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Based on interview and record review, the hospital failed to ensure Licensed Nurses (LNs) followed policies and procedures (P&Ps) in developing, maintaining current, and patient (Pt) specific nursing care plans (NCP- a process through which the nurse identifies, documents, and keeps track of a patient's state or condition, needs, and risks) for two of thirty (30) sampled patients (Pt 13 and Pt 26) when a NCP for Pt 13 and Pt 26 had not been updated or changed to reflect the active use of bilateral (having or relating to two sides; affecting both sides) restraints.

This failure resulted in LNs providing care without an assessment and development of a patient specific NCP to guide the LN in the management of Pt 13's and Pt 26's care needs and had the potential to result in their care needs going unmet and/or possibly an unnecessary extended time in restraints.

Findings:

During a review of Pt 13's "Face Sheet (FS-a document that contains a summary of a patient's personal information)," dated 3/16/25 and "History and Physical (H&P)", dated 3/17/25, the "FS" indicated Pt 13 was admitted to the hospital on 3/17/25 at 3:51 a.m. The "H&P" indicated, " ...5-month-old female ... with no reported past medical history ... History of Present Illness: unvaccinated ... is being admitted to the PICU (Pediatric Intensive Care Unit) for respiratory failure (a serious condition that makes it difficult to breathe on your own) in the setting of RSV (Respiratory syncytial virus (RSV) causes infections of the lungs and respiratory tract) and COVID (is a disease caused by a virus named SARS-CoV-2. It can be very contagious and spreads quickly) ..."

During a concurrent interview and record review on 3/18/25 at 9:51 a.m. with Registered Nurse (RN) 9, Pt 13's "Electronic Medical Record (EMR-an electronic record of health-related information on an individual)," 3/16/25 to 3/18/25, and "Flow Sheet (DEFINE)" dated 3/17/25 at 1700 (5:00 p.m.) to 3/18/25 at 0000 (midnight) were reviewed. RN 9 stated Pt 13 had restraints in place, this problem should be care planned by the nurse to make sure everyone is on the same page with the patient's care needs and progress.

During a review of Pt 26's "H&P", dated 3/12/25, the "H&P" indicated Pt 26 was 13-year-old with a bowel obstruction and significant autism (a neurodevelopmental condition characterized by significant challenges in social communication/interaction and restricted or repetitive behaviors of interests).

During a review of Pt 26's "Restraint Orders (RO)", dated 3/12/25, 3/13/25, 3/14/25, 3/16/25, 3/17/25, and 3/18/25, the "RO" indicated, Patient 26 had bilateral (left and right) soft wrist restraints due to interference with medical treatment.

During a review of Pt 26's "Restraint Flowsheet (RF)", dated 3/12/25 to 3/19/25, "RF" indicated Pt 26 was in left and right soft wrist restraints from 3/12/25 at 7:45 p.m. to 3/14/25 at 1:05 p.m. and from 3/16/25 at 12:00 p.m. to 3/19/25 at 9:00 a.m. The "RF" indicated documentation if the restraint device was intact, secured to bed frame, if maximum movement is allowed, if call light was within reach, if the restraint was continued, a visual check of patient, check patient's circulation, range of motion, if fluids or foods were offered, and if elimination (of bladder /bowel) was addressed.

During a concurrent interview and record review on 3/20/25 at 10:20 a.m. with Registered Nurse (RN) 8, Pt 26's "Care Plan (CP, an individualized plan for the patient's care, goals and interventions to reach those goals is documented and revised)", dated 3/12/25 to 3/19/25 was reviewed. RN 8 stated the care plan did not contain a plan of care for restraint use. RN 8 stated she was unsure if the [brand name of electronic medical record] had a care plan for restraint use available.

During an interview on 3/21/25 at 10:24 a.m. with Clinical Education Specialist (CES) 1, CES 1 stated she checked the in [brand name of electronic medical record] and a plan of care for restraint use was available in the electronic record.

During an interview on 3/21/25 at 11:07 a.m. with hospital Chief Nursing Officer (CNO), CNO stated she would have to would have to look at the policy on this [Restraints and Care Planning], heard directors talking about this, and how it is set up in "brand name EMR software." Violent vs. non-violent restraints would require education and ensuring that NCP follows suit with interventions. CNO stated the purpose of the interdisciplinary NCP is to coordinate care where the whole team sees the plan.

During a review of the hospital policy and procedure (P&P) titled, "Restraints and Seclusion (RS)", dated 2/2025, "RS" indicated, " ... restraint will be utilized in the least restrictive manner possible, and will be discontinued at the earliest possible time ...

