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Based on observation, interview and record review the facility failed to provide care in a safe environment when:

1. The facility failed to monitor one of three sampled Patients (Pt) 3) when Pt 3 came in the hospital for suicidal ideations (thoughts of killing himself) and current history of alcohol abuse. Pt 3 had abuse screenings that indicated he had alcohol intoxication or withdrawal. Pt 3 had a Clinical Institute Withdrawal Assessment (CIWA-a clinical assessment tool that healthcare providers use to determine the severity of alcohol withdrawal) done once on 1/9/25 and no further CIWA assessments were done. The Policy and Procedure (P&P) indicated to conduct CIWA every 2 hours and this was not done.

This placed Pt 3 at risk of not having symptoms of alcohol withdrawal addressed.

2. The hospital failed to ensure [Brand name 1] warmer for premoistened wipes were used in accordance with the operating instructions when [Brand name 1] warmer was storing non compatible [Brand name 2] rinse free conditioning shampoo caps.

This failure had the potential for fire or other hazards and did not ensure the right to care in a safe environment.

Findings:

During a concurrent interview and record review on 1/10/25, at 10:52 a.m., with the Assistant Manager of the Emergency Department (AMED), Pt 3's Emergency Department (ED) timeline dated 1/9/25 was reviewed. The AMED stated Pt 3's ED timeline indicated Pt 3 arrived at the ED on 1/9/25 at 11:13 a.m. with chief complaint of having suicidal ideations for the last couple of days. Pt 3's ED timeline indicated Pt 3 screened positive on the suicidal screening and the alcohol screening. First CIWA score was performed on 1/9/25 at 12:24 p.m. and provided a total score of 12 (score 0-9 indicated minimal to absent withdrawal; 10-19 indicated mild to moderate withdrawal; 20 or more severe withdrawal). The AMED stated no further CIWA assessments were done during Pt 3 stay in the ED. The AMED stated Pt 3 should have been monitored for alcohol withdrawal signs and symptoms.

During an interview on 1/10/25, at 11:45 a.m., with the Interim Director of Quality (IDQ), the IDQ stated the hospital did not have a policy for CIWA, but it did had order sets (a pre-defined template within a hospital's electronic medical record system that groups together a series of medical orders, like medications, tests, and procedures, specifically designed for a particular patient condition or clinical scenario) and in the CIWA order set it says staff should be reassessing the patient every two hours and the hospital was working on creating a CIWA policy.

During an interview on 1/17/25, at 8:16 a.m., with ED Registered Nurse (RN) 3, RN 3 stated she started at this hospital on 10/2024 and did not recall having a patient that was on CIWA since she had been here. RN 3 stated she took care of Pt 3 but was not informed nor did she read that Pt 3 had an issue with alcohol. RN 3 stated it was important to monitor patients that were going through alcohol withdrawal because they had the potential to become altered , have seizures (a temporary episode of abnormal electrical activity in the brain that can cause changes in movement, behavior, and awareness), cardiac arrythmias (irregular heart rhythm) and these could all be prevented.

During an interview on 1/17/25, at 8:24 a.m., with the Interim ED Manager (IEDM), the IEDM stated the orientation for new hire nurses into the ED department did not include treatment of alcohol withdrawal, but the ED was seeing patients more and more for substance abuse. The IEDM stated her staff was familiar with withdrawal and prevention and that she was not sure how Pt 3 alcohol withdrawal monitoring was missed.

During an interview on 1/17/25, at 12:39 p.m., with Chief Nurse Executive (CNE), the CNE stated it was important to follow the CIWA protocol and provide patients the appropriate care to keep them safe.

During a review of the hospital's General (GEN) CIWA ALCOHOL WITHDRAWAL (CIWA SET) order set, the CIWA SET indicated, " ... Alcohol Withdrawal Assessment ... Routine, EVERY 2 HOURS ... Assess for Sedation ... Routine, EVERY SHIFT ... Neurological Check ... Routine, EVERY SHIFT ... Seizure Precautions ... Routine, CONTINUOUS ..."

During a review of the hospital's policy titled, "Physician's Orders: Receiving, Transcribing, Reviewing," dated 5/2/22, indicated, " ...PURPOSE: A. To provide a standard format for Licensed Independent Practitioners and licensed clinicians for all orders given, received, transcribe and acknowledged to ensure safe patient care and outcomes ... POLICY: ... B. Physicians orders are part of the medical record and outline the physicians plan of care for each patient. Licensed Independent Practitioners (LIP) will use Computerized Physician Order Entry (CPOE) ... PROCEDURE: ... d. All orders are reviewed by the RN to assure correct transcription and/or acknowledged, within an appropriate time frame to assure safe and quality patient care, within the current shift ... E. The nurse will acknowledge ALL medication orders and document care provided. F. Every Shift Order Review: 1. The assigned nurse is responsible to review entered orders for each patient assigned toward the end of each shift. C. The nurse will confirm that the orders are being carried out as entered ..."

