HospitalInspections.org

Based upon observation, record review, and interview, the Governing Body failed to

A. ensure that 5 (PA #62, #100, #101, #102, and #103) of 5 Physician Assistant's (PAs) were granted privileges to order Moderate Sedation.

PAs were routinely ordering moderate sedation in the Interventional Radiology Department. The supervising Physician denied moderate sedation was being ordered by the PAs despite countersigning the Post Procedure Note where the orders were documented. Without the proper credentialing and delineation of privileges approved by the Medical Staff, the PAs placed all patients receiving moderate sedation at great risk for patient harm and possible subsequent death.


It was determined that these deficient practices posed an Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, impairment and /or subsequent death.


Cross Refer to Tag A0341


B. maintain a sanitary environment placing patients at risk for contracting and spreading infections and communicable diseases in 16 departments and areas of the hospital ( Dietary Department, 3rd Floor Medical ICU, Pharmacy, Laboratory, Radiology, 6 South, Labor and Delivery, Central Supply Warehouse, Emergency Room at Broadway, Emergency Room Main Emergency Room Main- West, 3N Orthopedic Department, 4WA and B -COVID Telemetry/ICU, Linen and Laundry, and 3rd floor IMC Medical/Surgical Unit.)

The facility failed to ensure the dietary department had properly working dishwasher to prevent excessive condensation dripping from the ceiling onto clean dishes and cookware for two weeks. The dishware was unable to be dried properly and stored to prevent food borne illness or bacterial growth that could spread such as Legionnaires Disease. The hospital administration nor infection control was aware of the issue.

It was determined that the deficient practice posed an Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, impairment and /or subsequent death.


Refer to Tag A0749


C. ensure sufficient numbers of nursing staff on 5 of 7 units reviewed for staffing (6 South, 6 North, Neuro Intensive care unit, Cardio-vascular intensive care unit and 2 North).

The facility failed to ensure sufficient Registered nurses (RN), Licensed vocational nurses (LVN) and Patient care assistants/technicians (PCA/PCT).

Refer to tag A0392 for additional information.


D. ensure nursing staff evaluated care. The facility failed to ensure nursing staff followed hospital policy to reassess pain after a pain medication or discharge from the ED. This was found in five (5) of 17 records that were reviewed, for pain reassessment after administration of a pain medication (Patient #'s 30, 31, 33, 34 and 43).

Refer to tag A0395 for additional information.


E. ensure individualized care plans in 9 of 9 patients reviewed for care plans (Patient #'s 1, 40, 43, 45, 46, 47, 57 58, and 93).

Patient #1 was self-administering medications and was on a bi-level positive airway pressure (BiPAP) ventilator assist system and there were no individualized care plans with interventions.

Patient#'s 40, 43, 45, 46, 47, 57 58, and 93 who were identified as critical care patients did not have complete individualized nursing care plans.

Refer to tag A0396 for additional information.

F. ensure medications were administered as ordered by the physician in 5 of 90 sampled patients (Patient #'s 2, 4, 5, 10 and 12).

The facility failed to ensure nurses followed physician ordered parameters for intravenous drips.

The facility failed to ensure medications were administered timely and nurses properly witnessed the administration of insulin.

Refer to tag A405 for additional information.


G. ensure physician orders were complete for blood transfusions. They failed to ensure post transfusion vital signs were completed and followed upon when out of range.

This deficient practice was found in 2 of 4 charts reviewed for blood administration (Patient #'s 50 and 51).

Refer to tag A0410 for additional information.


H. ensure 1 of 1 patients sampled for self-administration of medications received physician's orders, education, competency evaluation, and monitoring prior to self- administrating medications (Patient #1).

Patient #1 was self- administering eye drops without having physician orders or an prior evaluation. One of the eye drops that Patient #1 was administering was not listed on the medication administration record.


Refer to tag A0413 for additional information.


I. ensure a clean and sanitary environment was provided for the provision of surgical services in 4 (Digestive Disease Center, Day Surgery, Main Operating Room, Sterile Processing Department) of 5 areas observed.


