HospitalInspections.org

Based on interview, record review, digital video recordings and policy review, the Governing Body failed to ensure the Chief Executive Officer (CEO) was responsible for management of the entire hospital including accountability for the effective oversight of nursing staff. These failures had the potential to affect the quality of care and safety of all patients. The hospital census was 28.

Findings included:

Review of the hospital's document titled, "Medical Staff Bylaws," dated 12/01/20, showed that the property, business and affairs of the Medical Center shall be controlled and managed by its Board of Directors. The Medical Staff, Medical Center personnel and all auxiliary organizations, directly or indirectly, shall be responsible to the Board through the Administrator of Cameron Regional Medical Center.

Review of the hospital's document titled, "Clinical Assessment Coordinator Job Description," dated and signed by Staff U, Interim Director of Geriatric Psychiatry (Geropsych, a unit that focuses on treating mental health and psychiatric disorders in older adults), on 12/19/22, showed that a Bachelor's degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing or other related field was preferred and a minimum of three years of experience in a similar position and/or industry was a requirement. Responsibilities included correcting issues identified and report errors to the Program Director.

During an interview on 01/25/23 at 8:40 AM, Staff U, Interim Director of Geriatric Psychiatry, RN, stated that she had no orientation on the Geropsych unit and she did not know that staff were not doing the patient observation rounds per hospital policy. She did not have a lot of previous experience with psychiatric patients. She did not have a Bachelor's degree in chemical dependency, psychology, social work, counseling, nursing or other related field.

During an interview on 01/26/23 at 12:40 PM, Staff SS, Chief Executive Officer (CEO), stated that it was his decision to hire Staff U as the Interim Director of the Geropsych Unit. His expectation was that the director of the Geropsych Unit would know how to do patient observation rounding and provide appropriate care to the patients on that unit.

Based on interview and record review, the hospital's Governing Body failed to ensure that all contracted services were included in the Quality Assurance Performance Improvement (QAPI, process for reporting and/or identifying adverse events, near misses or review of high risk problem prone areas for patient safety) Program in order to measure the effectiveness and safety of services provided. This failure had the potential to place all patients at risk for substandard quality care and compromise their health and safety. The hospital census was 28.

Findings included:

Although requested the hospital did not provide a policy for their QAPI program.

Review of the hospital's document titled, "Hospital Departmental Summary of Performance Improvement Activities, 1st Quarter 2022," showed a listing of all patient services, finance and general services within the hospital. The listing failed to include contracted services.

Review of the hospital's untitled and undated spreadsheet showed a listing of 36 services that listed the date their contract was signed, the date the contract expired and the delineation of the contracted representative. The column designated for inclusion into QAPI was blank for all 36 services listed.

During an interview on 01/25/23 at 2:00 PM, Staff B, Assistant Director of Nursing (ADON), stated that she had taken over the QAPI responsibilities in 09/2022. She stated that contracted services were not included on the current list of services that were responsible for reporting quality data and that she wasn't aware that they needed to be. She stated that she had conferred with the Chief Executive Officer (CEO), that the QAPI plan did not include contracted services and he informed her that the physician groups listed did not have to be because the physicians were credentialed.

Based on observation, interview, record review, digital video recordings and policy review, the hospital failed to ensure that:
- Nursing staff completed patient observation rounds every 15 minutes per hospital policy for five current patients (#9, #10, #11, #12 and #13) on the Geriatric Psychiatry Unit (Geropsych, a unit that focuses on treating mental health and psychiatric disorders in older adults) and one discharged patient (#30) of six patients reviewed. (A-0395)
- There was adequate oversight and supervision of nursing personnel as the interim Geropsych Director was not qualified by education or experience in the services of psychiatric care and wasn't aware her staff were untrained for their unit positions. (A-0386)
- Emergency equipment was available in the stress testing room and/or stress testing area prior to starting a cardiac stress test (test that shows how the heart works during physical activity). (A-0395)
- Nursing staff administered medications according to hospital policy for three patients (#9, #10, and #11) of five patients observed who received medications. (A-0405)
- Staff followed hospital policy for crash cart (mobile cart that contains emergency supplies and medication) checks for four out of nine crash cart logs reviewed. (A-0395)

These deficient practices resulted in the hospital's non-compliance with specific requirements found under the Condition of Participation (CoP): Nursing Services. The hospital census was 28.

These failures created an unsafe environment and had the potential to place all patients at risk for their health and safety, also known as an Immediate Jeopardy (IJ).

As of 01/25/23, the hospital had provided an immediate action plan sufficient to remove the IJ when the hospital implemented the following actions:
- All current and oncoming staff of the Geropsych Unit were educated, verbally and in writing, on the Nursing Rounds Policy and Procedure. All remaining staff were educated prior to the start of their next shift.
- House Supervisors were to, at a minimum, make two unscheduled visits to the Geropsych unit each twelve hour shift to ask the Charge Nurse if there were any needs for the unit.
- House Supervisors were to accompany staff during Patient Observation Rounds to ensure staff were entering the room to ensure the patient was not in any distress.
- House Supervisors were to ask staff if they had any questions about the Nursing Rounds Policy and sign off on the Geropsych rounds sheet.