Documentation ... Nursing documentation will be reflected in the restraint flowsheet, this is inclusive of the Pre-restraint Application Assessment and ongoing restraint monitoring and assessment documentation as well as interventions ... routine clinical documentation relating to the patient overall condition will be reflected in the physical assessment and patient safety interventions. Goals, planned interventions, and desired outcomes will be identified and documented either electronic or paper ...".

During a review of the hospital's policy and procedure (P&P) titled, "Interdisciplinary Care Planning" dated 4/23, the P&P indicated, " ... Policy Patient and family care is defined in policies, Standardized Procedures, Interdisciplinary Care Plans, patient care conferences and individualized treatment plans. These mechanisms are used for planning, providing, monitoring and coordinating interdisciplinary care across the continuum... Mechanisms for Ensuring Interdisciplinary Care 1. Patient and family Plan of Care...2. ...the Registered Nurse will initiate a Plan of Care based upon the above named sources. All disciplines will participate in the development and updating of the interdisciplinary plan of care within their scope of practice... a. All patients will have a Plan of Care developed and implemented within 24 hours after the admission assessment. b. The Plan of Care is the basis for continuity and consistency in documentation and evaluation of care... d. Plans are reviewed and/or revised every shift, based upon reassessment data by Nursing. Consulting disciplines will update the plan of care weekly. Nursing will coordinate care with consulting disciplines to regularly to plan for discharge... E. The patient's plan of care will include: 1. Problems/Diagnosis(es) 2. Expected outcomes 3. Reference to intervention resources: a. Treatments b. Diagnostic Testing c. Education d. Referral/Consultation e. Follow-Up 4. Newly identified issues..."

During a review of a professional reference titled, "Nursing Process," dated 4/10/23, retrieved from https://www.ncbi.nlm.nih.gov/books/NBK499937/, the Nursing Process indicated, " ...Planning ...The planning stage is where goals and outcomes are formulated that directly impact patient care based on EDP (Evidence-based Practice- recommendations for nursing care that are based on scientific evidence) guidelines. These patient-specific goals and the attainment of such assist in ensuring a positive outcome. Nursing care plans are essential in this phase of goal setting. Care plans provide a course of direction for personalized care tailored to an individual's unique needs. Overall condition and comorbid conditions play a role in the construction of a care plan. Care plans enhance communication, documentation, reimbursement, and continuity of care across the healthcare continuum. Goals should be: 1. Specific; 2. Measurable or Meaningful; 3. Attainable or Action-Oriented; 4. Realistic or Results-Oriented; 5. Timely or Time-Oriented ...".

Based on observation, interview, and record review, the hospital failed to follow their policies and procedures (P&P) when:

1. Licensed Nurses (LNs) did not reassess two (2) of 30 patients' (Pt 9, and Pt 24) pain level
A. after administration of pain medication(s) within the expected timeframe and
B. at specified intervals.

These failures placed Pt's 9 and 24 at risk to receive inadequate pain management and had the potential for LNs to not recognize a change in condition.

2. LNs did not ensure a central line (a central venous catheter (CVC) is a long, flexible tube your provider inserts into a vein in your neck, chest, arm or groin) cart was left unattended and unlocked.

This failure had the potential to result in unauthorized access and use of sharps (any medical device that can puncture or cut the skin, like needles, scalpels, and lancets, requiring special handling and disposal to prevent injuries and infections) and potential harm or injury to staff, patients and/or visitors.

Findings:

1. A. During a review of Pt 9's "Electronic Health Record (EHR- a digital version of a patient's medical history)", Pt 9's "Face Sheet (FS-a document that contains a summary of a patient's personal and demographic (all of the non-clinical data about a patient [name, date of birth, address, etc.] information)," (undated) was reviewed. The FS indicated, "... admit: 3/18/25 ... Spontaneous Pneumothorax (the sudden onset of a collapsed lung without any apparent cause) ..."

During a review of Pt 9's "EHR", Pt 9's "History and Physical (H&P- a formal assessment of a patient's health that includes a medical history and physical exam)" dated 3/18/25, was reviewed. The "H&P" indicated Pt 9 was a "... 17-year-old ... with a recurrent spontaneous pneumothorax on the left side ..."

During concurrent interview and record review on 3/18/25 at 9:15 a.m. with the Director of the Emergency Department (DED), Pt 9's "EHR" and "Medication Administration Report (MAR)" dated 3/19/25 was reviewed. The "MAR" indicated, Pt 9 received a dose of morphine as ordered at " ... 0744 [7:44 a.m.] ..." The DED stated LN documented pain level at 7 out of 10 (7/10- Strong pain, keeps you from doing normal activities) on the numerical pain scale (a tool that uses numbers (typically from 0 to 10 to help people describe and quantify their pain intensity, with 0 representing no pain and 10 representing the worst possible pain.) The DED stated documentation of a pain reassessment was not done within the expected timeframe (pain was reassessed at 9:03 a.m., with documented pain level of 7/10). The DED stated the expectation was that pain be reassessed about 30 minutes after administration of pain medication, about that and the hour mark (or for Pt 9 by 8:44 a.m.).