1. ensure the temperature in the Operating rooms (OR) and Sterile Storage areas in Day Surgery was within acceptable standards to inhibit microbial growth, reduce the risk of infection, promote patient comfort and assure the physical safety of all patients in 8 (OR Room A, OR Room B, OR Room C, OR Room D, and OR Room E, Viewing Room, Consignment Room, Sterile Storage Room) of 8 areas observed. The facility also failed to follow their own policy.


2. ensure a current roster listing each practitioners privileges and a current roster of practitioners suspensions were available to all schedulers.

Cross Refer to A0945

Based on review of records and interview, the facility failed to ensure patients were presented written information on their patient rights prior to furnishing services for 2 patients (Patient #66 and #68) out of 5 patients' charts reviewed.

Findings included:

Patient #66 Chart Review

A review of Patient #66's chart was made on 7-21-2021. Patient #66 was a 46-year-old male who was admitted on 5-31-2021 and discharged on 6-6-2021. The patient was transferred from a separately licensed hospital and was a direct admission. Review of the chart showed that the Consent to Treatment form had not been completed. Page 2, Item N. of the Consent to Treatment form contained the documentation of receipt of patient rights information.

"N. Patient Rights: I have been given written materials about my rights as a patient. (Patient Initials: ___)"

Nursing notes from the time of admission and the nursing admission assessment was reviewed. No evidence was found that the patient had received written information about his rights as a patient.


Patient #68 Chart Review

A review of Patient #68's chart was made on 7-21-2021. Patient #68 was a 53-year-old female who was admitted on 6-27-2021 and discharged on 7-2-2021. The patient was transferred from a separately licensed hospital and was a direct admission. Review of the chart showed that the Consent to Treatment form had not been completed. Page 2, Item N. of the Consent to Treatment form contained the documentation of receipt of patient rights information.

"N. Patient Rights: I have been given written materials about my rights as a patient. (Patient Initials: ___)"

Nursing notes from the direct admission on 6-27-2021 were reviewed. The notes indicated that that patient was oriented to self only and not able to understand teaching. No evidence was found that the patient or the patient representative had received written information about Patient #68's rights as a patient.

Interviews:

Interview with RN #10 confirmed on 7-21-2021 confirmed that the Consent to Treatment form was missing from Patient #66 and #68's charts.

Interview with Staff #117 confirmed that the patient received a copy of the "Patient Information Handbook" upon the admission process. The printed booklet contained patient rights information and a "Patient Rights" form with additional rights was located in the front, inside pocket of the booklet. Staff #117 confirmed that when patients are directly admitted from a separately licensed facility, patients or their representatives are to sign the Consent to Treatment form and receive information regarding their patient rights for the hospital they are being admitted to.

Based on review of records and interview, the facility failed to ensure patients were presented with all information necessary to make an informed decision regarding treatment and that the informed decision was documented in the patient chart for 3 patients (Patient #66, #67, and #68) out of 5 patients' charts reviewed.

Findings included:

Patient #66 Chart Review

A review of Patient #66's chart was made on 7-21-2021. Patient #66 was a 46-year-old male who was admitted on 5-31-2021 and discharged on 6-6-2021. The patient was transferred from a separately licensed hospital and was a direct admission. Review of the chart showed that the Consent to Treatment form was not present.

Nursing notes from the time of admission and the nursing admission assessment was reviewed. No evidence was found that the patient had received information necessary for informed consent at the time of admission.

Patient #67 Chart Review

A review of Patient #67's chart was made on 7-21-2021. Patient #67 was a 62-year-old male who was admitted on 5-27-2021 and discharged on 6-7-2021. The chart contained two consents for Central Line Placement (Centers for Disease Control website, cdc.gov, definition: A central venous catheter, also known as a central line, is a tube that doctors place in a large vein in the neck, chest, groin, or arm to give fluids, blood, or medications or to do medical tests quickly.) The consents were lacking required information disclosing the physician performing the procedure and/or the patient condition that required a central line be placed in order to treat the patient.

A consent signed on 5-28-2021 providing verbal consent from Patient #67's wife did not contain the name of the physician who was performing the procedure.

