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The Hospital failed to consistently provide patient privacy for one of seven patients (Non-Sampled Patient #1) who had been placed on continuous cardiac monitoring in the Neonatal Intensive Care Unit (NICU).

The Surveyor toured the NICU at 9:40 A.M. on 10/27/2020 and was accompanied by the Assistant Chief Nursing Officer (ACNO) and the Professional Development Manager (PDM) for the NICU. The Cardiac monitor was placed in the hallway for viewing by the professional staff.

Of the eight neonates being monitored, seven had only their last names posted on the monitor. However, Non-Sampled Patient #1's full name was on display. The PDM said the hallway cardiac monitors were synched with the bedside online information. All of the newborns were labeled with the first name of "Baby" and their full last name. The PDM said the exception was when a baby transferred in from another Hospital, then their full first and last names was displayed. The PDM was unable to explain the differences.

A patients full name should not be posted where visitors or staff who are not involved in a patient's care can view the patient's full name.

Based on record review and interview the Hospital failed to comply with its policy for documentation of an adverse event for one patient (Patient #4) of three patients requiring a documented disclosure.

According to the Hospital's policy titled "Disclosure of Adverse Patient Events", documentation in the medical record should contain a complete, accurate and factual record of pertinent clinical information related to the event.

The Surveyor reviewed Patient #4's medical record on 10/27/2020. Patient #4's medical record failed to include an entry into the medical record that contained the facts related to his/her remains that were not handled according to the Hospital's policies.

The Senior Risk Manager was interviewed at 2:00 P.M. on 10/27/2020. The Senior Risk Manager said the event was being considered an adverse event by the Hospital.

Based on records reviewed and email correspondence, the Hospital failed to comply with the requirement for First Aid training for three of three Security Officers who were involved in restraint application.

Subsequent to Survey the Surveyor requested the Hospital to provide additional training for three of their Security officers who would be called upon as needed for restraint application.

According to the email sent by the Hospital's Senior Risk Manager, dated 11/2/2020, First Aid training was not required for the Hospital's Security Staff who participate in restraint application.

Based on observations and interview the Hospital failed to consistently adhere to Infection Prevention activities related to the handwashing sinks in the Neonatal Intensive Care Unit (NICU).

The Surveyor toured the NICU at 9:40 A.M. on 10/27/2020 and was accompanied by the Assistant Chief Nursing Officer (ACNO) and the Professional Development Manager (PDM) for the NICU. The PDM exhibited both a one and two bed NICU suites. The PDM said that the breast feeding mothers were taught to clean and rinse the breast feeding apparatus in the patients rooms between feedings. The PDM said that the two bed units were often used for related twins but could be used for two unrelated neonates.

The Surveyor interviewed the Lactation Consultant at 11:00 A.M. on 10/27/2020. The Lactation Consultant said that the mothers were taught to place the breast feeding apparatus to be cleaned in a bucket, add water and the castile soap, wash the items and then discard the wash water into the handwashing sink. The Lactation Consultant said then the breast feeding apparatus was then rinsed and the rinse water was discarded into the handwashing sink. No other sinks or toilets were available in the patients rooms.

The Surveyor noted that there was only a single handwashing sink in both the one and two bed NICU rooms. Handwashing sinks are dedicated to handwashing only and any other cleaning activities are to occur in a utility sink.

Based on observation and record review the Hospital failed to follow its procedure for temperature monitoring of intravenous solutions in the Operating Room (OR) Suite.

The Surveyor toured the OR at 8:30 AM on 10/28/2020 and was accompanied by the ACNO for Surgical Services and the OR Operations Manager. The Surveyor observed the intravenous refrigerator that contained both frozen and chilled solutions. The attached Temperature Monitor indicated that the refrigerator was to be monitored daily. The Temperature Log indicated that the refrigerator had only been checked six times during the month of October. On closer review the
Temperature Log was from October 2019.