During a concurrent interview and record review on 3/18/25 at 9:25 a.m. with the DED, Pt 9's "EHR" and "ED Timeline" dated 3/18/25 was reviewed. The "ED Timeline" indicated, an order at " ... 0837 [8:37 a.m.] ... morphine ... 4 mg/ml [milligrams per milliliter- the amount of one substance dissolved in a specific volume of a liquid] ... injection 4 mg; morphine 2 mg/ml injection 2 mg ..." was written. Pt 9's pain reassessment indicated "... 3/18 0903 [9:03 a.m.], Pain Screening/Assessment Scale Pain Assessment Scales: 0-10 Pain Score: 7 ... 1033 [10:33 a.m. an hour and a half later] morphine 4 mg/ml injection 4 mg Given ... 10:39 a.m. ... Pain Score: 7 ... 1058 [10:58 a.m.] ... to department [transferred to in patient admission unit] ..." The DED again stated her expectation was that LNs reassess pain, as previously stated and per policy and as ordered.

B. During a review of Pt 24's "History & Physical (H&P)", dated 3/13/25, the "H&P" indicated, Pt 24 was admitted to an acute care unit for a right renal (kidney) mass and two pulmonary (lung) nodules (small firm lumps of knots).

During a review of Pt 24's "Progress Note (PN)", dated 3/19/25, the "PN" indicated, Pt 24 had a port placement (surgically implanted device under the skin to provide long-term access to a large vein for treatments and blood draws) and tumor biopsy (a procedure where a small sample of tissue or cells is removed from the body for examination under a microscope) on 3/17/25. The "PN" indicated, Pt 24's post (after) surgery pain was to be managed by morphine (a narcotic for pain) PRN (as needed).

During an interview on 3/19/25 at 3:00 p.m. with Registered Nurse (RN) 8, RN 8 stated pain is assessed at least every four hours on the acute care units.

During a concurrent interview and record review on 3/20/25 at 10:10 a.m. with RN 8, Pt 24's "Pain Flowsheet (PF)", dated 3/19/25, was reviewed. The "PF" indicated, Pt 24's pain was assessed at 8:00 a.m. and not again until 8:30 p.m. RN 8 stated she could not see any pain assessment for Pt 24's between 8:00 a.m. and 8:30 p.m. on 3/19/25. The "PF" indicated, Pt 24 had vital signs (heart rate, respiratory rate, and blood pressure) taken between 8:00 a.m. and 8:30 p.m. on 3/19/25.

During an interview on 3/21/25 at 11:07 a.m. with the Chief Nursing Officer (CNO), the CNO stated, nurses were expected to follow hospital P&Ps. The CNO stated the potential risk to the patient for not reassessing pain is being over medicated (too much medication that can lead to harmful effects) or under medicated (not enough medication to treat and illness). The CNO stated the goal is to keep the patient comfortable. The CNO stated [this issue] has come up as an opportunity before, will need to implement measures to ensure staff follow policy.

During a review of the hospital P&P "Pain Management," the P&P indicated, " ... [Hospital name] is committed to making pain assessment a priority ... pain intensity and pain relief will be assessed and reassessed at regular intervals and will contribute to the choice of appropriate therapeutic intervention ... Patient assessments, reassessments, interventions, and responses to interventions will be documented ... Process ... Key Points ... Vital signs should not be used alone to assess pain ... Pain Reassessment ... Reassessment of pain shall occur at the following points ... With routine vital signs per department standards, regardless of pai intensity level ... Patients who are sleeping do not need to be awakened for a pain rating. However, their pain should be reassessed upon awakening ... At a suitable interval after each pharmacologic or non-pharmacologic intervention ... Within 30 minutes after parenteral [administered elsewhere than by mouth or anal] drug therapy, and within one hour after oral or rectal medication has been given ...".

2. During a concurrent observation and interview on 3/18/25 at 2:15 p.m. with Director Pediatric Intensive Care Unit (DPICU) (PICU- a specialized hospital unit designed to provide advanced care for critically ill or injured children, offering comprehensive monitoring and treatment for serious medical conditions), a cart was observed to be unattended, unlocked and in the hallway near the unit exit doors. DPICU observed the cart did not have a locking mechanism. DPICU stated the cart should be locked and in a secure location where staff can monitor and prevent unauthorized access to the supplies stocked in the line cart. DPICU stated there are central line kits [that contain needles/sharps] stocked in the line cart and should be locked. DPICU stated the potential risk of unauthorized access to sharps is harm or injury to staff, patients and visitors.