A consent signed by Patient #67's wife on 6-7-2021 did not contain the name of the physician who was performing the procedure or information about the patient condition for which the central line was required for treatment of that condition.

Interview with RN #10 at the time of the chart review confirmed that the information was missing and no other consents were found in the chart that contained the complete information.

Patient #68 Chart Review

A review of Patient #68's chart was made on 7-21-2021. Patient #68 was a 53-year-old female who was admitted on 6-27-2021 and discharged on 7-2-2021. The patient was transferred from a separately licensed hospital and was a direct admission. Review of the chart showed that the Consent to Treatment form was not present.

Nursing notes from the time of admission and the nursing admission assessment was reviewed. The notes indicated that that patient was oriented to self only and not able to understand teaching. No evidence was found that the patient or the patient representative had received information necessary for informed consent at the time of admission.

Interviews

Interview with RN #10 confirmed on 7-21-2021 confirmed that the Consent to Treatment form was missing from Patient #66 and #68's charts.

Interview with Staff #117 confirmed that when patients are directly admitted from a separately licensed facility, patients or their representatives are to sign the Consent to Treatment form and receive information regarding their patient rights for the hospital they are being admitted to.

Based on observation, record review, and interview, the facility failed to:

A. ensure NX- Stage dialysate fluids were stored in a clean storage area and that the temperature and humidity of the room was within range. Also, there was room of the storage that had a piece of equipment that staff RN #2 reported was equipment that held steam. Observed was water leaking thru rusty pipes under the door and into the area where NX-Stage Dialysate was stored. The steam equipment was putting off heat.

B. ensure that emergency hand cranks were available on the dialysis machine in case of power outage.

C. ensure the face of the dialysis machine was not chipped with bare metal exposed so that disinfecting of the machine could be completed.

D. secure the storage area where 50-gallons acid drums and acid jugs were stored.

E. ensure the dialysis staff had 5 continuing education hours in the past year in the area of dialysis for 3 of 3 dialysis files reviewed.

F. ensure dialysis staff were maintaining a clean and sanitary environment for the acute dialysis patient.

G. ensure that NX- Stage dialysate fluids were not expired and available to dialysis staff.

H. ensure dialysis Staff #32 was cleaning the dialysis machine after dialyzing in Patient #41's room. Also, the staff failed to follow the facility's policy for cleaning and disinfecting the dialysis machines.


Findings include:

A. The NX- Stage dialysate fluids were stored in a room off the back-loading dock. Some of the dialysate fluid were still in the shipping cardboard boxes sitting on wooden pallets, the floor was covered in trash , dust, and dirt particles. There were numerous bags of dialysate just lying on top of the cardboard boxes. There were 2 bags lying on the floor. A review of the temperature and humidity logs for the months of May, June, and July of 2021 revealed the following:

The log indicates to notify Bio-Med if the temperature was above 75 and if the humidity above 60%.

May 2021-Log

5/28/2021-75.2 There was no notification to Bio-Medical that the temperature was out of range.
5/29/2021-75.3 There was no notification to Bio-Medical that the temperature was out of range.
5/31/2021-75.3 There was no notification to Bio-Medical that the temperature was out of range.

June 2021-Log

6/12/2021-76.4 Notified plant services, but not the Bio-Medical that the temperature was out of range.
6/18/2021-78.9 There was no notification to Bio-Medical that the temperature was out of range.
6/21/2021-76.6 There was no notification to Bio-Medical that the temperature was out of range.
6/22/2021-75.5 There was no notification to Bio-Medical that the temperature was out of range.
6/23/2021-75.3 There was no notification to Bio-Medical that the temperature was out of range.
6/24/2021-76.4 There was no notification to Bio-Medical that the temperature was out of range.
6/25/2021-76.4 There was no notification to Bio-Medical that the temperature was out of range.
6/26/2021-76.6 There was no notification to Bio-Medical that the temperature was out of range.
6/28/2021-76.4 There was no notification to Bio-Medical that the temperature was out of range.

