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Based on document review, observation, and interview, it was determined that for 4 of 17 patients (Pts. #9, #10, #11, & #12) observed on the adult psychiatric unit with orders for close observation, the Hospital failed to ensure care in a safe setting by not ensuring completion of 15 minute observations, as required.

Findings include:

1. On 1/31/2022, the Hospital's policy titled, "Close Observation," reviewed by the Hospital on 2/2021, was reviewed. The policy required, "It is the policy of Nursing Services to institute close observation of a patient when: 1. Current behavior, or behavior prior to admission, is aggressive or assaultive... Procedure... 5. Staff will check off the reason(s) for Close Observation and document behavioral observations at 15 minute intervals on the Observation flow sheet..."

2. On 1/31/2022 at 9:50 AM, an observational tour was conducted in the Adult Psychiatric Unit (2 West). There were 17 patients on close observation precautions, requiring 15 minute monitoring. The Observation flowsheet, dated 1/31/2022, was reviewed during the tour at approximately 9:50 AM, and lacked 15 minute monitoring for 4 (Pt #9, Pt #10, Pt #11, and Pt #12) of the 17 patients on close observation precautions as follows:

- Pt. #9 was admitted on 1/29/2022, with schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) with suicidal tendencies, was last observed on 1/31/2022 at 9:00 AM, over 45 minutes earlier.

- Pt. #10 was admitted on 1/24/2022 with schizophrenia with psychosis (disconnection from reality), was last observed on 1/31/2022 at 9:00 AM, over 45 minutes earlier.

- Pt. #11 was admitted on 1/27/2022 with decompensated schizophrenia, was last observed on 1/31/2022 at 9:15 AM, over 30 minutes earlier.

- Pt. #12 was admitted on 1/26/2022 with Psychosis, was last observed on 1/31/2022 at 9:15 AM, over 30 minutes earlier.

3. On 1/31/2022 at 11:50 AM, an interview was conducted with the Director of Behavioral Health (E #2). E #2 stated that the reason that 15 minute observations were not completed every 15 minutes might be because the patients were not in their rooms or were in the TV room, when the observations were done.

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 February 1 - 2, 2022, 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 February 1 - 2, 2022, 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 document review, observation, and interview, it was determined that for 1 of 1 Housekeeper (E #3) in the Operating Room (OR), the Hospital failed to maintain a clean and sanitary environment to avoid sources and transmission of infection by not ensuring that cleaning products were used as recommended by the Manufacturer.

Findings include:

1. On 2/1/2022, the Hospital policy titled, "Operation Room Cleaning," dated 10/2002, was reviewed. The policy required, "Daily Cleaning (after each surgery)... Clean kick buckets, all stainless steel tables, etc..."

2. The label for "Diversey Alpha HP" cleaning solution was reviewed. The label required, "Directions... Allow [surface] to remain wet for 10 minutes for disinfection or 3 minutes for sanitizer for non food contact surfaces..."

3. On 2/1/2022 at 9:20 AM, an observational tour was conducted in the OR. A Housekeeper (E #3) cleaned OR suite #1's Mayo stand (stainless steel table). E #3 wiped the top and legs of the Mayo stand and then dried the Mayo stand with paper towel, rather than let the wet solution remain for 10 minutes.

4. On 2/1/2022 at 9:45 AM, an interview was conducted with E #3. E #3 stated that she used the cleaning solution in the bottle (Diversey Alpha HP) and wiped the solution off after application.


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B. Based on document review, observation, and interview, it was determined that for 1 of 1 Sterile Processing Technician (E #7) observed, the Hospital failed to maintain a clean and sanitary environment to avoid sources and transmission of infection by not ensuring the separation of clean and dirty areas during the decontamination process for surgical instrument.

Findings include:


1. The Hospital's policy titled, "Care and Handling of Surgical Instruments" (dated 9/21) , was reviewed on 2/2/2022, and required, "The Central Sterile Department will receive and render all soiled/contaminated items safe for handling and to maintain an area separate from a clean area for the processing of these items ..."