During a review of the hospital's policy titled, "Patient's Rights and Responsibilities," dated 7/18/22, the policy indicated, " ...PURPOSE A. To outline patient rights and responsibilities as required by State and Federal Regulations and The Joint Commission (TJC) ... 13. Receive care in a safe setting, free from ... neglect ..."




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2. During a concurrent observation and interview on 1/9/25 at 2:44 p.m. on medical floor with the Nurse Executive (NE) and Nurse Manager (RNM)1 observed [Brand name 1] warmer stocked with rinse free shampoo caps of [Brand name 2] along with [Brand name 1] pre moistened wipes. Both [Brand name 1] wipes and [Brand name 2] rinse free shampoo caps were stored right next to the warmer as well. RNM 1 stated on their unit it was their normal practice to use [Brand name 1] warmer for both [Brand name 1] & [Brand name 2] products. RNM 1 stated as far as she knew all brand products were compatible with the [Brand name 1] warmer.

During an interview on 1/16/25, at 5:06 p.m. with the NE, the NE stated she had reviewed the [Brand name 1] warmer's operating instructions. The NE stated the instructions clearly states that [Brand name 1] warmer was exclusively to be used with same brand [Brand name 1] products. The NE 1 stated the hospital was not using the [Brand name 1] warmer in accordance with instructions for use. The NE stated she understood the fire risk and risk for other hazards with the use of [Brand name 2] products in the [Brand name 1] warmer. The NE stated the practice had been stopped and going forward, the hospital team will only use [Brand name 1] wipes and products with the [Brand name 1] warmer.

During a review of [Brand name 1] "Warmer Operating Instructions", undated, the "Warmer Operating Instructions" indicated, " ...Please read and understand these instructions completely prior to operating the warmers ...IMPORTANT SAFETY INSTRUCTIONS This product is to be used SOLELY for warming premoistened cloth and hair care products manufactured by [Brand name 1] LLC. The warmer has been designed and safety tested to be used exclusively with these products. ANY other use of the warmer by the facility including, but not limited to, use with other bathing products, can result in overheating, fire or other hazardous conditions and is expressly forbidden ..."

Based on interview and record review, the hospital failed to follow their policy and procedure titled, "Physician's Orders: Receiving, Transcribing, Reviewing," for two of four sampled patients (Pt 3 and Pt 9) when:

1. Licensed Nurses (LN)s did not monitor Pt 3 when Pt 3 came in the hospital for suicidal ideations (thoughts of killing himself) and current history of alcohol abuse. Pt 3 had abuse screenings that indicated he had alcohol intoxication or withdrawal. Pt 3 had a CIWA (Clinical Institute Withdrawal Assessment- CIWA- a clinical assessment tool that healthcare providers use to determine the severity of alcohol withdrawal) done once on 1/9/25 and no further CIWA assessments were done. The Policy and Procedure (P&P) indicated to conduct CIWA every 2 hours and that was not done.

This failure had the potential for Pt 3 to not having his symptoms of alcohol withdrawal addressed and possible delay in implementing intervention to address the clinical need of Pt 3.

2. LNs did not follow the insulin (Is a hormone the body uses to allow sugar to enter cells to produce energy) order/protocol for Pt 9.

This failure placed Pt 9 at risk of receiving too much or too little insulin and had the potential for causing high or low blood sugars.

Findings:

1. During a concurrent interview and record review on 1/10/25, at 10:52 a.m., with the Assistant Manager of the Emergency Department (AMED), Pt 3's Emergency Department (ED) timeline dated 1/9/25 was reviewed. The AMED stated Pt 3's ED timeline indicated Pt 3 arrived at the ED on 1/9/25 at 11:13 a.m. with chief complaint of having suicidal ideations for the last couple of days. Pt 3's ED timeline indicated Pt 3 screened positive on the suicidal screening and the alcohol screening. First CIWA was performed on 1/9/25 at 12:24 p.m. and provided a total score of 12 (score 0-9 indicated minimal to absent withdrawal; 10-19 indicated mild to moderate withdrawal; 20 or more severe withdrawal). The AMED stated no further CIWA assessments were done during Pt 3's stay in the ED. The AMED stated Pt 3 should have been monitored for alcohol withdrawal signs and symptoms .