July 2021 -Log

7/1/2021-75.5 Notified plant services, but not the Bio-Medical that the temperature was out of range.
7/2/2021-76.2 There was no notification to Bio-Medical that the temperature was out of range.
7/6/2021-75.2 There was no notification to Bio-Medical that the temperature was out of range.
7/7/2021-75.5 Notified plant services, but not the Bio-Medical that the temperature was out of range.
7/8/2021-75.5 There was no notification to Bio-Medical that the temperature was out of range.
7/9/2021-75.2 There was no notification to Bio-Medical that the temperature was out of range.
7/10/2021-75.2 There was no notification to Bio-Medical that the temperature was out of range.
7/14/2021-76.8 There was no notification to Bio-Medical that the temperature was out of range.
7/15/2021-75.7 There was no notification to Bio-Medical that the temperature was out of range.
* 7/16/2021-77.7 There was no notification to Bio-Medical that the temperature was out of range.
* 7/17/2021-77.0 There was no notification to Bio-Medical that the temperature was out of range.
* 7/19/2021-77.5 There was no notification to Bio-Medical that the temperature was out of range.
7/20/2021-75.7 Notified plant services, but not the Bio-Medical that the temperature was out of range.

* Indicates manufacture out of range guidelines of temperatures above 77 degrees from the NX-Stage dialysate.


During the tour of the storage room where the NX-Stage dialysate was kept; there was an unlocked door to room that had some type of equipment that collected steam. The equipment was leaking water. The running of the door to area were the NX-Stage dialysate fluids were being stored. Surveyor ask the name of the equipment ,but never received an answer. Just that the equipment collected steam. The piece of equipment was wrapped with white colored cloth tape at the piping and the piping was rusted with water leaking.

An interview with Staff #35 on 7/20/2021 at 9:28 AM confirmed the above findings.


B. During a tour and observation of the Dialysis unit on 7/21/2021, observed emergency hand cranks were not present on 2 of 16 dialysis machines. Emergency hand cranks are to remain on each machine in the event of power outage, so blood may be returned to the dialysis patient in the event of power outage or disaster.

An interview with Staff #35 on 7/21/2021 at 1:15 PM confirmed the above findings.


C. Observed Staff #32 bringing a dialysis machine down the hallway from a patient's room. Dialysis machine #7KOS113620 had facial chipping and bare metal was exposed. The metal will rust with the use of bleach wipes. There was no way the staff could disinfect the metal chipped areas that had metal exposed.


An interview with Staff #2 and Staff #32 on 7/21/2021 at 12:59 PM confirmed the above findings.

D. During a tour of the facility on 07/20/2021 at 9:30 AM, observed the acute dialysis unit had 2 doors to the dialysis unit storage room where acid and dialysis supplies were stored. The door led directly to the dialysis supplies and products from the treatment floor area. One of the doors had key code access; which allowed Housekeeping or any department employees access into the dialysis unit and into the supply room.

This deficient practice allowed non-dialysis staff access to the acid jugs and 50-gallon drums allowing access to open jugs or tampering with the jugs and any dialysis products.


An interview with Staff #35 on 07/20/2021 at 9:40 AM confirmed the above findings.


E. A review of Staff files for CCHT (Certified Clinical Hemodialysis Technician) #2, RN #27, and RN #28 revealed the staff members did not have 5 continuing education hours for the last year in the area of dialysis.

An interview with Staff #35 on 07/20/2021 at 11:30 AM confirmed the above findings.


F. During a tour of the acute dialysis unit and the storage area on the morning of 07/20/2021 observed the following infection control issues:


Acute Dialysis unit:

* Rusty legs on the utility sink in the Bi-carb mixing room.

* The floor in the Bi-carb room under the utility sink was covered in white substance with small black particles.

* The wall behind the utility sink was covered in a brown substance.

* Shelves in the storage room (procedure room) dusty and dirty.

* There was a blue plastic container that was covered in dust and dirt particles. The lid was covered in white substance. The equipment in the container was old and not used any longer.

* The storage room had numerous pieces of equipment that was old and not being used. Staff #35 reported that the equipment room need to be cleaned out.

