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Based on document review, observation, and interview, it was determined that the Hospital (Hospital A and B) failed to ensure the maintenance of a sanitary environment in food handling and storage. This failure has the potential to affect an average of 45 patients receiving meals from the dietary department each day. As a result, the Condition of Participation (CFR 482.28) Food and Dietetic Services was not in compliance.

Findings include:

1. The Hospital failed to label opened food products and discard outdated food products to ensure that they were safe for consumption. See deficiency A-620 A.

2. The Hospital failed to measure and record food temperatures to ensure food is being served at safe temperatures. See deficiency A-620 B.

3. The Hospital failed to monitor the temperatures of patient nourishment refrigerator. See deficiency A-620 C.

4. The Hospital failed to ensure that the dietary dress code was followed by staff while in the kitchen. See deficiency A-620 D.

5. The Hospital failed to ensure that procedure was followed in maintenance of the concentration of the sanitation buckets. See deficiency A-620 E.

Based on observations 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 November 12-13, 2019, the facility failed to provide and maintain a safe environment for patients, staff and visitors.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710.

Based on observation, document review and interview, it was determined that the Hospital failed to ensure infection control practices were implemented and sanitary environment was maintained to prevent cross contamination. This failure has the potential to affect all patients receiving care from the Hospital. As a result, the Condition of Participation CFR 482.42, Infection Control was not in compliance.

Findings include:

1. The Hospital failed to implement policies related to prevention of infection when conducting a terminal room cleaning. See deficiency cited at A -0748.

2. The Hospital failed to ensure that isolation precautions were implemented and hand hygiene was followed. See deficiency cited at A -0749 C and D.

3. The Hospital failed to ensure that infection control practices were followed during the bedside blood glucose testing and medication preparation. See deficiency cited at A -0749 A & B.

Based on document review, observation, and interview, it was determined that for 2 of 2 patients (Pts. #23 and #24) reviewed for pain management on the 2nd Floor Medical Unit (2 North/South) at Hospital B, the Hospital failed to ensure that an assessment was conducted prior to administration of pain medications in order to assess the effectiveness of pain management.

Findings include:

1. The Hospital's policy titled, "Pain Management Plan" (dated 6/2019), was reviewed on 11/13/19 and required, "...Ongoing pain assessments and reassessments are performed by licensed nurses at least every shift, when a patient complains of pain and after an analgesic [pain reliever] is given to determine the effectiveness of the analgesic. Each pain assessment and reassessment will be documented in the patient medical record..."

2. The clinical record of Pt. #23 was reviewed on 11/12/19. Pt. #23 was admitted on 10/30/19, with a diagnosis of unspecified right upper arm and right knee wound. A physician's order, dated 11/10/19, indicated that oxycodone (a pain reliever) could be administered as needed every 4 hours for severe pain level of 7-10 (out of a 10 point scale, with 10 indicating the worst pain). Pt. #23's medication administration records indicated that oxycodone was administered on 11/11/19 at 11:45 AM and again at 6:00 PM; however, a pre-assessment of the patient's pain was not documented prior to either administration.

3. The clinical record of Pt. #24 was reviewed on 11/12/19. Pt. #24 was admitted on 10/7/19, with a diagnosis of open abdominal wound. A physician's order, dated 10/27/19, indicated that oxycodone could be administered as needed for moderate pain level of 5-6 (out of a 10 point scale, with 10 indicating the worst pain). Pt #24's medication administration record dated 10/27/19 did not include a pre-assessment of the patient's pain.

4. An interview was conducted with the Nursing Supervisor (E#15) on 11/12/19, at approximately 12:30 PM. E#15 confirmed that Pt. #23 and #24 did not have an appropriate pain assessment documented prior to administration of pain medication. E#15 stated that an assessment should be conducted prior to each administration of pain medication so that the nurse can effectively evaluate the effectiveness of the intervention.

Based on document review and interview, it was determined that the Hospital's Medical Record Departments at Hospital A and Hospital B failed to ensure medical records were completed within 30 days following discharge, as required.

Findings include:

1. The Hospital's Medical Staff Rules and Regulations (reviewed by Hospital 3/17) included, "Delinquent records are those that are incomplete, including signatures, after thirty (30) days following discharge of the patient."

2. On 11/13/19, the Medical Records Clerk (E #8) presented the surveyor with a letter of attestation which included, "As of today, November 13, 2019, ...(Hospital A) has one (1) delinquent medical record."

3. On 11/13/19 at approximately 10:20 AM, an interview was conducted with the Medical Records Clerk (E #8). E #8 stated that, the physicians are able to view and sign the records electronically, and medical records should be completed within 30 days of discharge.

4. A letter signed by the Director of Quality Management, dated 11/13/19, was reviewed on 11/13/19 and included, "As November 13, 2019, (Hospital B) has three records that are not completed within the 30 days of discharge."

5. An interview was conducted with the Medical Records Technician (E#22) on 11/13/19, at approximately 12:14 PM. E#22 stated that records should be completed within 30 days after discharge. E#22 stated that as of now, there are 3 delinquent records that have not yet been completed and are past 30 days from the patients' discharge dates.

Based on document review, observation, and interview, it was determined that for 1 of 2 nursing carts observed at Hospital B, the Hospital failed to ensure that carts with medications were locked when left unsupervised. This has the potential to affect all 11 patients on the 2 North/South Unit on 11/12/19.