During an interview on 1/10/25, at 11:45 a.m., with the Interim Director of Quality (IDQ), the IDQ stated the hospital did not have a policy for CIWA, but it did have order sets (a pre-defined template within a hospital's electronic medical record system that groups together a series of medical orders, like medications, tests, and procedures, specifically designed for a particular patient condition or clinical scenario) and in the CIWA order set it indicated staff should be reassessing the patient every two hours and the hospital was working on creating a CIWA policy.

During an interview on 1/17/25, at 8:16 a.m., with ED Registered Nurse (RN) 3, RN 3 stated she took care of Pt 3 but was not informed nor did she read that Pt 3 had an issue with alcohol. RN 3 stated it was important to monitor patients that were going through alcohol withdrawal because they had the potential to become altered, had seizures (a temporary episode of abnormal electrical activity in the brain that can cause changes in movement, behavior, and awareness), cardiac arrythmias (irregular heart rhythm) and these could all be prevented.

During an interview on 1/17/25, at 8:24 a.m., with the Interim ED Manager (IEDM), the IEDM stated the orientation for new hire nurses into the ED department did not include treatment of alcohol withdrawal, but the ED was seeing patients more and more for substance abuse. The IEDM stated her staff was familiar with withdrawal and prevention and that she was not sure how Pt 3 alcohol withdrawal monitoring was missed.

During an interview on 1/17/25, at 12:39 p.m., with Chief Nurse Executive (CNE), the CNE stated it was important to follow the CIWA protocol and provide the patients the appropriate care to keep them safe.

During a review of the hospital's General (GEN) CIWA ALCOHOL WITHDRAWAL (CIWA SET) order set, the CIWA SET indicated, " ... Alcohol Withdrawal Assessment ... Routine, EVERY 2 HOURS ... Assess for Sedation ... Routine, EVERY SHIFT ... Neurological Check ... Routine, EVERY SHIFT ... Seizure Precautions ... Routine, CONTINUOUS ..."

During a review of the hospital's policy titled, "Physician's Orders: Receiving, Transcribing, Reviewing," dated 5/2/22, indicated, " ...PURPOSE: A. To provide a standard format for Licensed Independent Practioners and licensed clinicians for all orders given, received, transcribe and acknowledged to ensure safe patient care and outcomes ... POLICY: ... B. Physicians orders are part of the medical record and outline the physicians plan of care for each patient. Licensed Independent Practitioners (LIP) will use Computerized Physician Order Entry (CPOE) ... PROCEDURE: ... d. All orders are reviewed by the RN to assure correct transcription and/or acknowledged, within an appropriate time frame to assure safe and quality patient care, within the current shift ... E. The nurse will acknowledge ALL medication orders and document care provided. F. Every Shift Order Review: 1. The assigned nurse is responsible to review entered orders for each patient assigned toward the end of each shift. C. The nurse will confirm that the orders are being carried out as entered ..."

During a review of the hospital's policy titled, "Patient's Rights and Responsibilities," dated 7/18/22, the policy indicated, " ...PURPOSE A. To outline patient rights and responsibilities as required by State and Federal Regulations and The Joint Commission (TJC) ... 13. Receive care in a safe setting, free from ... neglect ..."

2. During a concurrent interview and record review on 1/10/25, at 1:53 p.m., with Registered Nurse (RN) 4, Pt 9's electronic health records (EHR) for his hospital visit beginning 1/3/25 was reviewed. Pt 9's History and Physical (H&P), dated 1/3/25 at 5:33 p.m., indicated his chief complaint was generalized weakness with a significant past medical history of Insulin Dependent Diabetes Mellitus {IDDM-The pancreas[A gland in the abdomen that helps regulate blood sugar] makes little or no insulin (Insulin is a hormone the body uses to allow sugar to enter cells to produce energy)]}. Pt 9 was found to be in diabetic ketoacidosis (DKA- a life-threatening complication of diabetes that occurs when the body breaks down fat too quickly) and severe acidosis (a condition where the body's blood or fluids have dangerously high levels of acid). Pt 9 was admitted with orders for an insulin drip (administering insulin into a vein) to manage Pt 9's DKA.

During a review of Pt 9's GEN (general) DIABETIC KETOACIDOSIS protocol, the protocol indicated, " ... Check blood glucose every hour while receiving IV [intravenous- in a vein] insulin. Discontinue this Q1hr [every 1 hour] order when IV insulin is discontinued and follow frequency of POC [point of care- type of testing taking place] glucose ordered with subcutaneous [under all layers of skin] insulin ..."