* There was a cardboard box under the dirty sink that contained the clear plastic wrap that covers the equipment after the equipment has been cleaned.

* Rusted racks in the storage rooms where supplies were stored.

* The bottom shelf of the pyxis machine in the in-center dialysis unit was covered
in dust and dirt particles. Dialysis staff reported that it was the responsibility of the pharmacy to clean the pyxis machines.


An interview with Staff #35 on 07/20/2021 at 9:45 AM confirmed the above findings.

G. During a tour of the CVICU (Cardiovascular Intensive Care Unit) on the morning of 07/21/2021 at 10:30 AM there were 6 bags of expired NX-Stage Pure -Flow 2K-3CA dialysate in the medication room on a rolling cart. There were 4 bags that expired 05/05/2021 and 2 bags that expired 05/22/2021.

H. During a tour of the medical floors on 07/21/2021 at 12:59 PM observed Staff #32 rolling a dialysis machine down the hallway after coming out of Patient #41 room. Staff #32 did not wipe the machine with bleach wipes. Also, there was a gray bucket of dialysis supplies that were sitting on top of the dialysis machine that had been in the Patient #41's room.

Patient #41 was a 63-year-old gentleman with history of alcohol abuse, and was admitted with respiratory failure, pneumonia, sepsis, and acute kidney injury. Patient has MRSA with line sepsis.

A review of the facility's policy titled, "Cleaning and Disinfection General Policy for Inpatient Services" revealed the following:

"The purpose of this document is to provide guidance for cleaning and disinfection for Inpatient Services.

Bedside Treatment: The patient does not need to vacate the patient room. Once treatment is completed, the machine, PRO, and any non-disposable equipment must be externally disinfected prior to removing the machine from patient room."

An interview with Staff RN#2 and Staff RN #32 on 07/21/2021 at 12:59 PM confirmed the above findings.

Based on observation, document review, and interview the Medical Staff failed to ensure that 5 (PA #62, #100, #101, #102, and #103) of 5 Physician Assistant's (PAs) were granted privileges to order Moderate Sedation.

PAs were routinely ordering moderate sedation in the Interventional Radiology Department. The supervising Physician denied moderate sedation was being ordered by the PAs despite countersigning the Post Procedure Note where the orders were documented. Without the proper credentialing and delineation of privileges approved by the Medical Staff, the PAs placed all patients receiving moderate sedation at great risk for patient harm and possible subsequent death.


It was determined that these deficient practices posed an Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, impairment and /or subsequent death.


Cross Refer to Tag A0341

Based on observation, document review, and interview the Medical Staff failed to ensure that 5 (PA #62, #100, #101, #102, and #103) of 5 Physician Assistant's (PAs) were granted privileges to order Moderate Sedation. Also, the facility failed to ensure that the Interventional Radiology Department was informed of the privileges of 5 (PA #62, #100, #101, #102, and #103) of 5 Physician Assistants (PAs).

PAs were routinely ordering moderate sedation in the Interventional Radiology Department. The supervising Physician denied moderate sedation was being ordered by the PAs despite countersigning the Post Procedure Note where the orders were documented.


Findings Include:


A review of the Medical Credential Files for the Physician Assistants in the Interventional Radiology Department revealed the following:


Physician Assistant #62


A review of the credentialing file for Physician Assistant (PA) #62 was as follows:

" ...CORE PRIVILEGES:
Prescriptive authority as per state law (no Sch 2) ..."

No Moderate Sedation Privileges were requested or recommended.

Re-appointment as an Allied Health Professional was effective 7/14/2020 through9/14/2020.




Physician Assistant #100

A review of the credentialing file for Physician Assistant (PA) #100 was as follows:

" ...CORE PRIVILEGES:
Prescriptive authority as per state law (no Sch 2) ..."

No Moderate Sedation Privileges were requested or recommended.

Initial appointment as an Allied Health Professional was effective 9/25/2019 with a reappointment 7/27/2021.




Physician Assistant #101

A review of the credentialing file for Physician Assistant (PA) #101 was as follows:

" ...CORE PRIVILEGES:
Prescriptive authority as per state law (no Sch 2) ..."