Findings include:

1. The Hospital's policy titled, "Storage of Medications" (dated 6/2019), was reviewed on 11/13/19 and required, "...Locked storage areas and/or carts will be provided for each patient care unit... All medications will remain in a secured locked area or distribution system until administration..."

2. An observational tour of the 2nd Floor Medical Unit (2 North/ South) at Hospital B was conducted on 11/12/19, between approximately 9:35 AM and 1:30 PM. Between approximately 9:40 AM and 9:55 AM, a Registered Nurse (E#16) went into a patient's room (Pt. #23) to administer medications while leaving her nursing cart outside the room. The nursing cart was unlocked and contained an IV (intravenous) medication bag for another patient (Pt. #26). While using the computer in the room, E#16 had her back turned towards the cart and was not able to supervise the cart at all times.

3. An interview was conducted with the Registered Nurse (E#16) on 11/12/19, at approximately 1:20 PM. E#16 stated that the key to her cart has been lost and therefore her cart is unable to be locked.

A. Based on document review, observation, and interview it was determined that for 1 of 2 food service departments (Hospital A) and 2 of 3 patient care units (5th floor medical-surgical/telemetry and the High Acuity Unit) at Hospital A, the Hospital failed to manage dietary services by labeling opened food products and discarding outdated food products to ensure that they were safe for consumption. This failure has the potential to affect an average of 11 patients who consume daily meals at the Hospital.

Findings include:

1. On 11/13/19, the Hospital's policy titled, "Food and Supply Storage" dated 06/2019, was reviewed. The policy included, "2. Labeling and rotating food supply a. For food products that are opened and not completely used of prepared at facility and stored, the product should be labeled as to its contents and use-by dates. iv. All food removed from its original container must be labeled with the common name of the food."

2. On 11/12/19 between 9:10 AM - 10:30 AM, an observational tour of the High Acuity Unit (HAU) at Hospital A was conducted.
-The patient nourishment refrigerator contained one (1) unopened carton of milk with an expiration date of 10/2/19, two (2) unopened containers of thick and easy (food and beverage thickeners for patients with difficulty swallowing) with expiration dates of 5/8/18 and 10/28/19.

3. On 11/12/19 between 9:20 AM - 10:45 AM, an observational tour of the 5th floor medical-surgical/telemetry unit at Hospital A was conducted.
-There was one (1) unopened carton of milk with an expiration date of 11/11/19, one (1) opened carton of milk with an expiration date of 11/10/19, two (2) opened and unlabeled jars of sports drinks, one (1) container of jello with an expiration date of 10/30/19, two (2) unlabeled luncheon meat sandwiches in plastic wrap, one (1) unlabeled and undated container of grapes, and one (1) container of thick and easy with an expiration date of 10/19/19.

4. On 11/13/19 between 11:00 AM - 12:15 PM, an observational tour of the food service department at Hospital A was conducted.
-There was one (1) opened and unlabeled bag of couscous, one (1) can of cream of mushroom with an expiration date of 11/2018, and two (2) bottles of sherry cooking wine with an expiration date of 10/14/19 in the dry storage room.
-There were three (3) cartons of egg beaters with an expiration date of May 5, 2017. The following items were removed from their original package and unlabeled in the freezer #4: one (1) bag of frozen chicken wings, one (1) bag on unknown frozen meat, one (1) bag of frozen hot dogs, one (1) bag of frozen meat balls, one (1) bag of frozen mozzarella sticks, two (2) bags of frozen chicken patties, three (3) bags of frozen hamburger patties, three (3) bags of frozen sausage links, and two (2) bags of frozen turkey links.
-There was one (1) jar of mayonnaise with an expiration date of July 24, 2019. The following items were opened and unlabeled in refrigerator #5: one (1) jar of barbeque sauce, one (1) jar of pickles, and one (1) jar of cherries.
-There was one (1) pan of marinara sauce with a use by date of 11/4/19, one (1) pan of crushed tomatoes with an open date of 11/11/19, two (2) packages of sliced turkey breast with a freeze or use by date of 11/9/19, and one (1) opened and unlabeled package of sliced turkey breast in refrigerator #6.

5. On 11/12/19 at approximately 9:20 AM, an interview was conducted with a Registered Nurse (RN-E #9). E #9 stated that, all expired food or drinks should have been discarded because it is not safe for consumption.

6. On 11/12/19 at 9:25 AM, an interview was conducted with a Nurse Supervisor (E #2). E #2 stated that the food and drinks in the patient nourishment refrigerator should be labeled with the date and the patient's name. E #2 stated that it is the responsibility of the dietary and nursing staff to check the expiration dates on the food and drinks each day.

7. On 11/13/19 at approximately 11:30 AM, an interview was conducted with the Culinary Service Manager (E #4). E #4 stated that when food is removed from the original container and/or opened, it should be labeled with the opened date and the use by or expiration date. E #4 stated that expired food should be thrown away because they are not safe to serve to the patients. E #4 added that milk and sandwiches are sent to the nursing units on the patient trays for immediate consumption. Once the food has been delivered to the patients, E #4 stated that the milk and sandwiches should not be placed in the patient nourishment refrigerator as it can lead to cross-contamination.

B. Based on document review, observation, and interview it was determined that for 1 of 2 (Hospital A) food service departments, the Hospital failed to measure and record food temperatures to ensure food is being served at safe temperatures. This failure has the potential to affect an average of 11 patients receiving daily meals from the dietary department.