During an interview on 3/21/25 at 11:07 a.m. with the CNO, the CNO stated, nurses were expected to follow hospital P&Ps to ensure staff, patient and visitor safety while in the hospital.

According to the National Library of Medicine, retrieved electronically on 3/26/25, from: https://pmc.ncbi.nlm.nih.gov/articles/PMC8216297/ Woo K, Rigberg D, Lawrence PF. Safe Central Venous Access in an Overburdened Health System. JAMA. 2021 Jan 19;325(3):299-300. doi: 10.1001/jama.2020.20361. PMID: 33464338; PMCID: PMC8216297. "...an adequately stocked line cart increases the efficiency of line placements. This cart should have all the supplies and personal protective equipment (PPE) necessary to safely perform the procedure(s). An appropriately stocked cart minimizes potential clinician exposure to infectious agents and allows for a more streamlined performance. Further increases in the efficiency of clinician utilization can be realized by limiting the number of clinicians in the room performing the procedure to 2, with a runner outside the room to retrieve additional supplies as needed. This likewise can preserve PPE and minimize personnel exposed to infectious agents ..."

According to The Joint Commission (TJC-a US-based, independent, not-for-profit organization that accredits and certifies healthcare organizations and programs, focusing on improving patient safety and quality of care through standards and evaluations) electronically retrieved on 3/26/25 from: https://www.jointcommission.org/standards/standard-faqs/ambulatory/environment-of-care-ec/000001214/, TJC ..."defines "secure" as locked in containers, in a locked room, or under constant surveillance. Furthermore, in many cases, monitoring remotely via camera is not adequate in meeting constant surveillance if there is an opportunity for something to occur without the means to immediately react to minimize the risk ..." TJC indicated organizations are to conduct a risk assessment regarding unique security issues in accordance with standard EC.02.01.01. A course of action should be established that is both defensible and rational. The organization is expected to implement the course of action, then analyze if the desired effect was achieved. Reference EC.02.01.01 ..."

Based on observation, interview, and record review, the hospital failed to ensure unusable drugs were not available for patient use when an IV (intravenous, in the vein) solution bag subjected to conditions inconsistent with the manufacturer's approved labeling was in stock and available for patient use and the hospital's policy & procedure (P&P) did not consider the IV manufacturer's instructions for use.

These failures had the potential for patients to receive altered, ineffective, and contaminated medications.

Findings:

During a concurrent observation and interview on 3/18/25 at 1:20 p.m. with the Director of Acute Care (DAC) in an Apollo Acute Care Medication Room (room used for the storage and preparation of patient's medications) a 1000 ml (milliliters, a unit of measure) IV solution bag of 5% dextrose (sugar water) and 0.9% Sodium chloride (salt water) was found with its protective (moisture barrier) overwrap removed. The IV bag was labeled with a sticker indicating, " ... open 3/17/25 1700 [5:00 pm.] Exp [expires] 4/17/25 1700 ...". The manufacturer instructions printed on the bag indicated, " ... [Storage] Store in overwrap ..." The DAC stated staff are to date a bag with the time of opening and date expiration for 30 days later if not used once out of overwrap per the hospital policy.

During a review of the hospital's P&P titled, "Medication Stability (MS)", dated 1/2025, the "MS" indicated, " ... Purpose Statement ... Provides guidelines for the appropriate use of single-and multi-use medication containers [containers use one dose only and multiple doses] on patient care units to ensure they are used in a manner that assures sterility and stability of their contents ... Definitions ... BUD (Beyond use date) ... The date, or date and time, after which administration of a drug shall not begin, the preparation shall not be stored ... Process ... Nursing Unit Multiple Use Medication Container Beyond Use Dating BUD shall be assigned as follows ... Injectables ... IV fluid bags removed from the overwrap packaging must be labeled with a revised expiration date as follows ... > 100 mL [milliliters] bags 30 days after opening ..."

During a review of the IV solution' Manufacturer's "Prescribing Information Dextrose and Sodium Chloride Injection (PIDS)", date 12/14/18, The "PIDS" indicated, " ... Directions for use ... Do not remove unit from overwrap until ready to use ..."

During a review of a professional reference titled, "Working up a sweat (WUS)", dated 10/2002, the "WUS" indicated, " ... The purpose of the overwrap [for IV bags] is to improve shelf life and to stabilize the drug concentration. What happens then if a bag is removed from its overwrap and remains unused for days or weeks? Over time, the fluid volume inside the bag decreases and the drug concentration per milliliter [ml, a unit of measure] increases ... Don't remove the overwrap from any I.V. bag stored in your unit until you're ready to use the solution ..."

