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Based on document review, interview, and observation, it was determined for 2 of 3 (Pt. #21 and Pt #22) restraint records reviewed, 2 of 13 (Pt #31 and Pt #32) Behavioral Health Unit patients and an observational tour of the Intensive Care Unit (ICU) that the Hospital failed to ensure that the patient's rights were protected. This potentially affects current and future patients admitted to the Hospital. As a result, the Condition of Participation, 42 CFR 482.13, Patient Rights, was not in compliance.


Findings include:

1. The Hospital failed to keep syringes secured and unavailable to unauthorized users. See deficiency cited at A-144.

2. The Hospital failed to ensure that care was provided in a safe setting, by completing environmental rounds each shift (2 shifts per day) as required on the Adult Behavioral Health Unit. See deficiency cited at A 144 B.

3. The Hospital failed to ensure that care was provided in a safe setting by ensuring that staff were aware of the patients' safety precautions when conducting patient safety rounds. See deficiency cited at A 144 C.

4. The Hospital failed to ensure care in a safe setting by developing policies and procedures to address suicide/homicide precautions, screenings, and assessments for patients in the Behavioral Health Units. See deficiency cited at A 144 D.

5. The Hospital failed to ensure a restriction of rights was completed for patients placed in restraints. See deficiency cited at A 117.

6. The Hospital failed to ensure restraints were ordered by a physician or other licensed practitioner (LP), authorized to order restraints. See deficiency cited at A 168.

7. The Hospital failed to ensure documentation of a one-hour face to face evaluation was completed, as required. See deficiency cited at A 178.

Yoder, Samantha
Based on document review and interview, it was determined for 2 of 3 (Pt #21 and Pt #22) patients, reviewed for violent restraints, the Hospital failed to ensure a restriction of rights was completed, as determined by hospital policy. This has the potential to affect all patients who require the use of violent restraints.

Findings include:

1. The Policy titled "Restraint Management Policy (revised 12/2/2021)" was reviewed on 08/24/2022 at approximately 1:00 PM. On page 5, the policy stated, "4. A Restriction of Rights form for the patient must be completed for each restraint and/or seclusion episode with copies given to the patient's designated person, parent or legal guardian if applicable, substitute decision make if applicable, facility director, medical record, and any person of the patient's choosing, including the Guardianship and Advocacy commission."

2. The clinical record of Pt #21 was reviewed on 08/25/2022 at approximately 10:30 AM. Pt #21 presented to the Emergency Department (ED) on 03/20/2022 at 2:09 PM with a chief complaint of "Behavioral Health Evaluation." Pt #21 was admitted to the pediatric floor awaiting placement in adolescent behavioral health facility. While on the pediatric floor, Pt #21 was placed in "3 pt soft restraints with both wrists and right ankle" on 03/21/2022 at 1:40 AM. An order for 4 point violent restraints was placed at 2:03 AM. The record lacked documentation that the Restriction of Rights was completed.

3. The clinical record of Pt #22 was reviewed on 08/25/2022 at approximately 11:45 AM. Pt #22 presented to the ED on 02/26/2022 at 1:57 PM with a chief complaint of "hearing voices and violent outbursts." Pt #22 was placed in 4 point restraints on 2/28/2022 at 9:40 AM. An order for violent restraints was placed at 10:07 AM. The record lacked documentation that the Restriction of Rights was completed.

4. An interview was conducted with the Director of Quality (E #19) and the Chief Nursing Officer (E #5) on 08/26/2022 at approximately 9:30 AM. E #19 and E #5 reviewed the medical records of Pt #21 and Pt #22 and verbally agreed the medical record lacked documentation that the Restriction of Rights was completed.

A. Based on observation, document review, and interview, it was determined the Hospital failed to keep syringes secured and unavailable to unauthorized users and thus failed to ensure the provision of care in a safe setting for all patients.

Findings include:

1. On 8/23/2021 at approximately 1:30 PM - 2:30 PM, a tour of the 3 West Neuro/Medical/Surgical ICU was conducted with the Neuro / Medical / Surgical ICU Manager (E #7). The following was noted:
- Pt # 12's room (3020) unlocked cart containing needles in the 1st drawer and empty 3 milliliter (ml) and 10 ml syringes and 10 ml saline filled syringes in the 4th drawer.
- Pt # 13's room (3016) unlocked cart containing needles in the 1st drawer and empty 3 ml and 10 ml syringes and 10 ml saline filled syringes in the 4th drawer.