Based on observation, interview, record review and policy review, the hospital failed to ensure that the Director of Nursing (DON) provided adequate oversight and supervision of nursing personnel, when the Interim Geriatric psychiatry (Geropsych, a unit that focuses on treating mental health and psychiatric disorders in older adults) director had no experience in the care of psychiatric patients, and the Geropsych unit was staffed with non-trained and non-qualified staff.

These failures had the potential to affect the quality of care and safety of all patients in the hospital. The census on the Geropsych unit was five.

Findings included:

Review of the hospital's document titled, "Clinical Assessment Coordinator Job Description," dated and signed by Staff U, Interim Program Director, on 12/19/22, showed that a Bachelor's degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing or other related field was preferred and a minimum of three years of experience in a similar position and/or industry was a requirement. Responsibilities included correcting issues identified and reporting errors to the Program Director.

Review of the hospital's policy titled, "Nursing Rounds," dated 01/2016, showed the following:
- All staff are responsible to ensure a safe and therapeutic environment for patients, other staff, families and visitors.
- The Charge Nurse is responsible for assigning nursing staff to make unit/patient rounds in order to account for all patient's whereabouts and ensure a safe environment.
- Rounds are made a minimum of every 15 minutes.
- Rounds are completed by assigned staff.
- Staff will be assigned rounds for periods not to exceed two hours.
- The assigned staff member personally locates each patient listed and documents the rounds exact time, patient's location and behavior on the observation sheet under the appropriate column. Staff should obtain a verbal confirmation from patients during daytime rounds when not engaged in a scheduled group activity. The staff member places his/her initials at the top of the column above the time.
- In the event a staff member cannot complete their assigned 15 minute check the charge nurse must be notified to reassign and ensure hand off of communication between staff members.
- Documentation of 15 minute rounds is to occur at the time of assigned patient rounds and not in advance.
- While making rounds staff members are to observe for unsafe conditions.
- The staff member must enter the room to observe the condition of the patient, chest rising and respirations to ensure the patient is not in any distress.

During an interview on 01/25/23 at 8:40 AM, Staff U, Interim Director of Geropsych, RN, stated that she had no orientation on the Geropsych unit and she did not know that staff were not doing the patient observation rounds per hospital policy. She did not have a lot of previous experience with psychiatric patients. She did not have a Bachelor's degree in chemical dependency, psychology, social work, counseling, nursing or other related field.

During an interview on 01/25/23 at 8:15 AM, Staff NN, Licensed Practice Nurse (LPN), stated that she never received any type of training or instruction on performing patient observation rounds. Patient observation rounding was completed by whatever staff had the time to complete it. She did try to go into patient rooms for observation rounding, but often times got behind and just looked at the patients from the doorway. She had no idea that she was not doing patient observation rounding per hospital policy.

During an interview on 01/25/23 at 8:50 AM, Staff OO, Mental Health Technician (MHT), stated that she received training to check on patients every 15 minutes "or so," to ensure they were breathing and their location. Typically staff took turns completing 15 minute patient observation rounds. She did not know when it was her turn to complete the rounding, and it just depended on who had time to do it. Staff were to document patient observation rounding at the time the rounding was completed, but she did miss documenting at times and would go back and fill it in. Sometimes staff got busy with patient care and charting took time.

During an interview on 01/25/23 at 3:50 PM, Staff A, DON, stated that she did not know what the qualifications were for the Director of the Geropsych unit, or if Staff U had any previous experience with behavioral health patients. She would expect staff to complete the patient observation rounds according to the hospital policy.

Based on observation, interview, record review, digital video recordings and policy review, the hospital failed to:
- Ensure nursing staff adequately supervised Geriatric Psychiatry (Geropsych, a unit that focuses on treating mental health and psychiatric disorders in the older adults) Patients and performed patient observation rounds every 15 minutes (15-minute visualization and documentation of the safety of each patient) per hospital policy for all current patients (#9, #10, #11, #12 and #13), and one discharged Patient (#30) of six patients observed.
- Ensure emergency equipment was available in the stress testing room and/or stress testing area prior to starting a cardiac stress test (test that shows how the heart works during physical activity).
- Ensure staff followed the internal policy for crash cart (mobile cart that contains emergency supplies and medication) checks for four of nine crash cart logs reviewed.

These failed practices placed all patients at risk for their health and safety. The hospital census was 28.

