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Based on document review and interview, it was determined that for 1 of 2 clinical records reviewed for diabetic management (Pt. #2), the Hospital failed to ensure a registered nurse supervised the nursing care of patients by failing to follow the physician's orders.

Findings include:

1. On 8/10/2021, the Hospital's policy titled, "Insulin Administration and Care and Management of the the Diabetic Patient," effective 6/15/2021, was reviewed. The policy required, "Insulin products are High Risk/ High Alert medications... The licensed personnel must verify the type of insulin and amount to be given... and comparing both to the medical provider's order..."

2. On 8/10/2021, Pt. #2's clinical record was reviewed. Pt. #2 was admitted on 7/30/2021, with diagnoses of COVID [viral infection], hypertension [high blood pressure], and diabetes [low or high glucose/sugar level]. Pt. #2's physician's orders dated 7/31/2021 at 6:45 AM, included accucheck (blood glucose checks) before meals and at bedtime with Novolog insulin (medication to treat diabetes), subcutaneous administration, as follows:

- glucose 140 - 180 mg/dl (milligrams/deciliter), insulin 6 units
- glucose 181 - 220 mg/dl, insulin 9 units
- glucose 221 - 260 mg/dl, insulin 12 units
- glucose 261 - 300 mg/dl, insulin 15 units
- glucose over 300 mg/dl, call the doctor

Pt. #2's blood glucose results and insulin administration on 8/7/2021 and 8/8/2021 indicated that on 3 of 8 occasions, Pt. #2 blood glucose was greater than 300 mg/dl. The nurse administered 15 units of Novolog insulin on the following date and time:

8/7/2021 at 840 PM -blood glucose was 345 mg/dl
8/8/2021 at 4:00 PM -blood glucose was 323 mg/dl
8/8/2021 at 8:22 PM - blood glucose was 364 mg/dl

The clinical record of Pt. #2 did not include documentation that the physician had been notified on these dates and time when the blood glucose check was greater than 300 mg/dl.

3. On 8/10/2021 at 11:40 AM, an interview was conducted with the Chief Nursing Officer (E #2). E #2 stated that the physician should have been called when Pt. #2's glucose was over 300 mg/dl.

Based on document review, observation, and interview, it was determined that the Hospital failed to manage daily dietary services by ensuring that expired and/or opened food items were handled, as required. This had the potential to affect the 91 patients receiving oral diets on 8/11/2021.

Findings include:

1. On 8/11/2021, the Hospital's policy titled, "Food and Supply Storage" (revised 01/2021) was reviewed and required, "...Foods past the ["use-by", "sell-by", "best-by", or "enjoy-by"] date should be discarded ...Cover, label and date unused portions and open packaged ....Products are good through the close of business on the date noted on the label ..."

2. A tour of Dietary Services was conducted on 8/11/2021 from 11:15 AM until 12:30 PM. The following were observed:
- The dry storage room had an open box containing approximately 25 single-serve packages of French salad dressing that were labeled with a use date by 8/7/2021.
- The walk-in freezer #1, contained one open bin of diced chicken that was not labeled with the date opened or use-by date.

3. On 8/11/2021 at approximately 11:45 AM, an interview was conducted with the Director of Food and Nutrition (E #7). E #7 stated that food should be discarded according to the use date/expiration date. E #7 added that all food items should be labeled with the date opened or use-by date.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of a Full Survey Due to a Complaint conducted on August 10-11, 2021, the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of the Full Survey Due to a Complaint conducted on August 10-11, 2021, the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags.

A. Based on observation, document review, and interview, it was determined that for 2 of 2 staff (E #9/Anesthesia Aid and E #13/Environmental Service) observed for cleaning the operating room (OR), the Hospital failed to ensure methods for preventing and controlling the transmission of infection when cleaning the OR were followed.