2. An interview was conducted with E #7 during the tour. E #7 stated "The cabinets are to be locked at all times."

3. On 08/24/22 at approximately 9:00 AM, Director of Nursing - Critical Care and Women's and Children's (E #3) was interviewed. E #3 stated "the Hospital has educated staff on the Contraband Search and secured supplies storage." Staff education was completed by 8/12/22. "Secured Supply audits are conducted twice a day at shift change. If non-compliance is found, we do coaching with the nurses and the charge nurse. If there continues to be non-compliance, we would escalate."



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B. Based on document review and interview, it was determined that for 6 of 23 days (8/7/2022, 8/11/2022, 8/12/2022, 8/17/2022, 8/18/2022, and 8/21/2022) in August 2022 reviewed, the Hospital failed to ensure that care was provided in a safe setting, by completing environmental rounds each shift (2 shifts per day) as required on the Adult Behavioral Health Unit.

Findings include:

1. The Hospital's policy titled, "Patient Safety Checks" (revised 3/10/2022), was reviewed on 8/24/2022 and required, "...Environmental Rounds: Examine all the rooms carefully during the first half of the shift..."

2. "Safety Room Check Monitor" logs for both hallways (North and South) of the Adult Behavioral Health Unit from 8/1/2022-8/23/2022 were reviewed on 8/23/2022. The logs lacked documentation that a second environmental safety check of all rooms/areas was conducted on the following dates/locations: 8/18/2022 (both North and South hallways) and 8/21/2022 (North hallway). The records also lacked documentation that the shower areas, plumbing, hallways, room door lights, fixture covers, and restraint bag were checked on the following dates/locations: 8/7/2022 (South); 8/11/2022 (South); 8/12/2022 (North); and 8/17/2022 (North).

3. An interview was conducted with the Interim Behavioral Health Unit Manager (E #13) on 8/23/2022, at approximately 3:26 PM. E #13 stated that they have 2 shifts per day and staff are expected to complete the entire environmental safety round checklist each shift.


C. Based on document review, observation, and interview, it was determined that for 2 of 13 patients (Pt #31 and Pt #32) on the Adult Behavioral Health Unit, the Hospital failed to ensure that care was provided in a safe setting by ensuring that staff were aware of the patients' safety precautions when conducting patient safety rounds.

Findings include:

1. The Hospital's policy titled, "Patient Safety Checks" (revised 3/10/2022), was reviewed on 8/24/2022 and required, "All staff conducts patient rounds every 15 minutes using a visual verification on all their patients... Documentation of all patients rounding is entered on the Mental Health Observation Record..."

2. During a tour of the Adult Behavioral Health Unit on 8/23/2022, at approximately 2:47 PM, a Mental Health Counselor (MHC) (E #12) was observed conducting patient safety checks. The unit had a census of 13 patients. E #12 had a clipboard with the "Behavioral Health Intermittent Observation" records for each of the 13 patients. It was noted that 2 of the patients (Pt #31 and Pt #32) did not have the type of precautions or reason for precautions marked on the observation records.

3. An interview was conducted with the MHC (E #12) on 8/23/2022, at approximately 2:55 PM. When asked what precautions Pt #31 and Pt #32 were on, E #12 stated that she did not know. E #12 stated that during shift change, the nurses will report which precautions each of the patients are on. E #12 stated that both, Pt #31 and Pt #32 were admitted today (after shift change). E #12 stated that the nurse will give them (MHCs) a brief when the patients are admitted to the unit. E #12 stated, "It is important to know the type of precautions for each patient because there are certain behaviors and/or triggers to watch out for."

4. The clinical record of Pt #31 was reviewed on 8/23/2022. Pt #31 was admitted on 8/23/2023, at approximately 9:00 AM, with a diagnosis of bipolar disorder. Pt #31 had physicians orders for every 15 minute monitoring for suicide and homicide/aggression precautions.

5. The clinical record of Pt #32 was reviewed on 8/23/2022. Pt #32 was admitted on 8/23/2023, at approximately 1:00 PM, with a diagnosis of depression and suicidal ideation. Pt #32 had physicians orders for every 15 minute monitoring for suicide, homicide/aggression, and elopement precautions.

6. An interview was conducted with the Interim Behavioral Health Unit Manager (E #13) on 8/25/2022, at approximately 9:50 AM. E #13 stated that the expectation is for staff to mark the type and reason for precautions on the observation records. E #13 stated that staff conducting the patient safety check monitoring should know what precautions the patients are on.