During a concurrent interview and record review on 1/15/25, at 5:05 p.m., with ED Registered Nurse (RN) 5, Pt 9's admission to the hospital on 1/3/25 was reviewed. RN 5 stated, "Yes I do recall having him [referring to Pt 9], he had a lot of other concerns, his kidneys were going downhill, and I was chasing his potassium level [measurement of the amount of potassium (mineral) in the blood)]." RN 5 stated Pt 9 was on an insulin drip for DKA and Pt 9's blood sugars should have been checked every hour. Review of Pt 9's "Results Review" flowsheet dated 1/4/25, indicated Pt 9 was missing blood sugar results at 2 a.m., 3 a.m., and 5 a.m.

During a concurrent interview, record review, on 1/15/25, at 8:30 a.m., with RN 6 and Intensive Care Unit Manager (RNM) 1, Pt 9's insulin drip flowsheet dated from 1/5/25-1/6/25 was reviewed. RN 5 stated the insulin pump required nurse to manually adjust the levels and if this was not done the nurse would follow the same level the patient was already on, and it looked like this was missed when the drip was restarted on 1/6/25 at 3:19 a.m. Pt 9's insulin drip flowsheet, indicated on 1/6/25 at 1:45 a.m. insulin drip was placed on hold due to the blood sugar level 120 and was at Level 6 at that time. Per the hospitals protocol titled, "[name of Organization] Insulin Algorithm - Adult Non-Pregnant Insulin Infusion (not for Acute DKA/HHS)," the protocol indicated, " ... Moving Down: For BG [blood glucose] less or equal to 120 mg/dL [milligram/one-tenth of a liter - units of measurement], turn infusion off and recheck in 30 minutes ... When BG greater than 120 mg/dL, restart insulin infusion at one Level lower than previous Level (e.g. If drip was previously at Level 2, restart at Level 1) ..." Pt 9's blood sugar on 1/16/25 at 3:19 a.m. was 157, based on insulin protocol Pt 9 should have been started on Level 5 and insulin drip started back at 7 units/hour and instead was started at 9 units/hr. RNM 1 stated if the staff found an issue with the pumps not correlating with what was needed for insulin drips then this should have be escalated so that we could work out the issues. RNM 1 stated after reviewing this insulin protocol, it was complicated, and she would be reaching out to the hospitals critical care team to see about addressing this issue. RNM 1 stated the Insulin Protocol Algorithm was not followed for Pt 9, once it had one incorrect change it would then continue to be wrong.

During an interview on 1/17/25, at 12:39 p.m., with the Chief Nurse Executive (CNE), the CNE stated she was made aware of this insulin drip issues. The CNE stated her expectation was that staff followed the insulin orders and, "It is important for us to make it easy to follow." The CNE stated if the insulin drip order, "Is difficult for them to follow then we [referring to the hospital] need to address this."

During a review of the hospital's policy titled, "Physician's Orders: Receiving, Transcribing, Reviewing," dated 5/2/22, indicated, " ...PURPOSE: A. To provide a standard format for Licensed Independent Practioners and licensed clinicians for all orders given, received, transcribe and acknowledged to ensure safe patient care and outcomes ... POLICY: ... B. Physicians orders are part of the medical record and outline the physicians plan of care for each patient. Licensed Independent Practitioners (LIP) will use Computerized Physician Order Entry (CPOE) ... PROCEDURE: ... d. All orders are reviewed by the RN to assure correct transcription and/or acknowledged, within an appropriate time frame to assure safe and quality patient care, within the current shift ... E. The nurse will acknowledge ALL medication orders and document care provided. F. Every Shift Order Review: 1. The assigned nurse is responsible to review entered orders for each patient assigned toward the end of each shift. C. The nurse will confirm that the orders are being carried out as entered ..."

Based on observation, interview, and record review, the hospital failed to maintain a clean and sanitary environment to avoid sources and transmission of infection when one of one sampled operating room table (a table where a patient lies during surgery), anesthesia (A loss of feeling or awareness caused by drugs or other substances) cart (a portable medical cart that holds the tools and medications needed for anesthesia administration) and operating room floors were not maintained in accordance with the facility policies and procedures, and professional standards.

These failures had potential for all patients and staff at risk for transmission of infections (an infectious agent is transferred from a reservoir to a susceptible host), cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) and placed increased risk for hospital acquired infections.

Findings:

During a concurrent observation and interview on 1/9/25, at 3:09 p.m., with the Nurse Executive (NE) and Operating Room Manager (ORM), in the surgical services area, operating room (OR)1 and OR 2 were observed. In OR 1, the flooring was observed to have a seam running along the length of the floor near the OR table. The seam was split in several areas, with additional cracks visible throughout the floor. The OR table showed a reddish-brown substance around the entire base and had sticky residue in multiple locations. In OR 2, the anesthesia cart had a crack on its top surface where medications were prepared for administration. The flooring near the OR 2 doorframe displayed cracks, and the baseboard was peeling away from the walls. The NE acknowledged these observations, and stated that the surgical services flooring required replacement, and the hospital had a plan in place to address these issues. The NE stated the OR table with rust could potentially be a risk for infection.