Finding include:

1. On 8/11/2021 between 11:30 AM and 12:20 PM, during an observational tour of OR #2, the following was observed:

- At approximately 11:30 AM. E #9 was observed cleaning the cables of the Mindray Monitor Vitals Sensor (machine used to monitor patients under anesthesia). E #9, placed the cleaned cables on an unclean intravenous pole that was used during a previous procedure that had been scheduled in OR #2. E #13 also picked up the OR table's remote control from the floor and placed the remote control on the cleaned OR table.

- At approximately 12:20 PM, after OR #2 had been cleaned, the specialty OR table that was used for the surgical procedure had been wiped with disinfectant. However, approximately a 1-inch by 1-inch patch of sticky residue that contained white lint and other debris remained on the OR table. In addition, a different cleaned OR table was brought into OR #2. Per the Surgical Director (E#12), OR #2 was ready for patient use if needed. However, the new OR table that was brought in had 5 strips (approximately 1.5-inch by 3-inch) of sticky residue that contained white lint and other debris remaining on the belt.

2. On 8/12/2021 at approximately 9:00 AM, the Hospital's policy titled, "Perioperative Area Cleaning (Terminal and Between Cases) was reviewed and included, "... 10- If performing between case cleaning of OR Suites adhere to general guidelines... c. Work from high to low and from clean to less clean, d. Avoid soiling cleaned areas in the process of cleaning dirty ones."

3. On 8/11/2021 at approximately 12:30 PM, an interview was conducted with E #9. E #9 stated that he assumed that the intravenous pole was cleaned. E #9 stated that he usually comes after the OR cleaning has started. E #9 stated that he should have checked to make sure that the intravenous pole was clean before hanging the cleaned monitor cables.

4. On 8/11/2021 at approximately 12:35 PM, an interview was conducted with E #13. E #13 stated that she should have cleaned the remote control before placing it on the clean table.

5. On 8/11/2021 at approximately 12:25 PM and on 8/12/2021 at approximately 1:00 PM, interviews were conducted with the Surgical Director (E #12). E #12 stated that the belt needs to be changed and the residue should have been identified and removed during the room turnover/cleaning process. E #12 added that to prevent cross contamination, the cleaned monitor cables should have not been placed on an unclean surface, and the remote control should have been cleaned before placing it on the cleaned OR table.


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B. Based on document review, observation, and interview, it was determined that for 4 of 7 operating room (OR) staff (MD #1, MD #2, E #10, and E #11) observed, the Hospital failed to ensure that hand hygiene was performed after glove removal to prevent and control the transmission of infection.

Findings include:

1. The Hospital's policy titled, "Hand Hygiene" (effective 11/14/2017), was reviewed on 8/11/2021 and required, "...Indications for Hand Hygiene: Use of either hospital-approved hand sanitizer or soap and water is required: ...Before donning and after removing gloves. Gloves do not replace the need for hand hygiene as hands may become contaminated by small, undetected holes in gloves or during removal of gloves..."

2. During an observational tour of the OR area on 8/11/2021, the following were observed:

- Between approximately 10:45 AM and 10:55 AM, a patient was brought to OR #2 for a surgical procedure. The Anesthesiologist (MD #2) assisted in transferring and setting up the patient on the OR cart. MD #2 changed gloves 3 times after touching the patient, and did not perform hand hygiene in between glove changes.

- At approximately 10:57 AM, the Surgeon (MD #1) in OR#2 removed gloves after helping position the patient's legs into the stirrups for the surgical procedure. MD #1 did not perform hand hygiene after glove removal and pushed the button with his hand to open the door as MD #1 exited the room.

- At approximately 11:50 AM, two Radiology Technicians (E #10 and E #11) were in OR #1 positioning and preparing a patient for an interventional radiology procedure. After touching the patient, E #10 changed gloves without performing hand hygiene. After touching the patient, E #11 removed gloves and exited the room without performing hand hygiene and went to grab a new mask from a clean supply shelf.

3. An interview was conducted with Infection Preventionist and Manager (E #8) on 8/11/2021, at approximately 1:30 PM. E #8 stated that staff must perform hand hygiene after each glove removal.