D. Based on document review and interview, it was determined that the Hospital failed to ensure care in a safe setting by developing policies and procedures to address suicide/homicide precautions, screenings, and assessments for patients in the Behavioral Health Units.

Findings include:

1. Policies and procedures regarding suicide and homicide precautions for behavioral health patients were requested from the Hospital on 8/23/2022, at approximately 4:10 PM. On 8/25/2022, at approximately 9:40 AM, a policy titled, "Initial Suicide Screening and Assessment Process (Emergency Department and Non-Behavioral Health Inpatients)" was provided. No other policy was presented regarding specific safety precautions/assessments (suicide or homicide) for behavioral health inpatients.

2. An interview was conducted with the Interim Behavioral Health Unit Manager (E #13) on 8/25/2022, at approximately 9:50 AM. E #13 stated that at some point the behavioral health policy was supposed to be combined as a corporate wide policy; however, the final policy did not end up including the Behavioral Health Unit. E #13 stated, "None of us in behavioral health recognized it" until now and stated that she would be working on policies to address this concern.

Based on document review and interview, it was determined for 1 of 3 (Pt #22) patients records reviewed, who required the use of violent restraints, the Hospital failed to ensure restraints were ordered by a physician or other licensed practitioner (LP), authorized to order restraints. This has the potential to affect all inpatients and outpatients who require the use of restraints by the Hospital.

Findings include:

1. The Policy titled "Restraint Management Policy (revised 12/2/2021)" was reviewed on 08/24/2022 at approximately 1:00 PM. On page 3, the policy noted, "IV. Procedures Each episode of restraint or seclusion must be ordered by a physician or an authorized licensed practitioner responsible for the patient's ongoing care."

2.The clinical record of Pt #22 was reviewed on 08/25/2022 at approximately 11:45 AM. The "Emergency Department Notes" date 02/27/2022 at 1:45 PM stated, "Unable to redirect pt. Pt continues to be combative, agitated, threatening staff. All extremity restraints applied by security. Pt continues to yell and scream obscenities at staff still trying to head butt staff. Sitter and RN with pt." Pt #22's record lacked an order for restraints.

3. An interview was conducted on 08/25/2022 during the record review with the Director of Quality (E #19) and Clinical Educator (E #18). E #19 and E #18 reviewed Pt #22's record and verbally agreed, there is no order for restraints and stated, "There should be."

Based on document review and interview, it was determined for 1 of 2 pediatric patient's (Pt #21) clinical records reviewed for violent restraints, the Hospital failed to ensure documentation of a one-hour face to face evaluation was completed, as required. This has the potential to affect all patients placed in violent restraints.

Findings include:

1. The Policy titled "Restraint Management Policy (revised 12/2/2021)" was reviewed on 08/24/2022 at approximately 1:00 PM. The policy noted on page 4, "D. Violent, Self-destructive, or Seclusion 1. For restraint and/or seclusion for violent or self destructive behavior: a. ... the patient must be seen face-to-face within one hour after initiation of the intervention by a physician, a authorized licensed practitioner, or a trained supervisory nurse."

2. The clinical record of Pt #21 was reviewed on 08/25/2022 at approximately 10:30 AM. Pt #21 presented to the Emergency Department (ED) on 03/20/2022 at 2:09 PM with a chief complaint of "Behavioral Health Evaluation." Pt #21 was placed in "3 pt soft restraints with both wrists and right ankle" on 03/21/2022 at 1:40 AM. The "Restraint, Violent" documentation stated, "Reason for Restraint/Seclusion ; Prevent injury to self, Prevent injury to others... Behavior: Agitated, kicking, uncooperative, yelling/verbally hostile." An order for 4 point violent restraints was placed at 2:03 AM. The record lacked documentation of a 1 hour face-to-face.

3. An interview was conducted on 08/25/2022 during the record review with the Quality Manager (E #19). E #19 verbally agreed the 1-hour face-to-face documentation was not in the chart.

Based on document review, observation, and interview it was determined the Hospital failed to ensure proper safety precautions were maintained against radiation hazards. This has the potential to affect all staff and patients serviced by the Nuclear Medicine department.

Findings include:

1. The policy titled "Nuclear Medicine Film Badges and TLD rings" (revised 8/24/22) was reviewed 8/25/22. The policy noted "Store dosimeters away from radiation when not in use (do not store near a radioactive source or in an x-ray room...)."