Findings included:

1. Review of the hospital's policy titled, "Nursing Rounds," dated 01/2016, showed the following:
- All staff are responsible to ensure a safe and therapeutic environment for patients, other staff, families and visitors.
- The Charge Nurse is responsible for assigning nursing staff to make unit/patient rounds in order to account for all patient's whereabouts and ensure a safe environment.
- Rounds are made a minimum of every 15 minutes.
- Rounds are completed by assigned staff.
- Staff will be assigned rounds for periods not to exceed two hours.
- The designated staff member writes each patient's name on the observation sheet for the oncoming shift so it's prepared in time for the appropriate rounds, and dates the observation sheet.
- The assigned staff member personally locates each patient listed and documents the rounds exact time, patient's location and behavior on the observation sheet under the appropriate column. Staff should obtain a verbal confirmation from patients during daytime rounds when not engaged in a scheduled group activity. The staff member places his/her initials at the top of the column above the time.
- In the event a staff member cannot complete their assigned 15 minute check the charge nurse must be notified to reassign and ensure hand off of communication between staff members.
- Documentation of 15 minute rounds is to occur at the time of assigned patient rounds and not in advance.
- While making rounds staff members are to observe for unsafe conditions.
- The staff member must enter the room to observe the condition of the patient, chest rising and respirations to ensure the patient is not in any distress.
- Flashlights are used during the night rounds, taking care not to flash the light in the patient's face, but allowing staff to verify the patient is in his/her bed and breathing normally.

Observation on 01/23/23 at 3:00 PM, on the Geropsych Unit, with confirmation of digital video recordings, showed Staff W, Charge Nurse, and Staff X, Registered Nurse (RN), at the nurses station, where they remained until 3:30 PM, when Staff X, RN, left the unit. Four patients (#9, #11, #12, and #13) were in their patient rooms and Patient #10 was in the television room. At 3:20 PM, Patient #11 exited his room and walked to the nursing station then returned to his room at 3:29 PM, and slammed his door. No staff members were noted to walk down the hallway or go into patient rooms from 3:00 PM until 3:45 PM. At 3:45 PM, Staff W, Charge Nurse, walked down the patient hallway to open Patient #11's door and completed patient observation rounds, she did not have the patient observation rounding sheets with her. There was a book containing all five patient's patient observation rounding sheets at the nurse's station, Staff W documented her rounds upon returning to the nurses station.

Review of the hospital's document titled, "Patient Observation Rounds," dated 01/23/23, at 3:35 PM, showed that patient observation rounds were not documented at 3:15 PM or 3:30 PM, for all current inpatients.

During an interview on 01/23/23 at 3:35 PM, Staff W, Charge Nurse, stated that she needed to complete her documentation on the patient observation rounding sheets.

Review of the hospital's document titled, "Patient Observation Rounds," dated 01/23/23, at 3:50 PM, showed that patient observation rounds were documented for all five patients on the Geropsych unit, at 3:15 PM by Staff X, RN, and at 3:30 PM by Staff W, Charge Nurse.

Review of Patient #9's medical record showed the following:
- She was a 90-year-old female admitted to the Geropsych unit on 01/16/23 for aggression (behavior that is intended to harm another individual), agitation (a state of feeling irritated or restless) and violent behavior towards others.
- On 01/16/23, there was a physician's order for admission and for patient observation rounds every 15 minutes. There were no orders to discontinue the patient observation rounding every 15 minutes.
- Patient observation rounding sheets dated 01/23/23, showed that Patient #9 was on a monitoring level of every 15 minutes for aggression, assault (measures to alert staff of a patient's potential to become violent with others) and fall precautions.

Review of Patient #10's medical record showed the following:
- He was a 73-year-old male admitted to the Geropsych unit on 01/18/23 for hallucinations (seeing or hearing things which are not there) and confusion.
- On 01/18/23, there was a physician's order for admission and for patient observation rounds every 15 minutes. There were no orders to discontinue the patient observation rounding every 15 minutes.
- Patient observation rounding sheets dated 01/23/23, showed that Patient #10 was on a monitoring level of every 15 minutes for aggression, assault and fall precautions.

Review of Patient #11's medical record showed the following:
- He was a 74-year-old male admitted to the Geropsych unit on 01/16/23 for agitation and aggressive behavior.
- On 01/16/23, there was a physician's order for admission and for patient observation rounds every 15 minutes. There were no orders to discontinue the patient observation rounding every 15 minutes.
- Patient observation rounding sheets dated 01/23/23, showed that Patient #11 was on a monitoring level of every 15 minutes for aggression, assault and fall precautions.

Review of Patient #12's medical record showed the following:
- He was an 83-year-old male admitted to the Geropsych unit on 01/10/23 for agitation and aggressive behavior.
- On 01/10/23, there was a physician's order for admission and patient observation rounds every 15 minutes. There were no orders to discontinue the patient observation rounding every 15 minutes.
- Patient observation rounding sheets dated 01/23/23, showed that Patient #12 was on a monitoring level of every 15 minutes for aggression, assault and fall precautions.

Review of Patient #13's medical record showed the following:
- She was a 67-year-old female admitted to the Geropsych unit on 01/11/23 for agitation and increased confusion.
- On 01/11/23, there was a physician's order for admission and patient observation rounds every 15 minutes. There were no orders to discontinue the 15 minute safety rounding.
- Patient observation rounding sheets dated 01/23/23, showed that Patient #13 was on a monitoring level of every 15 minutes for aggression, assault and fall precautions.

