HospitalInspections.org

Based on record review, interview, and policy review, the provider failed to ensure the patient's nutritional needs were assessed and documented for two of two sampled obstetric patients (1 and 2) according to the provider's policy.
Findings include:

1. Review of patient 7's electronic medical record (EMR) revealed:
*She was admitted on 7/10/25 to the labor and delivery unit.
*The admission navigator (an admission assessment tool) questions for an obstetric (OB) patient had been completed on 7/10/25.
*A nutrition assessment had not been completed during her hospitalization.

2. Review of patient 4's EMR revealed:
*She was admitted on 7/13/25 to the labor and delivery unit.
*The OB admission navigator had been completed on 7/13/25.
*A nutrition assessment had not been completed during her hospitalization.

3. Interview on 7/16/25 at 2:30 p.m. with OB manager D regarding nutrition assessments for OB patients revealed:
*Staff would have completed the OB admission navigator upon a patient's admission to the facility.
*She agreed a nutrition assessment had not been included with the OB admission navigator questions and should have been completed.
*OB manager D stated all OB patients had not had a nutrition assessment completed.

4. Interview on 7/16/25 at 4:30 p.m. with registered nurse (RN) C regarding the OB admission navigator questions revealed:
*She would have completed the OB admission navigator with a patient upon the patient's admission to the facility.
*She agreed there was no nutrition assessment in the OB admission navigator and should have been completed.

Review of the provider's July 2024 Patient Nutrition Assessment and Screening policy revealed:
*"Nursing will screen patients within 24 hours of admission and record information in the EMR."
*"The admission navigator will be utilized for each patient. Nutrition areas to be addressed include:"
"-Unable to eat for 3 days."
-"Unintended weight loss > 10 pounds."
-"High Risk OB."

Based on observation and interview the provider failed to follow infection control practices to ensure:
*There was sufficient exhaust air flow for one of one decontamination room.
*Six of fifteen medical-surgical equipment items were free of rust in the operating room (OR).
Findings include:

1. Observation on 7/15/25 at 9:30 a.m. revealed air from inside the decontamination room was flowing through the door into the hallway.

Observation and interview on 7/15/25 at 9:35 a.m. with surgical technologist G revealed:
*She confirmed the air was coming out of the decontamination room and into the hallway.
*She had noticed the air coming out of the decontamination room a while ago.
*She agreed that the decontamination room should have been negatively pressured.

Observation and interview on 7/16/25 at 3:45 p.m. with maintenance director H revealed:
*He was not aware the decontamination room was positively pressured.
*The decontamination room pressurization was adjusted and balanced on 7/24/24 by a contracted company.
*Maintenance staff had not checked the airflow in the decontamination room since it was last balanced on 7/24/24.
*He agreed that the decontamination room should have been negatively pressured.
*He was unsure of how long the decontamination room had been positively pressured.

A policy regarding air flow for the decontamination room was requested on 7/16/25 at 3:45 p.m. The provider had been unable to provide the requested policy by the end of the survey.

2. Observation in the OR on 7/16/25 at 7:45 a.m. revealed:
*Three IV poles had rust on the legs and casters.
*Two metal tables had rust on the legs and casters.
*One ring stand had rust on the casters.

Interview on 7/16/25 at 7:50 a.m. with surgical technologist G revealed:
*She confirmed the equipment items above contained rust and were not cleanable surfaces.
*Equipment containing rust should not have been used or available for use in the OR.



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Interview on 7/16/25 at 9:35 a.m. with OR manager D regarding the rusted equipment items in the OR and the decontamination room revealed:
*She had been aware of the rusted equipment in the OR and scope room.
*The maintenance employees had been working on removing the rust from the equipment, but had to stop to attend to other projects.
*She had thought a rusted surface would have been a cleanable surface, but she had not researched the issue.
*OR manager D had not been aware that the decontamination area for surgical instruments required a negative airflow.

Interview on 7/16/25 at 10:00 a.m. with infection control coordinator B regarding the cleanability of a rusted surface revealed he had thought a rusted surface was uncleanable.

Interview on 7/16/25 at 3:15 p.m. with discharge planner E regarding rusted equipment revealed:
*Staff had placed rusted equipment in her office for removal from use.
*She agreed if equipment was rusted, it was not cleanable and should have been removed from use.

Interview on 7/16/25 at 3:55 p.m. with director of nursing (DON) A regarding rusted equipment revealed:
*She agreed rusted equipment should have been removed from use.
*DON A had not been aware that there was rusted equipment in the OR and the scope room that had remained in use.

Request for a policy on the removal of equipment from service had been requested, but the provider did not have a policy that indicated rusted equipment should have been removed from service.