Findings include:

1. The Hospital's policy titled, "Food Production" dated 06/2019 was reviewed on 11/14/19. The policy required, "6. Prior to placing food on the steam table for holding, check temperature to assure temperature is greater or equal to 135*F (degrees Fahrenheit). If not, reheat to 165*F for 15 seconds."

2. The Hospital's policy titled, "Food Temperature Measurement" dated 06/2017 was reviewed on 11/14/19. The policy required, "1. Cook all food to minimum internal temperatures (as referenced in FDA/Food and Drug Administration Food Code) as measured with a food thermometer before removing food from the heat source...Record final internal cooking temperature on food temperature log. Internal cooking temperature assures food safety by minimizing risk of microorganism contamination."

3. The Hospital's policy titled, "Tray Line Set Up, Service and Meal Delivery" dated 06/2017 was reviewed on 11/14/19. The policy required, "11. Take and record the temperature of hot or cold food before tray line starts."

4. On 11/13/19 at 11:40 AM, the lunch meal tray line was initiated. The food temperatures were not measured and recorded prior to starting the tray line.

5. On 11/13/19, the "Patient Food Temperature Log" dated 9/2019 - 11/13/19 was reviewed. The logs lacked documentation of dinner food temperatures on 9/2/19, 9/4/19, 9/9/19, 9/13/19 - 9/15/19, 9/17/19, 9/20/19 - 9/23/19, 9/26/19, 11/1/19, 11/2/19, 11/5/19, and 11/6/19. The logs lacked documentation of lunch and dinner food temperatures on 9/16/19. The logs lacked documentation of breakfast, lunch, and dinner food temperatures on 11/3/19 and 11/4/19. The logs lacked documentation of lunch food temperatures on 10/1/19, 10/9/19, and 11/13/19.

6. On 11/3/19 at approximately 11:20 AM, an interview with the Culinary Service Manager (E #4) was conducted. E #4 stated that the food temperatures should be measured for each meal served to the patients to ensure that the food is being served at safe temperatures.

C. Based on document review, observation, and interview, it was determined that for 2 of 3 patient care units (5th floor medical-surgical/telemetry and the High Acuity Unit) at Hospital A, the Hospital to failed to monitor the temperatures of patient nourishment refrigerators, as required, potentially affecting 12 patients on the census.

Findings include:

1. The Hospital's policy titled, "Refrigerator/Freezer Temperature Monitoring" (dated 6/2018) was reviewed and included, "...1. Proper monitoring of cold storage temperature to assure food safety. 2. Ambient (interior) temperatures of refrigerators and freezers where food is stored (e.g., refrigerators in the kitchen and in nourishment rooms) are monitored...each day to verify functioning of the equipment. 3 ...Nourishment room...refrigerator temperatures are checked and recorded once daily..."

2. On 11/12/19 between 9:10 AM - 10:30 AM, an observational tour of the High Acuity Unit (HAU) at Hospital A was conducted. The patient nourishment refrigerator and freezer temperature log for 7/2019 was reviewed and the log lacked documentation that temperatures were being monitored from 7/2/19 through 10/31/19.

3. On 11/12/19 at approximately 10:00 AM, the Nourishment Room Refrigerator and Freezer Temperature Log for HAU was requested for 7/2/19 through current date. On 11/12/19 at approximately 2:30 PM, the Hospital only provided Temperature log for 11/1/19 through 11/12/19.

4. On 11/12/19 between 9:20 AM - 10:45 AM, an observational tour of the 5th floor medical-surgical unit was conducted. The patient nourishment refrigerator and freezer temperature logs for October 2019 and November 2019 were reviewed. The refrigerator temperature log lacked documentation for 28 out of 31 days in the month of October 2019. The refrigerator temperature log lacked documentation from November 1, 2019 - November 11, 2019.

5. On 11/12/19 at 9:25 AM, an interview was conducted with a Nursing supervisor (E #3). E #3 stated that the patient nourishment refrigerators should be checked by the dietary staff each day.

6. On 11/13/19 at 11:30 AM, an interview was conducted with the Director of Dietary (E #4). E #4 stated that the nourishment refrigerator temperatures should be checked every day by the dietary staff.

7. On 11/14/19 at approximately 10:30 AM, an interview was conducted with the Culinary Service Manager E #4). E #4 stated that the dietary staff are responsible for checking and documenting the temperature on the patient nourishment refrigerators. E #4 stated that the refrigerator temperatures were not checked because the dietary staff were inconsistent when performing their assigned duties.


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D. Based on observation, document review and interview it was determined that, for 2 of 3 dietary staff (E #19 and E #20) observed in the kitchen at Hospital B for safe handling of food, the Hospital failed to ensure that the dress code was followed by staff while in the kitchen. This has the potential to affect 34 patients who received meals from the kitchen on 11/13/19.

Findings include:

1. On 11/13/19 between 10:30 AM to 11:30 AM, during the observational tour of the kitchen at Hospital B, the following were observed:

- The Cook (E #19) was seen cooking spinach for lunch without the hairnet and with a cap on exposing 2 (two) inches of hair all through the back of her neck.

- The Dietary Aide (E #20) was seen arranging food in the dry storage area without hair net.