During a review of a professional reference titled, "Expiration dates and removal of i.v. bag overwrap (EDR)", dated 9/1/95, the "EDR" indicated, " ... The overwrap protects against evaporation of the solution, desiccation [removal of moisture] of the container, drug oxidation [common way of degrading a drug], and photochemical [with light] inactivation of the drug. Without a barrier, substantial moisture loss may occur, increasing the drug concentration ... Manufacturers of these products recommend ... removing the overwrap just before the drug or solution is administered ..."

Based on observations, interviews and record review, the hospital failed to maintain a clean and sanitary environment in accordance with hospital policy and procedures, Centers for Disease Control (CDC- a U.S. federal government agency whose mission is to protect public health by preventing and controlling disease, injury, and disability) and clinical standards of practice for infection control when:

1. Patient freezers, refrigerators, and ice and water machines on multiple units in the hospital were visibly soiled with debris, spill and splatter marks, and/or textured stains. Freezers on several units in the hospital had excessive ice buildup.

2. Medication, clean and dirty utility rooms (rooms designated to prepare and/or store clean supplies/medications and waste products separately) on several units in the hospital had used patient equipment collected into buckets which were stored directly on the floor, clean supplies found on the floor, and/or trash and soiled linen bag(s) overflowing and spilling onto the floor. A new unused spill kit (a collection of equipment and materials used to clean up and dispose of spills) was found in a dirty utility room in the Neonatal Intensive Care Unit (NICU), inconsistent with other areas of the hospital.

3. Two (2) members of the PICU Interdisciplinary Rounds (IDRs- a structured approach where healthcare professionals from various disciplines (like physicians, nurses, therapists, and social workers that gather to discuss and coordinate patient care, often at the patient's bedside) were observed to be drinking from cups while actively participating in patient rounds in the hallway just outside of patient room doors.

These failures resulted in the potential risk of cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) to patients, visitors, and staff which can lead to infection and diseases.

Findings:

1. During a concurrent observation and interview on 3/18/25 at 10:33 a.m. during a tour of the Emergency Department (ED) with the Director of the Emergency Département (DED), in ED Zone 0, the freezer had built up ice. DED stated staff are expected to submit a work order to have Plant Engineering perform defrosting service as needed. In the ED nutrition areas, two (2) ice and water dispensing machines on the unit were visibly soiled, with splatter marks and white-colored/textured residue noted to the exterior, chutes, catch trays and racks of the machine. DED stated Plant Engineering performs preventive maintenance (PM) on the ice machines. DED stated she had to defer to them [Plant Engineering] on when the ice machines were last serviced or cleaned because she was not sure who cleaned them.

During a concurrent observation and interview on 3/18/25 at 1:17 p.m. during a tour of the Pediatric ICU (PICU- a specialized hospital unit designed to provide advanced care for critically ill or injured children, offering comprehensive monitoring and treatment for serious medical conditions), with Director of the PICU (DPICU), in the nutrition room, the refrigerator, freezer ice and water dispensing machine were visibly soiled with red colored spots, splatter marks and white colored, textured residue noted to the exterior, chutes, catch tray (was missing) and racks of the machine; freezers had built up and melting ice chunks and frozen popsicles in original boxes, opened and dated. DPICU stated although not clearly defined, unit practice is to date when the box is opened. The PICU patient personal food items refrigerator was visibly soiled with white and cream-colored spills where prepared formula and a patient cake were stored. DPICU stated it was his expectation that staff maintain and/or submit a report (computer or telephone call) to Environmental Services (EVS-housekeeping) or Plant Engineering, for them to respond and service.

During a concurrent observation and interview on 3/18/25 at 1:17 p.m. during a tour of the Operating Room (OR), Cath Lab (a specialized hospital room or area equipped with advanced imaging (x-ray) technology where doctors perform minimally invasive procedures to diagnose and treat heart and blood vessel conditions), Pre-op (a designated area in a hospital or surgical center where patients are prepared for surgery) and Post Anesthesia Care Unit (PACU- a critical care unit and specialty that focuses on patient recovery after surgery) departments with Peri-Op Leader/Liaison (POL) and Charge Nurse (CN) 1, CN 1 stated the nutrition room was shared by patients and staff. The ice and water dispensing machine in the nutrition room was visibly soiled, with splatter marks and white-colored/textured residue noted to the exterior, chutes, catch trays and racks of the machine. The tissue test (method used to determine is debris is present on a surface) performed on the water dispensing chute resulted in a small circular black plastic piece coming away from the water chute. The tissue test performed on the ice dispensing chute resulted in pink-colored stains on the tissue. CN 1 stated that was not expected [tissue test results] and a work order would be submitted for service by the Plant Engineering department. CN 1 and POL stated Environmental Services (EVS) clean the outside of the machine and Plant Engineering was responsible for cleaning the ice and water dispensing machines. POL stated expectation was that machines are cleaned regularly with staff alerting EVS or Plant Engineering as needed if there is a concern.