2. On 8/23/22 at approximately 1:00 PM, a tour of the Nuclear Medicine department was conducted. During the tour 3 dosimetry badges and 3 nuclear medicine rings (both used to measure radioactive levels the staff member is exposed to) were laying in a drawer inside a x-ray room.

3. On 8/23/22 at approximately 1:30 PM, an interview was conducted with the Director of Imaging (E #17). E #17 stated, "we probably could have had a better place to store them."

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety code portion of the Full Survey conducted August 23 & 24, 2022, the surveyors find that 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.

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 August 23 & 24, 2022, the surveyors find that 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.

Based on document review, observation, and interview, it was determined the Hospital failed to ensure outdated or expired supplies were not available for patient use. This has the potential to affect all patients receiving care in the Radiology and Surgery Departments.

Findings include:

1. The procedure titled "Management of Expiring Inventory" (no revision date) was reviewed 8/23/2022 at approximately 3:30 PM. The procedure noted, "If an expired item is found, the operations manager should be notified...The expired product should be disposed of using the item disposal process."

2. On 8/23/22 at approximately 12:30 PM, a tour of the Radiology Department was conducted. During the tour the following items were found:

(3) disposable Laryngoscopes (device used to aide in intubation of a patient): expiration date 5/15/22
(1) 10 ml (milliliter) vial of sterile water: expiration date 2/1/21
(1) 10 ml vial Sodium Chloride: expiration date 5/1/2020

3. On 8/24/22 at approximately 9:00 AM, a tour of the Surgery Department was conducted. During the tour the following items were found:

(7) boxes biological monitoring kit for sterile processing: expiration date 5/4/21
(3) LMA (laryngeal mask airway) (used for administration of anesthesia): expiration date 2/28/22
(1) bottle 70% Isopropyl Alcohol: expiration date 3/31/22

4. On 8/24/22 at approximately 1:30 PM, an interview with the Ascension Quality Manager (E #20) was conducted. E #20 verbally agreed the supplies were expired and should not be available for use.

A. Based on observation, interview, and document review it was determined for 1 of 5 patients (Pt#15) in Contact Precautions, the Hospital failed to ensure adherence to Contact Precautions as required. This has the potential to affect all patients receiving care at the Hospital, with a current average daily census of 245 patients.

Findings include:

1. On 8/24/2022 at approximately 9:35 AM, a tour of the Acute Care of Elderly (ACE) Unit was conducted with the Nurse Manager (E #1). On the tour it was observed room #8004 had a contact isolation sign posted, in the room Registered Nurse (E #10) was observed providing care for the patient without wearing a gown, which is required Personal Protective Equipment (PPE).

2. On 8/24/2022 during the observational tour, an interview with the Nurse Manager (E #1) was conducted. E #1 stated that the nurse was not following infection control policy and should be wearing a gown.

3. On 8/24/2022 at approximately 2:00 PM, the Hospital policy titled "Standard and Transmission Based Isolation Precautions (last revised 8/21/2020)" was reviewed. The policy required, "... E. Contact Precautions.... 4. ii Wear a gown when entering the room for all interactions that may involve contact with the contaminated areas in the patient's environment."



B. Based on observation, interview, and document review it was determined that for 4 of 5 staff members (E #6, E #8, E #9 and E #14) observed for infection control practices, the Hospital failed to ensure that staff changed gloves and performed hand hygiene as required by the infection prevention and control program. This has the potential to affect all patients receiving care.

Findings include:

1. On 8/23/2022 at approximately 3:15 PM, Registered Nurse (E #8) was observed inserting an IV (needle placed in vein to give medications or fluids). E #8 donned gloves, cleaned extremity with alcohol, then answered cell phone with the right gloved hand, after call ended, E #8 proceeded to palpate the patient's right antecubital area, cleansed the site with alcohol and inserted the IV, without changing gloves between tasks or performing hand hygiene.

2. On 8/23/2022 at approximately 3:30 PM, an interview with the Stroke Coordinator (E #4) was conducted. E #4 stated that the infection control policy was not followed and gloves should have been changed and hand hygiene completed after answering cell phone.