During a concurrent observation and interview on 1/9/25, at 3:16 p.m., with the ORM in OR 1, the ORM stated the OR table with rust and residue was not acceptable. The ORM stated the OR table observed in OR 2 was a loaner table while the original OR table was being repaired. The ORM stated the loaner table should not had been used in OR 2 and he would plan on replacing the table as soon as possible. The ORM stated rust and sticky residue have the potential to harbor germs and could be a source for infection for surgery patients. The ORM stated the anesthesia cart surface with cracks was not acceptable and he would work on getting it repaired. The ORM stated the anesthesia team used the surface of the anesthesia cart to mix medication and/or draw medication for administration and could be a source of contamination. The ORM stated the flooring in the OR 2 was not ok, cracks and groves on any surface made it very difficult to clean and disinfect as required for cleaning the surgical environment and could potentially be a significant source for infection in the OR.

During an interview on 1/17/25 at 8:42 a.m. with the Infection Preventionist (IP- professionals who make sure healthcare workers and health facilities are doing all the things they should to prevent infections from spreading), the IP stated she was made aware of the OR observations and agreed that cracked seams in the OR flooring were not acceptable and were a potential source for infection. The IP stated because the cracked floor was around the operating room table there was a risk that blood and body fluids could collect in the cracks, and it would not be possible to clean and disinfect the cracked floor effectively. The IP stated OR staff should have alerted the leadership team and filled out a work order to have the floors fixed. The IP stated the rust or sticky residue on the operating table was not acceptable and could be a major source of infection. The IP stated she advised the ORM to get rid of the OR table and the table should not have been allowed in the OR because the rust was not a cleanable surface. The IP stated the crack on the anesthesia cart was a break in integrity and could not be cleaned and thus could be a source of cross contamination.

During an interview on 1/17/25 at 1:15 p.m. with the Chief Executive Officer (CEO), the CEO stated she was made aware of the OR observation findings. The CEO stated it was not appropriate to use the OR table with "rust" and sticky residue as it was difficult to clean and disinfect. The CEO stated the table could have potentially been a source of cross contamination therefore the hospital should have already replaced the OR table. The CEO stated the hospital already had a plan in place to change the OR floors and were awaiting regulatory approval to start construction. The CEO stated she was not aware of the cracks on the anesthesia cart surface, but she will get it repaired right a way to avoid any infection control issues.

During a review of the facility's policy and procedure (P&P) titled, "Cleaning and Disinfecting in the Perioperative environment", last revised on 11/30/23, indicated " ...Purpose ...To provide a safe clean environment in the perioperative The time around a patient's surgery or procedure, and the care they receive during that time.)setting ...Cleaning and disinfecting procedures are performed on a regular basis to reduce the amount of dust, organic debris and microbial [the number and form of pathogens (an agent that causes disease in a host) that cause contamination] load in the surgical environment ...The perioperative nurse will visibly inspect the operating room for cleanliness before supplies are brought in to the room ... The perioperative team is responsible for confirming and containing contamination during procedures ...Clean and disinfect all equipment per manufacturers recommendation; (e.g. ....entire OR bed, base, cord ...Clean and disinfect the anesthesia cart and machine ...At the end of the daily surgery schedule, terminal cleaning (is a meticulous method that deeply cleans and disinfects) will be performed ...clean and disinfect areas that should include, but are not limited to: ...All furniture and equipment ...OR bed ...Each surgical suite and areas adjacent to the surgical suites will be cleaned daily ...Machine scrub the floor and mop ...Apply wax if required ..."

During a review of the AORN publication Outpatient Surgery article, "How to Maintain a Clean OR Environment," dated 10/10/2007, indicated,"...To ensure a clean environment, evaluate the environment weekly or monthly for overall cleanliness as well as general condition...Are there cracks, nicks, or grooves on the floor? If so, repair them immediately to prevent bacteria from festering in the spaces..."

During a review of the Health Facilities Management article titled, "The role of maintenance in infection prevention," dated 8/16/19, indicated, "...Health care-associated infections (HAI) concerns to look for include: Damaged flooring in clinical areas. Damaged flooring does not provide a smooth, cleanable surface and can result in an infection prevention concern; Peeling paint or damaged wall surface. A wall surface that is not smooth is not cleanable..."