During an interview on 01/23/23 at 3:00 PM and 3:50 PM, Staff W, Charge Nurse, stated that all staff did 15 minute safety rounding and it was not one person's specific duty. She performed the 3:15 PM patient observation rounding.

During an interview on 01/23/23 at 4:00 PM, Staff X, RN, stated that she did not know who completed the patient observation rounding at 3:15 PM or 3:30 PM.

Review of the hospital video recordings titled, "BHU 2023-01-24_03_30_42_925," dated 01/24/23, showed a view of the Geropsych nurses station and hallway. The review showed that from 3:03 AM until 4:18 AM, no staff members walked down the patient hallway, entered each patient's room or documented in the patient observation rounding book until 4:18 AM.

Review of the hospital's document titled, "Patient Observation Rounds," dated 01/24/23, showed that patient observation rounding sheets were documented with a behavior code and location for all five patients as being completed at 3:15 AM, 3:30 AM, 3:45 AM and 4:00 AM by Staff OO, Mental Health Technician (MHT).

During an interview on 01/25/23 at 8:50 AM, Staff OO, MHT, stated that she received training to check on patients every 15 minutes "or so," to ensure they were breathing and their location. Typically staff took turns completing the 15 minute patient observation rounds. She did not know when it was her turn to complete the rounding, and it just depended on who had time to do it. Staff were to document patient observation rounding at the time the rounding was completed, but she did miss documenting at times and would go back and fill it in. Sometimes staff got busy with patient care and charting took time.

Review of Patient #30's medical record showed the following:
- She was a 92-year-old female admitted to the Geropsych unit on 10/21/22 for physical and verbal aggression, anxiety (a feeling of fear or worry experienced intermittently) and agitation.
- Nursing documentation on 10/25/22 at 8:44 PM, showed that Patient #30 was found not breathing during the patient observation rounds and was ashen gray in color. Two RNs verified the death of the patient.
- Patient observation rounding sheets dated 10/25/22, showed that Patient #30 was on every 15 minute checks for fall precautions. Staff NN, Licensed Practice Nurse (LPN), documented on 10/25/22, at 8:45 PM, 9:00 PM, 9:15 PM, 9:30 PM and 9:45 PM, that she witnessed Patient #30 in her room with confirmation of her chest rising and falling. Those entries were marked through with error wrong patient written to the side.
- Physician documentation showed that Patient #30 was found deceased from presumed natural causes.

During an interview on 01/25/23 at 8:15 AM, Staff NN, LPN, stated that there was another patient on the unit with the same initials as Patient #30 and she documented patient observation rounding on the wrong patient. The patient observation rounding sheets were kept in a book at the nurse's station and she did not look at the patient name at the top of the page before she documented, she documented on all the patients at the same time. She never received any type of training or instruction on performing the patient observation rounding. Patient observation rounding was completed by whatever staff had the time to complete it. She did try to go into patient rooms for the observation rounding, but often times got behind and just looked at the patients from the doorway. She had no idea that she was not doing patient observation rounding per hospital policy.

During an interview on 01/25/23 at 8:40 AM, Staff U, Director of Geropsych, RN, stated that she had no orientation on the Geropsych unit and she did not know that staff were not doing the patient observation rounds per hospital policy. She did not have a lot of previous experience with psychiatric patients. She did not have a Bachelor's degree in chemical dependency, psychology, social work, counseling, nursing or other related field. Patient observation rounding should have been assigned to one person for a two hour period. She would expect staff to enter the patient's room to check on them, document and complete the rounding in real time. A lot could happen to a patient in an hour.

During an interview on 01/24/23 at 2:15 PM, Staff A, Director of Nursing (DON), stated that patient observation rounding should be assigned to one person so that all staff were on the same page. She expected staff to check on patients rather than just look at them from the doorway, a lot could happen to a patient in an hour.

2. Review of the hospital's policy titled, "Intravenous Lexiscan Myocardial Nuclear Imaging Perfusion Scan," revised 02/02/09, showed that myocardial (heart) perfusion studies used Lexiscan (a medication used for stress tests) to determine a patient's heart function. Before starting the test, staff were instructed to verify that emergency equipment was accessible in the testing room.

Review of the hospital's policy titled, "Dobutamine Stress Echocardiography," (a test that makes images of the heart and surrounding structures), revised 11/15/07, showed that myocardial perfusion studies used dobutamine (a medication used for stress tests) to determine a patient's heart function. Before starting the test, staff were instructed to verify that emergency equipment was available in the stress testing area.

Review of the hospital's policy titled, "Dobutamine/Myocardial Perfusion Stress Test," revised 11/15/07, showed that heart perfusion studies used dobutamine to determine a patient's heart function. Before starting the test, staff were instructed to verify that emergency equipment was available in the stress testing area.