3. On 8/23/2022 at approximately 2:00 PM, a tour of the Neuro / Medical / Surgical Unit was conducted with the Nero/Medical Manager (E #7) and Stroke Coordinator (E #4). During the tour MD (E #6) was observed leaving room #3023 ambulating down the hall donned with PPE (mask and gloves). E #6 removed and discarded the gloves and used the phone outside room #3020. E #6 then obtain gloves from room #3020, put the gloves on, put a glove over the bell of E #6's personal stethoscope and entered patient room #3023. E #6 failed to perform hand hygiene prior to putting gloves on and after removing gloves .

4. On 8/23/2022 at approximately 2:15 PM, an interview was conducted with E#4 and E#7, both agreed the hospital infection control policy was not being followed.

5. On 8/24/2022 at approximately 9:15 AM, a tour of the Orthopedic/Surgical Unit was conducted with the Unit Manager (E #9). During the tour a lab technician obtained a blood specimen from the patient in room #7027. After the procedure, the lab technician removed their gloves and exited the patient room failing to perform hand hygiene or sanitize hands.

6. On 8/24/2022 at approximately 9:30 AM, an interview was conducted with E#9. E#9 stated that staff are expected to perform hand hygiene before and after removing gloves.

7. During an observational tour of the Decontamination Room in the Sterile Processing Department on 8/24/2022, at approximately 10:30 AM, a Sterile Processing Technician (E #14) was verbalizing and demonstrating how to perform high-level disinfection. E #14 went to retrieve a thermometer and testing supplies from a clean table. E #14 was still wearing the same gloves used to wash soiled surgical instruments. Some water from the glove had dripped on the clean table.

8. An interview was conducted with the Sterile Processing Supervisor (E #15) on 8/24/2022, at approximately 11:00 AM. E #15 stated that the table is used to set equipment that have already been cleaned via high-level disinfection and is considered a clean area. E #15 stated that E #14 should have removed the gloves and washed hands before touching anything on the table.

9. On 8/24/2022 at approximately 3:00 PM, the Hospital Policy titled "Standard and Transmission Based Isolation Precautions (last revised 8-21-2020)" was reviewed. The policy required, "... C. Gloves... 4. Change gloves between tasks and procedures on the same patient and after contact with material that may contain a high concentration of microorganisms."

10. On 8/25/2022 at approximately 10:00 AM, the policy titled "Hand Hygiene Policy (last revised 10/18/2021)" was reviewed. The policy required, "Gloves should be worn during all patient care activities that may involve exposure to blood or potentially infectious materials. Gloves do no provide complete protection against hand contamination and hand hygiene should be performed before donning and after doffing gloves... Hand sanitizer is acceptable for use in the following settings provided that hands are not visibly soiled: ... Before accessing clean or sterile supplies..."





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C. Based on document review, observation, and interview, it was determined that for 2 of 2 Sterile Processing Staff (E #14 and E #15), the Hospital failed to ensure that staff performed verification testing of high-level disinfectant solution per manufacturer's instructions as part of the Hospital's infection prevention and control program. This has the potential to affect all patients who receive surgical services.

Findings include:

1. The Hospital's policy titled, "Cleaning, Disinfection and Sterilization of Devices, Instruments and Equipment (revised 10/8/2019)", was reviewed on 8/24/2022 and required, "...High Level Disinfectant: Metracide OPA; Follow department policies and FDA approved manufacturer's guidelines for use..."

2. The Metricide OPA Directions for Use were reviewed on 8/24/2022 and required, "...Chemical Indicator: Always use Metricide OPA Plus Solution Test Strips to monitor the concentration of ortho-phthallaldehyde [active ingredient] before each use..."

3. The Metricide OPA Plus Solution Test Strips Directions for Use were reviewed on 8/24/2022 and required, "...Completely submerge indicating pad of strip into Metricide OPA Plus Solution. Hold for two seconds and remove. Immediately remove excess solution with a single vigorous shake of the strip... Read results at 60 seconds after removal from solution..."

4. An observational tour of the Decontamination Room (in the Sterile Processing Department) was conducted on 8/24/2022, at approximately 10:30 AM. During the tour, a Sterile Processing Technician (E #14) was observed demonstrating the process for high-level disinfection. E #14 stated that after the dipping the test strip in the solution, she waits "about a minute." E #14 stated that she does not use a timer or clock. E #14 stated that she just sets the strip down on the sink and goes to do other tasks and by the time she comes back at least a minute will have passed.

5. An interview was conducted with the Sterile Processing Supervisor (E #15) on 8/24/2022, at approximately 10:35 AM. E #15 stated that after dipping the test strip in the solution, wait 90 seconds before comparing the pad to the color chart on the bottle.