2. The Hospital policy titled, "Core: Personal Hygiene - Nutrition and Culinary Services - Safety, Cleaning and Sanitation" dated 06/2017 was reviewed. The policy included, "Protective measures are necessary to minimize the risk of the potential transfer of foodborne illness causing pathogens from a food handler or food service workers who may be handling the food, food services utensils, food service equipment, and other items used in the service of food to patients ...8. Hair Restraints (applies to personnel in the kitchen): a. Hair restrains such as hats, hair coverings or nets, and beard restraints are worn at all times when in the kitchen ...b. Hair is to be fully contained inside the covering."

3. On 11/13/19 at approximately 10:45 AM, the Dietary Aide (E #20) at Hospital B was interviewed. E #20 stated that, he was in a hurry and not sure when the hair net fell off his (E #20's) head.

4. On 11/13/19 at approximately 10:50 AM, the Supervisor of Food Services (E #21) at Hospital B was interviewed. E #21 stated that, the hair net must be worn while in the kitchen. Before, the staff enter the kitchen, all kitchen staff are required to wash their hands and wear hair net for safe handling of food. E #21 continued to say that, no hair must be exposed. Hair can cause contamination of food.

E. Based on observation, document review and interview it was determined that for 3 of 3 buckets (red buckets used for sanitary purposes) used in the kitchen at Hospital B, the Hospital failed to follow the manufacturer's guidelines to maintain the concentration of the sanitizing solution. This can potentially affect 34 patients in the Hospital as of 11/13/19.

Findings include:

1. On 11/13/19 between 10:30 AM to 11:30 AM, during the observational tour of the kitchen at Hospital B, the following were observed:

- The disinfectant bucket one (1) solution used to clean the cooking area surfaces was tested using the QT (quaternary) 40 dip paper (test strip). The paper was immersed for 10 seconds and the indicator read zero (0) ppm (parts per million).

- The disinfectant bucket (2) solution used to clean the cutting area surfaces was tested using the QT 40 dip paper. The paper was immersed for 10 seconds and the indicator read zero (0) ppm (parts per million).

- The disinfectant bucket (3) solution used to clean all other surface areas was tested using the QT 40 dip paper. The paper was immersed for 10 seconds and the indicator read zero (0) ppm (parts per million).

2. The Hospital policy titled, "Core: Cleaning and Sanitizing Food Service Equipment and Work Surfaces" dated 06/2018 was reviewed. The policy included, "...Proper cleaning and sanitizing stationary food service equipment and food contact surfaces to minimize the growth of microorganisms that may result in food contamination ...Procedure: 1. Food -contact surfaces are washed, rinsed, and sanitized: a. After each use, b. Before switching preparation to another type of food ...Sanitizer Solution: 1. Prepare sanitizer solution per manufacturer instructions ...2. Before using and as needed, test concentration of sanitizer using the correct test strips (e.g., QT -40 quaternary test strips for Oasis 146) ...Note: If concentration is not in the correct range per manufacturer recommendation,prepare a new solution or adjust amount of water or sanitizer to achieve correct levels (e.g., manufacturer recommendations for Oasis 146 is 200 to 400 ppm [parts per million] ) ...3. Prepare a new sanitizer solution as needed if the water becomes visibly dirty or the concentration falls below acceptable levels ...5. Sanitize the food-contact surfaces of the equipment with clean sanitizing solution at the proper concentration and clean clothes."

3. On 11/13/19 at approximately 11:35 AM, the Supervisor of Food Services (E #21) at Hospital B was interviewed. E #21 stated that, it is not acceptable. The surface areas are not disinfected correctly since the solution was not prepared correctly. E #21 continued to say that, he had advised the kitchen staff to change the disinfectant solution for all the three (3) red buckets every 2 hours and as needed. He (E #21) was not sure at what time the disinfectant buckets were prepared. E #21 stated, "I have a lot of education and training to provide to our kitchen staff."

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 November 12-13, 2019, 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 that for 1 of 1 (E #5) Environmental Service Worker at Hospital A observed for room cleaning, the Hospital failed to implement policies related to prevention of infection when conducting a terminal room cleaning.

Findings include:

1. The Hospital's policy titled, "Terminal Cleaning of a Patient Room" dated 06/2019 was reviewed on 11/14/19. The policy required, '8. Dry high dusting and wipe down: a. Dust and wipe down all ceilings and walls...d. Be sure to wipe/dust everything shoulder high and above. 9. Damp dust the following with disinfectant: c. bars...e...curtains. 10. General patient room areas/appliances...g. Clean the bathroom area with approved cleaners including: 6. Bathroom handrails."

2. On 11/13/19 at 2:15 PM, an observation of a terminal cleaning of a patient room was conducted along with the Chief Clinical Officer (E #1). During the terminal cleaning of room 407-2, E #5 did not wipe the wall signs that were covered with plastic, lower left bed rail with red substance, a blue lever at the foot of the bed with brown substance, a wall with two metal towel rails in the patient bathroom and the shower curtain.

3. On 11/13/19 at 3:15 PM, an interview was conducted with E #5. E #5 stated that she should have wiped down the wall signs, and the bathroom wall and metal towel rails. E #5 stated that the red and brown substance left on the bed was removable and E #5 proceeded to clean the substances off of the bed. E #5 stated that she did not remove the shower curtain because the shower was not used by the previous patient and the shower curtain was changed prior to the last patient's admission to the room. When E #5 was asked how she knows the previous patient did not use the shower, E #5 stated that she inspected the shower curtain and it did not look like it had been used.