Observation on 01/26/23 at 10:35 AM, showed a cardiac stress test was in progress. There was no crash cart or emergency equipment within close vicinity. Upon surveyor request, Staff UUU, RN, attempted to unlock the door to the cardiac rehabilitation (cardiac rehab) room, where the crash cart was kept. Her key did not work, and she had to get a different key to open the door. The crash cart was not in the cardiac rehab room. Staff UUU walked over to a locked office in the cardiac rehab room and attempted to unlock the office door. Her key did not work, and she had to get the house supervisor's key to unlock the office door. The crash cart was in the office.

Observation on 01/26/23 at 12:11 AM showed it was 80 feet from the medical/surgical units' crash cart to the cardiac stress test room. It was 26 feet and two locked doors from the cardiac rehab rooms' crash cart to the cardiac stress test room.

During interviews on 01/26/23 at 10:40 AM and 11:47 AM, Staff UUU, RN, stated that she performed cardiac stress tests. A crash cart should be readily available during a stress test. Physically, there was no room in the cardiac stress test room for a crash cart to be present. They tried many different configurations of the room and equipment, but there was just no way to fit the crash cart in the cardiac stress test room, so they shared the crash cart with cardiac rehab. Normally, the crash cart was easy to access, and Staff UUU had not been told that the crash cart had to be in the room when she performed a cardiac stress test. She was not in charge of checking the crash cart and stated that cardiac rehab was responsible for checking the crash cart. She did not check the crash cart before performing a cardiac stress test.

During an interview on 01/26/23 at 12:05 PM, Staff A, DON, stated that emergency equipment was available down the hallway on the Med/Surg unit if needed in an emergency during a stress test.

3. Review of the hospital's policy titled, "Crash Carts," revised 02/02/12, showed that crash carts will be checked by nursing personnel on a regular basis to assure they are ready for use. The crash cart will be checked every shift and documented. Crash carts in areas where staff is not present at all times (e.g. cardiac rehab, recovery room) will be checked every day there is staff working.

Record review of the Obstetrics (OB, the branch of medical science concerned with childbirth and caring for and treating women in or in connection with childbirth) department crash cart logs showed the following:
- No check for day shift on 08/10/22, 08/29/22 and 08/30/22;
- No check for night shift on 08/27/22;
- No check for day shift on 09/27/22;
- No daily check on 09/28/22;
- No check for day shift on 10/01/22, 10/02/22, 10/06/22, 10/13/22, 10/29/22 and 10/30/22;
- No check for night shift on 10/05/22;
- No check for day shift on 11/17/22, 11/18/22, 11/23/22, and 11/24/22;
- No check for night shift on 11/01/22 and 11/26/22;
- No check for day shift on 12/30/22;
- No check for night shift on 12/15/22, 12/16/22, and 12/22/22; and
- No check for night shift on 01/18/23.

Record review of the Medical Surgical unit's checklist for the crash cart logs showed the following:
- No check for night shift on 08/28/22;
- No check for night shift on 09/11/22;
- No check for day shift on 09/26/22 and 09/29/22;
- No check for day shift on 10/11/22;
- No check for day shift on 11/04/22; and
- No daily check on 12/27/22 and 12/28/22.

Record review of the Intensive Care Unit's (ICU, a unit where critically ill patients are cared for) checklist for the crash cart logs showed the following:
- No check for night shift for one of two crash carts on 08/27/22;
- No check for night shift for two of two crash carts on 09/11/22;
- No check for day shift for one of two crash carts on 10/14/22;
- No check for day shift for one of two crash carts on 11/04/22;
- No check for night shift for one of two crash carts on 11/19/22;
- No check for night shift for two of two crash carts on 12/09/22;
- No check for night shift for one of two crash carts on 12/17/22 and 12/18/22; and
- No check for day shift for two of two crash carts on 12/31/22.

Record review of the Cardiac Rehabilitation department's checklist for the crash cart logs showed no daily check on 01/04/23, 01/05/23, 01/09/23, 01/12/23, 01/18/23, 01/19/23 and 01/26/23.

Record review of the cardiology schedule for 01/2023 showed the following:
- One patient had a cardiology test performed on 01/04/23;
- One patient had a cardiology test performed on 01/05/23;
- Four patients had cardiology tests performed on 01/12/23;
- One patient had a cardiology test performed on 01/18/23; and
- Three patients had cardiology tests performed on 01/26/23.

During an interview on 01/23/23 at 3:15 PM, Staff F, RN, OB Manager, stated that the unit had a responsibility checklist with staff assigned each month for the checking of the crash cart and that this checklist was posted on the unit bulletin board.

During an interview on 01/25/23 at 3:50 PM, Staff A, DON, stated that she expected crash carts to be checked twice daily, at the beginning of every shift.


41474




46856

Based on observation, interview and policy review, the hospital failed to ensure staff followed medication administration guidance when staff did not administer medications to three current patients (#9, #10 and #11) per hospital policy, of five patient medication administrations observed. These failed practices placed all patients at risk for their health and safety.