2. On 2/1/2022 between 9:45 AM-10:10 AM, a tour of the decontamination area was conducted. During the tour, E #7 (Central Processing Technician) was observed cleaning a scope (used for gastrointestinal procedures). E #7 donned full PPE (personal protective equipment) and then began the scope cleaning process at the sink. During the process, E #7 noted that she was missing a piece of equipment needed to complete the cleaning. E #7 left the dirty sink area and went to the clean supply area searching for the needed item, touching multiple supplies, while still wearing the used PPE (including gloves). E #7 did not remove PPE prior to going to a clean area.

3. On 2/1/2022 at 9:50 AM, the Central Processing Manager (E #8), was present during the scope cleaning process, and acknowledged that E #7 should not have went from "dirty-to-clean", while still wearing contaminated PPE.



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C. Based on document review, observation, and interview, it was determined that for 3 staff (E #3, E #5, and E #6) observed performing operating room cleaning, the Hospital failed to ensure a clean and sanitary environment to avoid sources and transmission of infection by not performing hand hygiene and cleaning procedures in accordance with policies.

Findings include:

1. On 2/1/22, the Hospital's policy titled, "Operating Room Cleaning" (revised 10/02) was reviewed and required, " ... The operating room (OR) must be cleaned immediately after a patient is removed from the room ... Wipe down all surfaces ... Wash hands using standard hand washing procedures ..."

2. On 2/2/22, the Hospital's policy titled, "Hand Hygiene" (revised 4/21) was reviewed and required, "Hand hygiene is the single most important means of preventing the health care worker from transmitting infection to patients and themselves ... Hand hygiene requires the use of antimicrobial agent and is indicated following contact with patients and contaminated or possibly contaminated items ..."

3. On 2/1/22 between 9:55 AM through 11:50 AM, an observation tour of the Operating Room (OR) #6 was conducted. The following were observed:

-At approximately 9:58 AM, a Registered Nurse, (RN-E#6) was observed cleaning OR #6. E#6 was observed removing soiled linen and placing in linen cart, then removed gloves and donned new gloves. E#6 then proceeded to use a cleaning solution (cavicide) to disinfect a side steel table, then placed the bottle of cleaning solution on the clean table.

-At approximately 10:07 AM, an anesthesiology aide (E#5) was observed entering the OR while a housekeeping staff (E#3) was trying to mop the floor. E#5 proceeded to remove, and discard used supplies from previous procedure into a garbage bag. E#5 was observed opening the garbage bag to discard used items, then used cleaning solution (cavicide-cleaning solution) to clean the top surface of the cart. E#5 then opened a supply drawer from the anesthesia cart and removed new supplies and placed them on the cart. E#5 did not perform hand hygiene or change gloves after touching contaminated surfaces and used supplies.

-At approximately 10:26 AM, a housekeeping staff (E#3) was observed applying a wet mop pad to the mop handle and proceeded to mop the floor in OR #6. E#3 was observed moving equipment (an intravenous pole and a Dornoch Suction machine) which had already been cleaned with dirty wet gloves.

4. On 2/1/22 at approximately 11:58 AM, an interview was conducted with the Anesthesia Aide (E#5). E#5 stated that E#5 should have performed hand hygiene and changed gloves after discarding used supplies and before handling new supplies to prevent contamination of new supplies and prevent infection.

5. On 2/1/22 at approximately 12:00 PM, these findings were discussed with the Director of Nursing (DON-E#1). E#1 stated that staff are expected to perform hand hygiene every time after performing a task and moving on to another task, including using alcohol-based rub or soap and water. E#1 stated that once equipment has been cleaned, staff should not touch with soiled/dirty gloves to prevent contamination. E#1 stated she will have OR #6 redone due to unacceptable to not perform hand hygiene when preparing for new procedure.