A. Based on observation, document review, and interview it was determined that for 2 of 2 (E #12 and #13) employees, observed performing point of care blood glucose testing at Hospital B, the Hospital failed to ensure that infection control practices were followed. This has the potential to affect all 19 patients on the 3rd Floor on 11/12/19.

Findings include:

1. On 11/12/19 between 12:00 PM to 12:45 PM, during the bedside glucose testing for Pts. #17 and Pt. #21 on 3rd floor at Hospital B, the following were observed:

- Prior to entering Pt. #21's room, Registered Nurse (E #12) was seen wearing a pair of gloves. After entering Pt. #21's room (an isolation room), E #12 touched Pt. #21's arms. Without changing her (E #12's) gloves, E #12 reached inside her pocket, obtained a blood glucose strips, then performed blood glucose testing on Pt. #21. Afterwards, E #12 took and placed the used glucometer to the medication cart that was outside of Pt. #21's room. Then, E #12 opened and dipped her hands inside a container of Sani cloth wipe (bleach wipe). E #12 did not change her gloves between patient care.

- After performing blood glucose testing on Pt. #17 who is in isolation, Registered Nurse (E #13) was seen cleaning the glucometer without changing her (E #13's) gloves.

2. On 11/12/19 the clinical record of Pt. #17 was reviewed. Pt. #17 was admitted to Hospital B on 11/01/19 with a diagnosis of cerebral infarction (brain death) on a ventilator. Pt. #17's physician order dated 11/01/19 included, placing the patient (Pt. #17) on contact precautions due to MRSA (methicillin resistant staphylococcus aureus/a bacteria resistant to antibiotics) in blood, sputum and urine on admission. Accu check (bedside glucose) testing every six (6) hours.

3. On 11/12/19 the clinical record of Pt. #21 was reviewed. Pt. #21 was admitted to Hospital B on 11/09/19 with a diagnosis of infected wounds on the skin. Pt. #21's physician order dated 11/09/19 included, placing the patient on contact isolation for MRSA (Methicillin Resistant Staphylococcus Aureus) in the wound. Accu check (bedside glucose) testing every six (6) hours.

4. On 11/12/19 the policy titled, "Core: Nova Statstrip Point of Care Blood Glucose Testing" dated 06/2019 was reviewed. The policy included, "Enter the Patient ID [identification] ...press the scan button to activate the scanner ...scan the barcode on the patient armband ...review the patient demographics on the meter screen ...insert a test strip into the strip port ...11. Cleaning and Maintenance: When performing testing on patients, follow the cleaning and disinfection times of the germicidal wipe for the meter."

5. On 11/12/19 the Hospital policy titled, "Core: Transmission-Based Precautions" dated 06/2019 was reviewed. The policy included, "4. Patient Care Equipment: a) Dedicate use of non-critical patient care equipment for the patient in contact precautions. b) If this is not possible, the equipment should be cleaned and disinfected before use on another patient using an disinfectant ...c) Items are to be cleaned in the patient's room, then brought out and left to air dry."

6. On 11/12/19 at approximately 12:50 PM, the Registered Nurse (E #12) on 3rd Floor at Hospital B was interviewed. E #12 stated, that she (E #12) should not have put her gloved hand into her coat pockets. She (E #12) was sorry that, she kept the contaminated glucometer on the medication cart, instead of having it cleaned with the bleach wipes inside the isolation room. E #12 continued to say that, she should not have removed the lid of the bleach wipe container with her contaminated gloved hand to remove the wipes.

7. On 11/12/19 at approximately 12:55 PM, the Registered Nurse (E #13) on 3rd Floor at Hospital B was interviewed. E #13 stated, that she (E #13) should not have used the same contaminated gloved hand to clean the glucometer.


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B. Based on document review, observation, and interview, it was determined that for 1 of 1 Registered Nurse (E#16) observed on the 2nd Floor Medical Unit at Hospital B, the Hospital failed to ensure that staff disinfect medication vials during preparation, in order to control the potential spread of infection.

Findings include:

1. The Hospital's policy titled, "Administration of Medications via Injection" (dated 6/2019), was reviewed on 11/14/19 and required, "...If medication needs to be drawn up into a syringe do so using aseptic technique..."

2. The "ISMP [Institute for Safe Medication Practices] Safe Practice Guidelines for Adult IV [Intravenous] Push Medications" (dated 2015), was reviewed on 11/14/19 and required, "...the 'pop-off' vial caps from manufacturers are considered 'dust covers' and are not intended to maintain sterility of the vial diaphragm or access point. Thus, the diaphragm must always be disinfected after removing the cap of a new vial. According to the Association for Professionals in Infection Control and Epidemiology (APIC) Safe Injection, Infusion, and Medication Vial Practices in Health Care, practitioners should disinfect vials by cleansing the access diaphragm 'using friction and a sterile 70% isopropyl alcohol... or other approved antiseptic swab'..."

3. During an observational tour of the 2nd Floor Medical Unit (2 North/ South) at Hospital B on 11/12/19, at approximately 10:19 AM, a Registered Nurse (E#16) was preparing an IV (intravenous) medication in the medication storage room. E#16 opened the medication vial and withdrew the contents of the vial without disinfecting the rubber septum prior to piercing it.