Findings included:

Review of the hospital's document titled, "Medication Practices," dated 01/2016, showed that staff on the Geriatric psychiatry (Geropsych, a unit that focuses on treating mental health and psychiatric disorders in older adults) unit were to follow the hospital's policy regarding medication administration practices in addition to identification of two patient identifiers.

Review of the hospital's policy titled, "Medication Administration," dated 04/01/13, showed the following directives for staff:
- The medications will be taken to the bedside by the nurse.
- The nurse will scan the patient armband to check identification.
- The nurse will proceed to give the medications by the route ordered scanning each medication prior to administration.
- The time of administration will appear on the medication administration record as scanned.

Observation with concurrent interview on 01/23/23 at 4:00 PM, showed Staff X, Registered Nurse (RN), pulled medications from the medication dispensing machine for Patient's #9, #10, #11, #12 and #13 and placed the medications, in their packaging, in a styrofoam cup with the patient's first name written on it. Staff X stated that she pulled the medications for all the patients at once and just wrote the patients name on the cup. Staff X then opened up four medications for Patient #10 and put the pills in a clear medication cup, and the opened packaging back into the styrofoam cup, placing it back on the medication cart. Staff X took the opened medication to Patient #10 and did not look at or scan his arm band, she then went back to the medication room and opened up a book containing Patient #10's picture, with a barcode label below the photo. Staff X stated that she did not have to scan the patient's armband prior to administration of medications, she used the book in the medication room with a barcode to scan the patient, she knew all of the patients so she did not need to ask them their names. She scanned the bar code label and then scanned the medication packages. Staff X stated that she did not need to scan the medication package before she administered them, if a patient refused their medications then she could easily go in and amend the medication. Staff X repeated this procedure for Patient #9 and Patient #11's medication administration. Staff X stated that she was probably supposed to take the computer and scanner with her to pass the medications.

During an interview on 01/24/23 at 2:15 PM, Staff U, Interim Director of Geropsych, RN, stated that she would expect staff to pull the medications for patients according to the medication administration record (MAR), take the medications in their packaging to the patients room, scan the patients identification armband, then scan each medication as it was administered. There was a book in the medication room with a picture of each patient that could be used if the patient refused to have their identification armband scanned or if the armband was unable to be scanned. If staff utilized the book they were to take it to the patient's room with them.

During an interview on 01/24/23 at 2:15 PM, Staff A, Director of Nursing (DON), stated the staff were to pull the medications according to the MAR, take the medication to the patient, scan the patients ID armband, then scan the medications in front of the patients when they took them.

Based on observation, interview and policy review, the hospital failed to ensure staff followed infection prevention policies when:
- Staff did not perform hand hygiene with glove changes, dressing changes and catheter care for five patients (#5, #14, #21, #31, and #34) of five patients observed;
- Staff did not perform hand hygiene during medication administration for four patients (#9, #10, #11, and #28) of four patients observed;
- Staff did not follow hospital policy for intravenous (IV, in the vein) insertions for one patient (#18) of one patient observed;
- Staff did not prepare a clean work surface prior to dressing changes and IV insertion for two patients (#14 and #21) of two patients observed; and
- Multi-use bottles were used for more than one patient, multi-use bottles were not dated after being opened, and staff did not remove expired supplies from use.

These failures had the potential to expose all patients, visitors and staff to cross contamination and increased the potential to spread infection. The hospital census was 28.

Findings included:

1. Review of the hospital's policy titled, "Gloves," dated 11/2021, showed that gloves would be worn:
- To prevent cross contamination from patient to patient, patient to employee, and employee to patient; and hands should be washed after removing gloves and gloves do not replace hand washing.
- When touching excretions, secretions, blood, body fluids, mucous membranes, or non-intact skin;
- When handling potentially contaminated objects; and
- When it was likely that hands would come into contact with any type of body fluid or any type of infectious material.

Review of the hospital's policy titled, "Catheterization: Intermittent/Indwelling/Urinary/Suprapubic Insertion, Removal, and Care Of," revised 03/30/10, showed that catheter care should be completed once per shift and as needed. Prior to performing catheter care, staff are to wash or sanitize their hands and apply gloves. After performing catheter care, staff are to remove their gloves and wash or sanitize their hands. Staff were to wash or sanitize their hands and apply gloves prior to removing an indwelling catheter.

Observation on 01/24/23 at 3:00 PM, on the Medical/Surgical Unit, showed Staff J, Registered Nurse (RN), performed a urinary catheter (a small flexible tube inserted into the bladder to provide continuous urinary drainage) removal on Patient #5. Staff J touched her mask with her gloved hand after touching Patient #5's catheter and after she removed the catheter, and Staff J touched the bathroom door with her gloved hand after touching the removed catheter with gloved hands.

Observation on 01/25/23 at 9:22 AM, on the Medical/Surgical Unit, showed Staff YY, Certified Nurse Assistant (CNA), and Staff ZZ, Restorative Nurse's Aide, performed urinary catheter care on Patient #14. Staff ZZ changed her gloves once and did not perform hand hygiene between her glove changes.