During a concurrent observation and interview on 3/18/25 at 2:07 p.m. with RN 4 in acute care oncology (where patients with cancer are treated) unit's patient nutrition room (where food for patients is stored) #1, the refrigerator was noted to have a large puddle of clear liquid on the bottom shelf. A label on the bottom shelf of the refrigerator indicated, " ... BOTTOM SHELF Breastmilk Storage Only ..." RN 4 stated the liquid could be condensation but should not be there as the bottom shelf was where breastmilk was stored.

During a concurrent observation and interview on 3/18/25 at 2:13 p.m. with RN 4 in acute care oncology unit's patient nutrition room #2, the refrigerator was noted to have a large puddle of clear liquid on the bottom shelf. The refrigerator also had six small white frozen pieces, and one large white frozen chunk of a substance stuck to the bottom shelf. RN 4 stated the substance could be from food defrosting or something leaking from upper shelves. RN 4 stated this could be an infection issue.

2. During a concurrent observation and interview on 3/18/25 at 10:33 a.m. during a tour of the Emergency Department (ED) with the Director of the ED (DED), in a Medication Room, 3 white buckets containing used patient equipment were stored, for recycling, directly on the floor. The DED stated was not aware that buckets should not be stored on the floor. In the ED clean supply and equipment room, trash was observed to be overflowing and spilling over onto the floor. DED stated trash should not be overflowing and spilling onto the floor. DED stated her expectation was staff monitor and report to EVS to prevent trash from overflowing.

During a concurrent observation and interview on 3/18/25 at 10:40 a.m. with the Director of Neonatal Intensive Care Unit (DNI) and Registered Nurse (RN) 9 in the NICU soiled utility room (a designated area for temporary storage and handling of soiled materials and equipment before they are cleaned, processed or disposed of) a new unused spill kit was found. RN 9 stated everything in the soiled utility is considered dirty.

During an observation on 3/18/25 at 11:00 a.m. in the acute care medical unit's clean utility room (a designated area where clean supplies are stored), a spill kit was stored.

During a concurrent observation and interview on 3/18/25 at 1:17 p.m. during a tour of the Pediatric ICU with DPICU in the medication room, an unused/plastic wrapped syringe was found on the floor. DPICU stated, the syringe should not be on the floor and should not be used on patients after being on the floor due to risk for cross contamination. In the soiled utility room, a blue plastic bag was observed on the floor. DPICU stated the bag must have "fallen out" of the soiled linen container. DPICU stated trash and soiled linen bags should be contained in designated container and not be overflowing and falling onto the floor.

During an observation on 3/18/25 at 1:20 p.m. in the acute care respiratory unit 's clean utility room, a spill kit was stored.

During an observation on 3/18/25 at 1:40 p.m. in the acute care surgical unit's clean utility room, a spill kit was stored.

3. During a concurrent observation and interview on 3/18/25 at 1:17 p.m. during a tour of the Pediatric ICU with DPICU two (2) members of the PICU IDRs were observed to be drinking from cups while actively participating in patient rounds in the hallway just outside of patient room doors. DPICU stated staff are to keep drinks in designated areas on the unit away from patient care equipment and supplies. DPICU stated drinking outside of these designated areas poses a risk of cross-contamination and illness to patients, visitors, and staff.

During an interview on 3/20/25 at 9:38 a.m. with the Manager, Plant Engineering (MPE), MPE stated once monthly maintenance of ice machines: copy of work form provided. MPE stated these work orders are generated monthly and assigned for work to be done. MPE stated techs are assigned by Zones and the tech remains as primary contact for these zones for consistency and rapport with leaders and staff. Semi-annual take down full inspection and cleaning of all surfaces, inspection and replacements as indicated and replace filters (sediment and charcoal), per hospital policy. Will be replacing the uncleanable stained w/textured staining and have nearly completed cleaning of hospital ice machines. Refrigerators: Mechanical and condensers are maintained by Eng.

During an interview on 3/20/25 at 1:36 p.m. with the Director of EVS (DEVS), DEVS stated refrigerators require use of food safe chemicals, nutrition [services] does these. Human milk is cleaned by nutrition or unit staff. Staff are expected to disinfect, allowing for dwell time (s the amount of time a disinfectant must remain visibly wet on a surface to effectively kill a specific pathogen) then come back to polish off the film and polish off smudges and fingerprints. DEVS stated the expectation was for it to be done twice per day on the morning and evening shifts. DEVS stated on the PACU department, EVS staff are expected to clean in evening- not during day due to cleaning focused on the flow of room turnover (cleaning and sanitizing between patients), but at night [shift] a full clean was expected. DEVS stated EVS staff are expected to clean outside of the refrigerators and ice machines. DEVS stated he will have to speak with staff and follow up with them to ensure they are meeting expectation. DEVS stated from viewing pictures, it did not look like it was happening as expected. DEVS stated he participates in regularly scheduled Environment of Care (EOC) rounds which occur with unit leadership, Quality Assurance, Plant Engineering and EVS to identify deficiencies and have unit leadership correct and will recommend adding these observations to track and monitor compliance with expectations.