4. An interview was conducted with the Registered Nurse (E#16) on 11/12/19, at approximately 1:20 PM. E#16 stated that she usually wipes the top of the vial prior to drawing out the medication; however, if it's a "new" vial, with a cap still on it, she sometimes does not wipe it. E#16 stated, "I thought it was sterile."

5. An interview was conducted with the Infection Control Nurse (E#14) on 11/14/19, at approximately 1:45 PM. E#14 stated that all medication vials should be disinfected during preparation, regardless of a new vial.

C. Based on observation, document review and interview, it was determined that for 3 of 4 employees (E #11, #16, and #18), 1 of 3 patients (Pt #26), and 2 of 4 rooms (room #218 and 225) at Hospital B, the Hospital failed to ensure isolation precautions were implemented, maintained, PPE was used, and hand hygiene was followed. This potentially placed all 34 patients on census at risk.

Findings include:

1. On 11/12/19 at approximately 9:45 AM, during the observational tour of 3rd Floor at Hospital B, the House Keeping staff (E #11) was observed cleaning Pt. #16's room who was on contact isolation precautions. E #11 was bringing out the dirty rags, trash, and biohazard red bag without double bagging and without placing into a secondary container.

2. On 11/12/19, the clinical record of Pt. #16 was reviewed. Pt. #16 was admitted to Hospital B on 10/25/19 with a diagnosis of respiratory failure on ventilator. The physician's order dated 10/25/19 of Pt. #16 included, placing the (Pt. #16) on contact (wearing gown and glove) isolation for MDRO (multiple drug resistant organism - bacteria) present on admission in the sputum, wound and urine.

3. The Hospital's policy titled, "Regulated Medical Waste Management" dated 06/2017 was reviewed. The policy included, "1. Regulated medical waste should be separated from the general waste stream at the point of origin. This is generally in the patient care areas. Appropriate containers should be used at the point of origin, and to store this type of waste until transport ...ii. Red bio-hazardous bags or bags marked with the universal biohazard symbol are used to collect solid and semi-solid wastes. Double bagging is required if the waste may potentially leak. iii. Place biohazard bags, even if they contain only a small amount of medical waste, in a proper secondary container. NOTE: Bio-hazardous containers should not go through trash or laundry chutes because of potential for breakage."

4. On 11/12/19 at approximately 9:55 AM, the House Keeping staff (E #11) on 3rd Floor at Hospital B was interviewed. E #11 stated that, the isolation room cleaning is done wearing the PPE (personal protective equipment) like the gown and the glove, since the patient (Pt. #16) is in contact isolation. After the cleaning is complete, she (E #11) discards the trash, waste, dirty rags and the red biohazard bag from the isolation room into the common trash bin that is located at the end of the door. E #1 continued to say that, she removes the PPE (gown and glove) and puts it into the same common bin. Then, she (E #11) continues with the cleaning of the next patient room by using the same common trash bin and the cleaning cart.

5. On 11/12/19 at approximately 11:00 AM, the Infection Control Nurse (E #14) at Hospital B was interviewed. E #14 stated, "This is not something we want to see happen again. I will make sure to teach and train all the environmental services/housekeeping crew today.

6. The Hospital's policy titled, "Transmission-Based Precautions" (dated 6/2019), was reviewed on 11/13/19 and required, "Definition 2...Contact Precautions...A. 4. Post the appropriate precaution signage visible outside patient room...C...2. Place and maintain an adequate supply of appropriate personal protective equipment [PPE] inside the isolation room, beside the door or use an over-the-door system (e.g., masks, gowns, gloves, goggles, etc.)..." used for patients with known or suspected infections or evidence of syndromes that represent an increased risk of contact transmission... E. Precaution-Specific Expectations...Contact Precautions... b) Gloves c) Gowns..."...General Care Considerations: ...Dedicate use of noncritical patient care equipment for the patient in contact precautions..."

7. The Hospital's posted contact precautions sign included, "...Everyone entering this room must... Wear GLOVES upon entering. Wear a GOWN upon anticipating direct contact with patient or potentially contaminated environmental surfaces and equipment..."

8. The clinical record of Pt. #23 was reviewed on 11/12/19. Pt. #23 was admitted on 10/30/19, with a diagnosis of unspecified open wound on right upper arm and right knee. Pt. #23 had an order for contact isolation precautions upon admission (10/30/19) due to MRSA (methicillin-resistant staphylococcus aureus/bacteria that is resistant to antibiotic) infection.

9. An observational tour of the 2nd Floor Medical Unit (2 North/ South) at Hospital B was conducted on 11/12/19, between approximately 9:35 AM and 1:30 PM. At approximately 9:45 AM, a Patient Relations Representative (E#18) entered Pt. #23's room. Pt. #23's room had a yellow contact isolation sign posted on the door. E#18 did not put on gloves or gown upon entering the room and touched Pt. #23's food tray.

10. An interview was conducted with Registered Nurse (E#16) on 11/12/19, at approximately 1:20 PM. E#16 stated that E#18 should have put on gloves and a gown before entering the room.

11. An observational tour of the 2nd Floor Medical Unit (2 North/ South) at Hospital B was conducted on 11/12/19, between approximately 9:35 AM and 1:30 PM. At approximately 10:04 AM and again at 10:44 AM, a Registered Nurse (E#16) entered Pt. #26's room without wearing a gown. Pt. #26's room did not have any precaution signs posted on the door. A visitor was also present in Pt. #26's room and was not wearing gloves or a gown.