Observation on 01/24/23 at 11:33 AM, on the Medical/Surgical Unit, showed Staff DD, RN, did not remove her gloves and perform hand hygiene after performing a blood glucose (sugar) check on Patient #21. While wearing her gloves, Staff DD touched multiple objects in Patient #21's room, after performing the blood glucose test.

Observation on 01/25/23 at 9:13 AM, on the Medical/Surgical Unit, showed Staff WW, CNA, and Staff XX, Licensed Practical Nurse (LPN), performed urinary catheter care on Patient #21. Staff WW changed her gloves five times, and did not perform hand hygiene between glove changes.

Observation on 01/25/23 at 9:55 AM, on the Intensive Care Unit, (ICU, a unit where critically ill patients are cared for) showed Staff UU, RN, entered Patient #31's room, to perform lower leg dressing changes. Staff UU cleansed between the patients' toes; then removed his gloves and did not perform hand hygiene and reapplied gloves.

Observation on 01/25/23 at 9:47 AM, on the Medical/Surgical Unit, showed Staff YY, CNA, and Staff AAA, CNA, performed urinary catheter care on Patient #34. Staff AAA lifted her dirty washcloth up over Patient #34's bedside table and belongings before disposing of the washcloth. Staff AAA finished the catheter care, then touched the television remote, television guide and the blankets without changing her gloves or performing hand hygiene.

During an interview on 01/25/23 at 9:58 AM, Staff AAA, CNA, stated that she should have washed her hands and changed her gloves after catheter care and prior to touching other objects in Patient #34's room. She should not have lifted the dirty washcloth over Patient #34's bedside table and belongings.

During an interview on 01/26/23 at 10:07 AM, Staff C, Infection Prevention RN, stated that hand hygiene should always be done between glove changes.

2. Review of the hospital's policy titled, "Medication Administration," dated 04/01/13, showed that medications will be taken to the bedside by the nurse, washing her hands as she enters the room, then washing her hands after completion of the medication pass.

Observation on 01/23/23 at 4:00 PM, on the Behavioral Health Unit, showed Staff X, RN, did not perform hand hygiene before or after administering medications to Patient's #9, #10 and #11.

Observation on 01/24/23 at 2:36 PM, on the Medical/Surgical Unit, showed Staff J, RN, did not perform hand hygiene before administering two medications to Patient #28.

During an interview on 01/23/23 at 4:00 PM, Staff X, RN, stated that she should have performed hand hygiene prior to, and after medication administration for each patient.

During an interview on 01/24/23 at 2:15 PM, Staff U, Interim Director of Geriatric Psychiatry (Geropsych, a unit that focuses on treating mental health and psychiatric disorders in older adults), RN, stated that she would expect staff to perform hand hygiene before and after administering medications to patients.

3. Review of the hospital policy titled, "Infection Control," revised 01/04/97, showed direction for Nuclear Medicine (a branch of medicine that deals with the use of radioactive substances in research, diagnosis and treatment) department staff to follow infection control guidelines of its parent institution.

Review of the hospital policy titled, "Intravenous Therapy," reviewed 10/2020, showed direction to staff to initiate and maintain IV access for fluid and medication administration.
The policy did not show direction for staff to take if in the event an IV attempt was unsuccessful.

Observation on 01/24/23 at 9:05 AM, in the Radiology Department, showed Staff AA, Nuclear Medicine Supervisor, attempted IV access to Patient #18 in preparation for injection of a radiopharmaceutical (a drug that contains a radioactive substance used to diagnose or treat disease) for a diagnostic test. Staff AA inserted the needle through the patient's skin but did not gain access into her vein. Staff AA removed the needle and attempted access in a different location with the same needle.

During an interview on 01/24/23 at 9:52 AM, Staff AA stated that he didn't change needles because he "didn't get in" and wasn't able to gain IV access within the vein so he didn't think he needed to change needles.

4. Review of the hospital's policy titled, "Clean and Contaminated Dressing Changes", dated 01/29/08, showed that equipment is placed on a clean, flat surface and maintain a sterile field for clean wounds.

Observation on 01/26/23 at 9:16 AM, on the Medical/Surgical Unit, showed Staff UU, RN, and Staff QQQ, CNA, performed a coccyx (tailbone area) dressing change on Patient #14. Staff UU did not clean his workspace prior to laying out his supplies, and placed his supplies on the patient's bed.

Observation on 01/24/23 at 10:00 AM, on the Medical/Surgical Unit, in Patient #21's room, showed Staff DD, RN, preparing supplies to insert an IV. She opened the sterile supplies onto the sheet of the patient and proceeded to cleanse the skin with an alcohol preparation. She placed the used and dirty alcohol preparation on the patients' sheet.

During an interview on 01/24/23 at 10:30 AM, Staff DD, RN, stated that she should have cleaned the patients' tray table and placed the supplies on it.