During an interview on 3/20/25 at 3:11 p.m. with the Director of Culinary Services (DCS) photos of refrigerators and freezers were shared with DCS. DCS stated her understanding was the unit aides were responsible for maintaining the cleanliness of the inside of the fridge, EVS wipes down the outside. DCS stated nutrition staff (reporting to DCS) are responsible for monitoring when centralized temperature monitoring is not active. DCS stated staff stocks food in the fridge, rotating stock and looking for any expired items and rotate out the formulas. DCS stated EVS doesn't look in the refrigerators/freezers. DCS stated unit aides maintain cleanliness of nourishment rooms. DCS reacted to the photos shown by stating there was "obvious formula spill" in the refrigerator in the PICU. DCS stated her staff does not clean the bins in refrigerator used to separate patient items. DCS stated keeping the refrigerators clean prevents risk of cross contamination; spores (a cell that certain fungi , plants (moss, ferns), and bacteria produce) could be growing, if something is left open in the fridge. DCS stated her team doesn't clean [the refrigerators or freezers]. DCS stated there is an opportunity to begin accountability rounds for her team, along with Environment Of Care rounding to include the cleanliness of the nutrition rooms including refrigerators, freezers on their rounds. DCS stated "we don't defrost freezers because they have to be turned off leaving the unit without a refrigerator." DCS stated if she has this issue [ice buildup] on her unit, they put in a work order [to Plant Engineering].

During an interview on 3/21/25 at 10:39 a.m. with the Manager of Infection Prevention (MIP), and the Vice President (VP) of Quality Assurance (QA), photos of the observations were shared with MIP. MIP stated, anything on the floor needed to be thrown away. VPQA stated the risk of unidentified liquid and built-up ice in refrigerators, could indicate temperature dysregulation and identifying the source is important to prevent infection. VPQA stated there was concern for possible contamination and spoilage [of food items]. VPQA stated staff should help by cleaning up spills and contacting EVS. VPQA stated [for refrigerators and freezers] EVS is responsible to clean outside, inside cleaned by unit aides. VPQA reviewed photos, and stated the photo indicated that those items should not be as found . VPQA and MIP stated they were not aware the "Who Cleans What [Appendix table]" did not indicate what department cleans the refrigerators.

During an interview on 3/21/25 at 10:41 a.m. with the Manager of Infection Prevention (MIP), the MIP stated an unused spill kit is a clean item and item in a soiled utility room are considered dirty.

During an interview on 3/21/25 at 10:44 a.m. with the MIP, the MIP stated the frozen and liquid substances in the patient nutrition refrigerators could be condensation of defrosting food and could be a potential for cross-contamination of patient food.

During an interview on 3/21/25 at 11:07 a.m. with the Chief Nursing Officer (CNO), the CNO stated, supplies for patients should not be on the floor in the clean supply room. The CNO stated when supplies were found on the floor they should not be used on patients and should go back to the central supply department, or in the trash. The CNO stated it was her expectation that if an infection control concern is observed, the staff was expected to make good decisions and escalate the concern to have EVS clean/sanitize as needed.

During a review of the hospital's policy and procedure (P&P) titled, "Infection Prevention Program" dated 2/25, the P&P indicated, "... Policy ... 2. Organizational Oversight...F. Observe procedures for decontaminating equipment and environmental surfaces ... K. ... 3. A clean and sanitary environment for patients, personnel and visitors will be maintained. All cleaning, disinfection, sterilization and decontamination procedures, agents, equipment and schedules shall be defined in writing and approved by the Infection Prevention & Control Subcommittee ... L. 3. Department managers shall enforce infection prevention and control policies and ensure that all personnel in their department are competent to participate in infection prevention and control activities ..."

During a review of the hospital's P&P titled, "Disinfection of Patient Care Equipment and Devices" dated 2/23, the P&P indicated, " ... Purpose Statement Reusable ... The purpose of this procedure is to prevent healthcare associated infections that are associated with contaminated patient care equipment and devices... Definitions...Cleaning The removal of visible soil ... from objects and surfaces ... Appendix A: Who Cleans What ... ITEMS: Ice Machine STANDARD: Scheduled METHOD: Per policy GROUP: Facilities/Engineering cleans inside of machine EVS cleans outside ... ITEMS: Refrigerators, nutrition rooms STANDARD: When visibly soiled or dusty METHOD: Hospital-approved disinfectant GROUP: EVS ..."

