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Based on observation, record review and interview, the hospital failed to ensure 2 of 2 patients (Patient #21 and #22) being processed for admit were provided with information regarding the hospital's policy on advance directives and information on the state's advance directives to assure each patient could effectively exercise their right to make informed decisions about their care.


Findings:
On 05/28/25 from 11:00 a.m. to 11:30 a.m. observations of two patients (Patients #21 and #22) being admitted to the hospital by the admitting personnel showed no documented evidence of advance directives information being provided to the patients.


A review of the hospital policy titled "Advance Directives," dated 12/2018, read in part, "The purpose of this policy is the provide the requirements for placing advance directives forms into the medical record." A further review of the policy showed no documented evidence of when or how advance directives information would be provided to the patients.


On 05/30/25 at 10:00 a.m. Staff H stated advance directive information was not provided to patients upon admit and patients were only asked if they had an advance directive.

Based on record review and interview, the hospital failed to ensure the nursing staff developed a nursing care plan for each patient based on assessing all the patient's nursing care needs and not solely those needs related to the admitting diagnosis in 3 of 3 (Patient #1, #2, and #3) medical records reviewed for nursing care plans out of 20 medical records.


Findings:
A review of Patient #1 medical record, read in part, Patient #1 was admitted to the hospital with a diagnosis of acute kidney injury. A review of the patient's medical history showed the patient also had a present history of bipolar disorder and chronic obstructive pulmonary disease. The care plan showed the patient only had a documented care plan with goals and treatment plans for weakness, infection, fall risk, pain, and skin integrity. A further review of the nursing care plan and the medical record showed no documented evidence that the patient had nursing care plans developed for the other medical diagnoses of bipolar disorder and chronic obstructive pulmonary disease.


A review of Patient #2 medical record, read in part, Patient #2 was admitted to the hospital with a diagnosis of chronic obstructive pulmonary disease and hypoxia. A review of the patient's medical history showed the patient also had a present history of diabetes and hypertension. The care plan showed the patient only had a documented care plan with goals and treatment plans for chronic obstructive pulmonary disease, pain, and skin integrity. A further review of the nursing care plan and the medical record showed no documented evidence that the patient had nursing care plans developed for the other medical diagnoses of diabetes and hypertension.


A review of Patient #3 medical record, read in part, Patient #3 was admitted to the hospital with a diagnosis of postoperative care. A review of the patient's medical history showed the patient also had a present history of hypertension, constipation, and anemia. The care plan showed the patient only had a documented care plan with goals and treatment plans for skin integrity, infection, pain, and falls. A further review of the nursing care plan and the medical record showed no documented evidence that the patient had nursing care plans developed for the other medical diagnoses of hypertension, constipation, and anemia.


A review of the hospital policy titled "Care Planning," dated 03/2021, read in part, "Care, treatment, and services are planned to ensure that they are individualized to the patient's needs. The hospital shall provide an individualized plan of care for all patients that is appropriate to the patient's needs, strengths, limitations, and goals."


On 05/29/25 at 11:55 a.m. Staff D stated the nurses only developed patient care plans based on the patient's main diagnoses and stated the care plans were not comprehensive or developed for all the patient's current diagnoses or care needs.

Based on observation, record review, and interview the facility failed to ensure staff maintained a functional and sanitary environment, according to acceptable professional standards of infection control practice as evidenced by:

1. failing to ensure surgical staff processed surgical items according to acceptable sterilization guidelines and/or manufacturer's IFU when processing and sterilizing surgical items in paper-plastic peel pouches in observations of 15 of 15 paper-plastic peel pouches that were not light weight or low profile and were double-pouched,


2. failing to ensure dietetic staff maintained safe food storage practices by observations of nutritional items being stored in 12 of 12 cardboard boxes in the refrigerator, and


3. failing to ensure staff labeled the HLD test strip bottle when opened with the open date and the new expiration date in 1 of 2 observations of HLD test strip bottles.


Findings:


1. failing to ensure surgical staff processed surgical items according to acceptable sterilization guidelines and/or manufacturer's IFU when processing and sterilizing surgical items in paper-plastic peel pouches in observations of 15 of 15 paper-plastic peel pouches that were not light weight or low profile and were double-pouched,


On 05/28/25 at 12:10 p.m., observations in the Sterile Supply Room showed sterile items processed in paper-plastic peel pouches that were not low profile with visible tenting and creasing of the sterile packages. Further observations showed sterile items processed in paper-plastic peel pouches that were not light weight with visible stress on the package's sealed seams. The sterile paper-plastic peel pouches were also observed to be double-pouched with the inner pouch sealed.