During an interview on 01/26/22 at 10:07 AM, Staff C, Infection Prevention RN, stated that staff were educated to place a clean field when doing dressing changes or inserting IV's.

5. Review of the hospital's policy titled, "Infection Prevention Out Dated Products", dated 10/2020, showed that all departments will check for outdates on a monthly basis. Products that are outdated may not be used on any patient. The departments will check all supplies for outdates monthly. Solutions that are opened and used will be dated with the date they are opened and will be discarded on the 28th day.

Observation on 01/23/23 at 2:35 PM, on the Obstetrics (OB, the branch of medical science concerned with childbirth and caring for and treating women in or in connection with childbirth) department showed one opened, undated, bottle of mineral oil in the triage (process of determining the priority of a patients treatment based on the severity of their condition) room.

Observation on 01/23/23 at 2:53 PM, in an empty OB patient room, showed one opened, undated, bottle of mineral oil.

Observation on 01/23/23 at 2:55 PM, in an empty OB exam room, showed one opened, undated, bottle of antiseptic skin cleanser.

Observation on 01/23/23 at 3:05 PM, in Nursery supply room, showed one opened, undated, bottle of iodine cleanser.

Observation on 01/23/23 at 3:10 PM, in a supply room within the nursery, showed seven expired 4.0 endotracheal tubes (a tube inserted through the mouth or nose that extends into the lungs, to maintain an open airway). The endotracheal tubes showed an expiration date of 10/16/2022.

Observation with concurrent interview on 01/24/23 at 10:00 AM, in Patient #21's room, on the Medical/Surgical Unit, showed one opened, undated bottle of sterile water. Staff DD, RN, stated that the sterile water had not been opened by her and she did not know what it was being used for. She stated that it should have been dated when opened.

Observation on 01/25/22 at 9:55 AM, on the ICU, showed Staff UU, RN, entered Patient #31's room, to perform lower leg dressing changes. Staff UU cleansed the patients' legs with a no rinse foam cleanser which was not dated when opened. Staff UU used a wound irrigation solution which was not dated when opened. Staff UU removed the solution from the room.

During an interview on 01/25/22 at 10:30 AM, Staff UU, RN, stated that the wound irrigation solution bottle would be wiped with cleanser and used for more than one patient.

During an interview on 01/23/23 at 3:15 PM, Staff F, RN, OB Manager, stated that the unit had a responsibility checklist with staff assigned each month for the checking of outdated supplies and that this checklist was posted on the unit bulletin board and that opened multi-use bottles should be dated with the date they were opened.

During an interview on 01/26/22 at 10:07 AM, Staff C, Infection Prevention RN, stated that the OB department did monthly checks for expired supplies and so nothing should be missed.



32280




41474




46856

Based on observation, interview, record review and policy review, the hospital failed to ensure a current roster, listing each practitioner's specific surgical privileges and restricted surgical privileges was available in the surgical suite and the area where surgical procedures were scheduled. This failed practice had the potential to compromise the safety and health of all patients undergoing surgical procedures if these procedures were performed by physicians without surgical privileges or restricted privileges. The hospital performed approximately 93 surgeries per month. The hospital census was 28.

Findings included:

Review of the hospital's policy titled, "Practitioner Privileges," revised 03/28/22, showed that all practitioners performing surgery at Cameron Regional Medical Center must have surgical privileges. Surgical privileges must correspond with the established competencies of each practitioner.

Observation on 01/25/23 at 10:15 AM, in the Surgical Services scheduling area, located in the pre and post procedure area, showed no roster listing each practitioner's specific surgical privileges and restricted privileges.

Observation with concurrent interview on 01/25/23 at 10:20 AM, in the Surgical Services department, located through a set of doors and down the hallway from the scheduling area, was Staff GGG, Registered Nurse (RN), Surgical Services Supervisor's office/desk area. Inside a drawer in no particular order were several sheets of paper. Staff GGG, Surgical Services Supervisor, stated that she kept physician privileges inside this drawer. Physician privileges were not posted in the operating rooms. Surgical services staff could contact Staff TTT, Credentialing Coordinator, if they had a question about physician privileges.

During an interview on 01/26/23 at 8:15 AM, Staff TTT, Credentialing Coordinator, stated that she worked Monday through Thursday from 6:15 AM to 4:30 PM and on Fridays until noon. She was available by cell phone after hours but would not know what privileges physicians had if she was not in her office.

During an interview on 01/25/23 at 10:47 AM, Staff HHH, Surgical Services unit secretary, stated that she scheduled surgeries for the hospital. Physician privileges were located in a drawer by Staff GGG's desk. She had never looked in the drawer to verify a physician's privileges.

During an interview on 01/26/23 at 10:30 AM, Staff VVV, Surgical Services RN, stated that she had worked in the operating room for two years. She had not looked in the drawer by Staff GGG's desk to verify any physician privileges. Staff GGG lets staff know what privileges the physicians had.