During a review of the hospital's P&P titled, "Refrigerator Policy" dated 4/22, the P&P indicated, " ... Purpose Statement To ensure that medications and patient food are stored at the appropriate temperatures to ensure medication integrity and patient safety ..."
During a review of the hospital's procedure titled, "Nutrition Room Cleaning Procedure" (undated), the procedure indicated, " ... Step 3 - Disinfection damp wipe of surfaces: The Tech will use a microfiber towels saturated in disinfectant solution or premixed disinfection wipe for cleaning of surfaces in the room. The saturated microfiber towels are to be gently wringed out to retained dampness for dwell time of the chemical. Start the disinfection wipe of items/fixtures from the doorway of the room and work in a clockwise direction through the room. The disinfection wipe will include all horizontal surfaces and spot wipe of vertical high touch surfaces. It is important to keep used dirty wipes from touching clean wipes. After carefully wiping down all the required surfaces and the dwell has been reached, the Tech should go over surfaces with a dry wipe to remove chemical residue ..."

During a review of the hospital's procedure titled, "Soiled Utility Room Procedure" undated, the procedure indicated, " ... It is the practice of the EVS department to ensure that the Soiled Utility room is cleaned thoroughly once per day and policed continuously ..."
During a review of the document provided by the hospital titled, "Environment of Care (EOC) Manager Rounds" dated 3/12/25, the EOC Tracer indicated, "... Location ... Discovery... Observe/Check/Verify ... X...16. Storage - 6" (6 inches) off the floor and 18" (18 inches) from ceiling ... Finding #0232 Storage on the floor ... resolved ... 20. All supplies/products have current dates; no expired supplies/products. 21. Patient food stored, labeled, dated and/or discarded per policy. 22. Refrigerators that store patient food are clean ..."

During a review of the document provided by the hospital titled, "Environment of Care (EOC) Tracer" dated 1/14/25, the EOC Tracer indicated, "... Location ... ED ... N/A...16. Storage - 6" (6 inches) off the floor and 18" (18 inches) from ceiling ..."

According to the "Brand Name Ice Machine and Dispensers" Cleaning and Sanitizing Instruction for Use (IFU) provided by the hospital, the IFU indicated "... Periodic cleaning of "brand name" ice and water dispenser and ice machine system is required to ensure peak performance and delivery of clean, sanitary ice. The recommended cleaning procedures that follow should be performed at least as frequently as recommended and more often if environmental conditions dictate ..."

During the review of a professional reference titled, "Managing Condensation in Medical-Grade Refrigerators (MC)", dated 2019, the "MC" indicated, " ... Why condensation removal is important ... The management of condensation inside a refrigerator is important for several reasons. First, molds and other biofilms can grow in wet environments. Small microscopic water droplets forming on the walls of shelving inside a refrigerator can be an ideal site for the growth of molds, yeasts and bacteria that are in the ambient air. The drier the environment, the less likely this is to occur ... In addition, packaging inside the units can be moist and soggy if the condensation is not adequately removed from the storage cabinet ..."

During a review of a professional reference from the Agency for Healthcare Research and Quality (AHRQ) titled, "Infection Prevention (IP)" (undated), "IP" indicated, " ... Providing a sanitary environment ... There is a clear separation of clean and dirty work areas. Clean areas are used for storage and preparation of medications and unused supplies; dirty areas are used for contaminated equipment ..."

During a review of the professional reference titled, "The role of the surface environment in healthcare-associated infections", dated August 2013, the professional reference indicated, " ... Hospital surfaces are frequently contaminated with important healthcare-associated pathogens (bacteria). Contact with the contaminated environment by healthcare personnel is equally as likely as direct contact with a patient to lead to contamination of the healthcare provider's hands or gloves that may result in patient-to-patient transmission of nosocomial (originating from the hospital) pathogens ..."

During a review of the professional reference titled, "Good Storage and Distribution Practices for Medical Products", (retrieved from https://www.who.int/publications/m/item/trs-1025-annex-7) dated 6/17/20, the professional reference indicated, " ... Storage and distribution are important activities in the supply chain management of medical products ... Storage areas should be of sufficient capacity to allow orderly storage of the various categories of medical products ... Storage areas should be appropriately designed, constructed, maintained or adapted. They should be kept clean and there should be sufficient space and lighting ... Materials and medical products should be stored off the floor, away from walls and ceilings, protected from direct sunlight and suitably spaced, to permit ventilation, cleaning and inspection ... Materials and medical products should be handled and stored in such a manner as to prevent contamination, mix-ups and cross-contamination..."