 AM, showed Staff III, RN, failed to clean her stethoscope prior to replacing it around her neck after performing a physical assessment on Patient #22.

During an interview on 08/27/24 at 11:50 AM, Staff W, ICU Director, stated that she expected a stethoscope to be cleansed after each patient use.

10. Review of the hospital's policy titled, "Cleaning and Disinfectant Policy," dated 01/2024, directed staff to remove visible dust and disinfect surfaces for patient care items regularly.

Observation on 08/28/24 at 9:45 AM, in the post anesthesia care unit, showed dust accumulation on the top of the crash cart.

During an interview on 08/8/24 at 9:45 AM, Staff C, Surgical Services Director, stated that there should be no dust accumulation on the crash cart and nursing was responsible for cleaning the crash cart.

During an interview on 08/28/24 at 9:47 AM, Staff RR, Infection Prevention, Safety and Emergency Preparedness Supervisor, stated that he would not expect to see dust accumulation on the top of the crash cart.

During an interview on 08/29/24 at 9:55 AM, Staff V, Nursing VP, stated that she expected nursing staff to keep the top of the crash cart clean.

11. Review of the hospital's document titled, "Infection Prevention Plan," dated 03/18/24, showed infection prevention is an integral part of all services and prevention of infection is a primary responsibility of all healthcare workers.

The hospital failed to follow their infection prevention plan which placed all patients at risk for infection.


48359

Based on observation, interview and policy review, the hospital failed to ensure infection control policies were followed when they failed to:
- Clean the anesthesia storage room;
- Clean the table in the decontamination room;
- Clean the kitchen floor in the dishwasher area;
- Clean the equipment in the kitchen area;
- Clean the microwave on one patient care unit; and
- Follow their Infection Prevention Plan to maintain a sanitary environment.

Findings included:

1. Review of the hospital's policy titled, "Cleaning and Disinfectant Policy," dated 01/2024, showed cleaning involves the removal of visible dust, soil and other foreign material. Responsible persons should be designated by the nurse manager for each nursing unit, or the Department Director of each patient care department.

Observation on 08/28/24 at 9:30 AM, showed an anesthesia supply storage room with dusty shelves, dusty bins and numerous bins with sticker residue, not allowing for a smooth surface for cleaning.

During an interview on 08/28/24 at 9:40 AM, Staff C, Surgical Services Director, stated that the shelves and bins should not be dusty, and the outside of the bins should be smooth and free of debris.

During an interview on 08/28/24 at 9:42 AM, Staff RR, Infection Prevention, Safety and Emergency Preparedness Supervisor, stated that there should not be dust in the bins or on the shelves and the bins should be cleanable and the labels smooth.

2. Although requested, the hospital failed to provide a policy that addressed when to clean the tables in the sterile processing department (SPD, area designated to clean, prepare, sterilize [process that eliminates viruses and bacteria], store and track reusable medical and surgical instruments or equipment).

Observation on 08/28/24 at 9:50 AM, showed a paper covered table in the decontamination area of SPD with frayed edges and tape present.

During an interview on 08/28/24 at 9:50 AM, Staff SS, SPD Supervisor, stated that the table cover was changed weekly.

During an interview on 08/28/24 at 9:50 AM, Staff C, Surgical Services Director, stated that she would not expect to see frayed edges or tape present on the table in SPD. She stated this would be difficult to clean.

3. Although requested, the hospital failed to provide a policy that addressed kitchen floor cleaning.

Observation on 08/28/24 at 10:10 AM, showed a long piece of red fraying sticky tape on the floor marking a boundary area for the dishwashing area.

During an interview on 08/28/24 at 10:10 AM, Staff TT, Food Services Director, stated that there should be a smooth surface on the floor and debris could get caught in the sticky area.

During an interview on 08/29/24 at 10:18 AM, Staff RR, Infection Prevention, Safety and Emergency Preparedness Supervisor, stated that the kitchen floor should be a smooth surface for thorough cleaning.

4. Review of the hospital's policy titled, "Cleaning of Food and Nonfood Contact Surfaces," dated 06/2024, showed:
- Food contact surfaces are in good condition and are easily cleanable;
- To prevent cross-contamination, kitchenware and food contact surfaces of equipment shall be washed, rinsed and sanitized after each use;
- The food contact surfaces of all cooking equipment shall be kept free of encrusted grease deposits and other accumulated soil; and
- Nonfood contact surfaces of equipment shall be cleaned as often as is necessary to keep the equipment free of accumulation of dust, dirt, food particles and other debris.

Observation on 08/28/24 at 10:35 AM, showed:
- Muffin tins with a build up of food debris and were located on the clean cart;
- Four bins that contained flour, sugar, corn meal and breadcrumbs with debris on the outside of the container;
- Two ovens with grease build up on the interior racks;
- Two drawers that contained cleaning gloves and sponges with debris present on the gloves, sponges and inside the drawer;
- A tilt skillet with debris build-up on the back ledge and liquid contained inside the bin of the skillet; and
- Dust on the ledge behind the fryers.

During an interview on 08/28/24 at 10:45 AM, Staff TT, Food Services Director, stated that she expected all food containers, both inside and outside, to be clean and free of debris. She also stated that ovens, drawers and equipment should be free of dust and debris as well as grease build up.

During an interview on 08/29/24 at 9:50 AM, Staff DDD, President, stated that he expected the kitchen area to be clean and was maintained by the contracted company.

5. Review of the hospital's policy titled, "Cleaning and Disinfectant Policy," dated 01/2024, showed cleaning involves the removal of visible dust, soil, and other foreign material. Responsible persons should be designated by the nurse manager for each nursing unit, or the Department Director of each patient care department.

Observation on 08/26/24 at 4:00 PM, showed a dirty microwave in the nutrition area of unit Three F.

During an interview on 08/26/24 at 4:00 PM, Staff G, Nursing Manager, stated that she was not sure who cleaned the microwave.

During an interview on 08/29/24 at 10:18 AM, Staff RR, Infection Prevention, Safety and Emergency Preparedness Supervisor, stated that the microwave oven on the patient care units should be clean.

6. Review of the hospital's document titled, "Infection Prevention Plan," dated 03/18/24, showed infection prevention is an integral part of all services and prevention of infection is a primary responsibility of all healthcare workers.

The hospital failed to follow their infection prevention plan which placed all patients at risk for infection.