A review of the AORN Guidelines for Perioperative Practice 2021 edition: Guidelines for Packaging Systems, read in part, Use peel pouches (i.e., paper-plastic, polyethylene material, polyester film) according to a manufacturer IFU and/or according to AORN packaging guidelines. Sterile items processed in peel pouches should be light weight and low profile to maintain the sterility of the package contents and not compromise the package or the seal integrity (caused by heavy items or tenting). Sterile peel pouches should not be double-pouched (placing the item in one pouch and then placing this pouch inside another) with the inner pouch sealed unless the pouch manufacturer's IFU allows this practice. Improper double pouching may entrap air and/or inhibit sterilant contact and can lead to polyethylene material seal failure. Sterility is event-related and not time-related and may be affected by events such as, amount of handling, improper storage, and properties of the packing material.


A review of the hospital policy titled "Event-Related Sterility Maintenance," dated 04/29/2025, read in part, "Events that may compromise the sterility of packages include ...packaging materials. All items processed for sterilization will be properly wrapped and processed."


On 05/28/25 at 12:10 p.m. Staff E stated that all sterile items processed in paper-plastic peel pouches were double-pouched with the inner pouch sealed. Staff E stated they were aware that sterile items processed in paper-plastic peel pouches were supposed to be light weight and low profile and they were not aware there were so many sterile items packaged incorrectly. They stated their policy did not address specific paper-plastic peel pouch guideline requirements. Staff E further stated the manufacturer of the paper-plastic peel pouches approved double-pouching but did not know if the manufacturer approved sealing the inner pouch.


2. failing to ensure dietetic staff maintained safe food storage practices by observations of nutritional items being stored in 12 of 12 cardboard boxes in the refrigerator.


On 05/28/25 at 4:30 p.m. observations in the dietary department's refrigerator showed nutritional food items being stored in their original cardboard boxes. The cardboard boxes were observed to be stacked on top of one another in the refrigerator and were noted to be damp when touched.


A review of the hospital policy titled "Food Storage," dated 08/2017, read in part, "Food items will be stored, thawed, and prepared in accordance with good sanitary practice."


The CDC guidelines on Food Safety in Healthcare, read in part, The USDA and the CDC advise against storing cardboard boxes in refrigerators. While cardboard boxes can be a convenient storage solution, it's not recommended for food safety due to the potential for moisture, bacteria, and increasing the risk of contamination. Moisture can damage the cardboard, potentially affecting the contents or creating a breeding ground for bacteria. Cardboard may not be as effective at maintaining consistent temperatures of food items, causing temperature fluctuations which can potentially affect the stored items.


On 05/28/25 at 4:40 p.m. Staff G stated the dietary personnel kept nutritional foods items in their original cardboard boxes and stacked the boxes on top of one another, due to space limitations and refrigerator storage convenience. Staff G stated they were not aware of the food safety guidelines on cardboard box use in refrigerators.


3. failing to ensure staff labeled the HLD test strip bottle when opened with the open date and the new expiration date in 1 of 2 observations of HLD test strip bottles.


An observation on 05/28/25 at 12:20 p.m. of two HLD test strip bottles showed one of the HLD test strips bottles was not labeled with the open date or the new expiration date.


A review of AORN Guidelines for Perioperative Practice, 2021 edition: Guideline for High-Level Disinfectant, read in part, "Use a test strip specific to the disinfectant before each use of the HLD solution to determine whether the concentration of the active ingredient in the HLD is above or below the minimum effective concentration. Use and store the test strips in accordance with the manufacturer's IFU."


A review of the test strip manufacturer IFU, read in part, "The test strips have a shelf life of 180
days after opening the bottle. The strips should be used within 180 days of opening or before the
printed expiration date on the bottle, whichever comes first. Date the bottle with the open date and the new expiration date after opening. Expired test strips can provide inaccurate results, so it's important to discard them when expired."


On 05/28/25 at 12:20 p.m. Staff E stated the open date and the new expiration date for one HLD test strip bottle was not labeled on the bottle.


On 05/30/25 at 11:30 a.m. the infection control breaches were discussed with Staff F. Staff F stated they were not aware of the above infection control issues, as the above processes were not routinely being monitored in infection control. Staff F stated the facility followed AORN, APIC, and CDC in their infection control program.