12. The clinical record of Pt. #26 was reviewed on 11/12/19, at approximately 1:10 PM. Pt. #26 was admitted on 11/11/19, with a diagnosis of disruption of external surgical wound. Pt. #26 had an order for contact precautions, upon admission (11/11/19), to rule out potential CRE (carbapenem-resistant enterobacteriaceae/a bacteria resistant to certain antibiotics) infection. The order included, "DC [discontinue] if negative." Laboratory results for CRE included, "Rectal swab 11/12/19 00:50 [12:50 AM]: collected by nursing... specimen received in lab [at] 11/12/19 12:15 [PM]." The results of the CRE screen were not available as of 11/12/19 at 1:15 PM.

13. An interview was conducted with the Registered Nurse (E#16), in the presence of the Nursing Supervisor (E#15), on 1/12/19 at approximately 1:20 PM. E#16 stated that the nurse who admitted Pt. #26 last night had received report that Pt. #26 was not placed on isolation at the transferring hospital. E#15 stated that Pt. #26 should have been placed on contact isolation precautions as ordered, regardless of the report received from the transferring hospital. E#16 could not find any documentation of CRE screening results in the record. E#16 stated that she would change the sign on Pt. #26's door.

14. The Hospital's posted contact precautions sign included, "...Everyone entering this room must... Wear gloves upon entering...Everyone entering this room must...Clean hands upon entering and leaving...wear a gown...Doctors and staff must: Use patient dedicated or disposable equipment. Clean and disinfect shared equipment..."

15. The "APIC [Association for Professionals in Infection Control and Epidemiology] Position Paper: Safe Injection, Infusion and Medication Vial Practices in Healthcare" (dated 7/30/09), was reviewed on 11/14/19 and required, "...Never store vials in clothing or pockets..."

16. An observational tour of the 2nd Floor Medical Unit (2 North/ South) at Hospital B was conducted on 11/12/19, between approximately 9:35 AM and 1:30 PM. At approximately 9:40 AM, a Registered Nurse (E#16) entered Pt. #23's room. Pt. #23 was on contact isolation precautions for MRSA (methicillin-resistant staphlococcus aureus) infection. After administering medications to Pt. #23, without changing gloves, E#16 locked the medication cabinet in the room using a key attached to her right wrist. E#16 exited the room without disinfecting the key. At approximately 10:20 AM, E#16 removed 2 medications from the medication storage room and placed both of them in her left pocket. At approximately 10:30 AM, E#16 entered Pt. #23's isolation room. E#16 touched the computer in the room with gloved hands, then reached into her left pocket to retrieve one of the medications. At approximately 10:57 AM, E#16 entered another patient's room. E#16 used the key on her wrist to open the medication cabinet and then reached into her left pocket to retrieve a medication vial. Without changing gloves, E#16 prepared and administered the medication.

17. An interview was conducted with the Registered Nurse (E#16) on 11/12/19, at approximately 1:20 PM. E#16 stated that no supplies/equipment taken into an isolation room should come out of the room, unless it can be disinfected after use. When asked about placing medications in her pocket, E#16 stated, "I usually only pull one patient's medication at a time and carry it in my hand directly to the patient's room, but today I needed to give both of them soon." E#16 stated that each nurse carries a key with them that can open the medication cabinets in the patients' rooms.

18. An interview was conducted with the Infection Control Nurse (E#14) on 11/14/19, at approximately 1:45 PM. E#14 stated, "We follow APIC guidelines for infection control." In regards to staff placing medications in their pockets, E#14 responded, "That's a definite no."

19. An observational tour of the 2nd Floor Medical Unit (2 North/ South) at Hospital B was conducted on 11/12/19, between approximately 9:35 AM and 1:30 PM.

- At approximately 9:36 AM, room #218 had a contact isolation precaution sign posted on the door. There were no PPE supplies available to put on prior to entering the room. The storage shelf of PPE supplies was located on the wall midway into the room and was not accessible without touching potentially contaminated items/equipment in the room.

- At approximately 11:19 AM, room #225 had a contact isolation precaution sign posted on the door. There were no PPE supplies available to put on prior to entering the room. The storage shelf of PPE supplies was located on the wall inside the room. A Registered Nurse (E#16) inside the room had to lean over furniture/equipment in the room to retrieve a gown from the shelf, during which her scrubs contacted the potentially contaminated furniture/equipment.

20. An interview was conducted with the Nursing Supervisor (E#15) on 11/12/19, at approximately 9:39 AM. E#15 stated that some rooms do not have the PPE supplies available right as you enter. E#15 stated that they are aware of the problem and are working on moving the storage shelves outside of the rooms.

21. The Hospital's policy titled, "Hand Hygiene" (dated 6/2018), was reviewed on 11/13/19 and required, "...Five (5) Moments for Hand Hygiene will be performed as follows: ... e. After touching a patient's surroundings/environment..."

D. Based on observation, interview, and document review, it was determined that for 1 of 1 Respiratory Therapist (RT-E #7) on the High Acuity Unit (HAU) observed providing tracheostomy (an opening in the neck created for ventilation) care to a patient at Hospital A, the Hospital employee failed to perform hand hygiene and maintain aseptic technique while performing tracheostomy care.

Findings include:

1. An observational tour of the HAU was conducted on 11/13/19, between 9:20 AM and 9:35 AM:

- At approximately 9:20 AM, a Respiratory Therapist (E #7) was observed dropping and picking up from the floor a closed package containing an inner cannula (plastic tube used to keep tracheostomy open) with a gloved hands and placing it on a table inside the patient's room. Then, E #7 was observed donning sterile gloves on top of soiled gloves and proceeded to perform tracheostomy care. E #7 took the soiled dressing from the tracheostomy site care and used supplies to the garbage can and pushed down into garbage can. E #7 then went back to the patient and proceeded to change the tracheostomy neck tie and sterile dressing. E #7 did perform hand hygiene and change gloves while providing patient care.

2. On 11/13/19 at approximately 9:40 AM, the above findings were discussed with the Director of Respiratory Services (E #6). E #6 stated that, staff should perform hand hygiene and put on new gloves before and after starting new tasks. E #6 stated that after removing the soiled dressings and disposing in the garbage can, hand hygiene should be performed. E #6 added that if supplies are intended to be used on a patient and fell on the floor, the supplies should be discarded even if the package is closed. E #6 also stated that the Hospital uses the Lippincott manual as reference for tracheostomy care.

3. The Hospital's policy tilted, "Hand Hygiene" (reviewed by Hospital 6/27/18), was reviewed and required, "...2. Five moments for Hand Hygiene will be performed as Follows: a. Before touching a patient. b. Before a clean/aseptic procedure. c. After touching a patient...e. After touching a patient's surroundings/environment...3. g. Before donning and after removal of gloves..."

4. On 11/13/19 at approximately 10:30 AM, the Hospital presented a document from Lippincott Procedures titled, "Tracheostomy tube cannula and stoma care" (revised 12/14/18) and required, "To prevent infection, you should perform tracheostomy care using sterile technique ...use sterile gloves for all manipulations at the tracheostomy site ...If you'll be replacing the disposable inner cannula, open the package containing the new inner cannula while maintaining sterile technique ...Caring for a disposable inner cannula. Put on clean gloves. Using your dominant hand, remove the patient's inner cannula ...Pick up the new inner cannula ...Inset the cannula into the tracheostomy ...Remove and discard your gloves ...Cleaning the stoma and outer cannula. Perform hand hygiene. Put on clean gloves. Remove the tracheostomy ties and apply new ties ...Apply a new sterile tracheostomy dressing ..."

Based on document review and interview, it was determined that for 1 of 3 patients' (Pt. #3) clinical records reviewed for discharge planning at Hospital A, the Hospital failed to complete a timely assessment of the patient's discharge needs.

Findings include:

1. On 11/14/19 at approximately 10:30 AM, the clinical record of Pt. #3 was reviewed, Pt. #3 was admitted on 8/12/19 with a diagnosis of respiratory failure. The clinical record indicated that discharge planning assessment was conducted on 8/15/19 (3 business days after the patient's admission).

2. On 11/14/19 at approximately 1:00 PM, the Hospital's policy titled, "Discharge Planning" (released date 6/19) was reviewed and included, "... 1. Case Managers... will provide individual discharge planning to each patient through assessment of discharge needs at admission... Procedure...2. Within 2 business days of admission, the Case Manager will identify discharge planning needs... through assessment..."

3. On 11/14/19 at approximately 10:30 AM, findings were discussed with E #10 (Director of Case Management). E #10 stated that the discharge planning assessment was not done timely. E #10 stated, "It was done a day late."

Based on document review and interview, it was determined that for 2 of 3 patients' (Pt. #2 and Pt. #3) clinical records reviewed for discharge planning at Hospital A, the Hospital failed to document in the patients' medical record that a list of SNFs (skilled nursing facility) was presented to patient or to the individual acting on patient's behalf.

Findings include:

1. On 11/14/19 at approximately 10:15 AM, the clinical record of Pt. #2 was reviewed. Pt. #2 was admitted on 8/12/19 with a diagnosis of respiratory failure. On 9/6/19, the clinical record indicated that Pt. #2 was identified as needing SNF placement after discharge. Pt. #2 was discharged on 10/22/19 to a SNF facility; however, the clinical record lacked documentation that a list of SNF was presented to Pt. #2 or to the individual acting on Pt. #2's behalf.

2. On 11/14/19 at approximately 10:30 AM, the clinical record of Pt. #3 was reviewed, Pt. #3 was admitted on 8/12/19 with a diagnosis of respiratory failure. On 9/6/19, the clinical record indicated that Pt. #3 was identified as needing SNF placement after discharge. Pt. #2 was discharged on 9/9/19 to a SNF facility; however, the clinical record lacked documentation that a list of SNF was presented to Pt. #3 or to the individual acting on Pt. #3's behalf.

3. On 11/14/19 at approximately 1:00 PM, the Hospital's policy titled, "Discharge Planning" (release date 6/19) was reviewed and included, "... Procedure... 4. Should the patient have an identified need for a post discharge provider, the Case Manager provides the patient/family with a list of... skilled nursing facilities that are available to the patient...The Case Manager documents that this list was presented to the patient or to the individual acting on the patient's behalf."

4. On 11/14/19 at approximately 10:30 AM, findings were discussed with E #10 (Director of Case Management). E #10 could not provide documentation that the list was provided to Pt. #2 and Pt. #3. E #10 stated, "We should have documented it... It's not documented..."