No Moderate Sedation Privileges were requested or recommended.

Initial appointment as an Allied Health Professional was effective 10/28/2020 through 4/26/2022.



Physician Assistant #102

A review of the credentialing file for Physician Assistant (PA) #102 was as follows:

" ...CORE PRIVILEGES:
Prescriptive authority as per state law (no Sch 2) ..."

No Moderate Sedation Privileges were requested or recommended.

Initial appointment as an Allied Health Professional was effective 5/27/2020.



Physician Assistant #103
A review of the credentialing file for Physician Assistant (PA) #103 was as follows:

" ...CORE PRIVILEGES:
Prescriptive authority as per state law (no Sch 2) ..."

No Moderate Sedation Privileges were requested or recommended.

Re-appointment as an Allied Health Professional was effective 3/31/2020.



An interview was conducted with Staff #28 on 7/22/2021 after 1:00 PM. Staff #28 was asked if any PAs had privileges to give moderate sedation. Staff #28 stated, "None of our PAs have privileges for moderate sedation. It's not included in the core privileges. We would have to do the core privileges over and add that because right now it is not even an option for them to ask for moderate sedation privileges." Staff #10 confirmed this also.


An observation tour of the Radiology Department was conducted on 7/23/2021 after 8:00 AM with Staff #84. The following was observed:

Patient #90

This surveyor observed Patient #90 in the Intervention Radiology (IR) Procedure room on 7/23/2021 after 8:00 AM. Patient #90 was consented for Moderate Sedation by MD #121 and PA #103. MD #121 was in the procedure room after the patient was prepped and draped for the procedure. MD #121 washed his hands and left the room before 9:00 AM. A verbal order was given to RN #76 by PA #103 for "just a little bit of Versed" at 9:02 AM. This was after MD #121 left the room. An additional verbal order was given to RN #76 for 1mg of versed.

A review of the post procedure note revealed PA #103 documented Patient #90 was given "Deep Sedation."

An interview was conducted with PA #103 at 9:20 AM on 7/23/2021. PA #103 was asked if he was aware that he did not have privileges for moderate sedation. PA #103 stated, "No I was not. I thought we all had privileges for moderate sedation."

An interview with RN #77 and RN #76 was conducted on 7/23/2021 after 8:00 AM. RN #78 was asked if the PAs are the ones that order the moderate sedation for the IR Procedures. RN #77 stated, "The PAs are the ones that always order the medicines for these cases. We hardly ever have a MD in the procedure room. We usually never have 2 nurses but today we do." RN #77 confirmed the PAs order all the moderate sedation medications.

An interview with Staff #84 was conducted on 7/23/2021 after 9:00 AM. Staff #84 was asked if he was aware that the PA's did not have privileges to order moderate sedation for patients. Staff #84 stated, "No, I was not aware of that." Staff #84 was asked if the PA's are ordering the moderate sedation during their procedures. Staff #84 confirmed that the PA's order the sedation medications for the procedures. Staff #84 was asked why the immediate post procedure note was documented as deep sedation and not moderate sedation. Staff #84 stated, "That is all that is in the drop down menu there."

An interview with Staff #56 and #57 was conducted on 7/23/2021 at 8:30 AM. Staff #56 and #57 were asked if they knew the PA's were ordering sedation medications for moderate sedation in the procedures they were doing in the department. Staff #56 and #57 replied, "We had no idea the PAs were doing moderate sedation."

An interview with MD #121 was conducted on 7/23/2021 at 11:44 AM. MD #121 was asked if he was aware the PAs were ordering moderate sedation for the IR Procedures. MD #121 stated, "PAs don't give conscious sedation. I'm not aware that they give moderate sedation during the cases." MD #121 was asked if he was the supervising physician for the PAs. MD #121 stated, "I am the PA Liaison and I am the supervising physician." MD #121 was asked if he cosigned the notes after the procedures were complete. MD #121 replied, "Yes but I am not in the room with them because its just me and I don't have the time to be in all the cases that they do."

MD #121 was presented with a Final Report dictated by PA #101.

The final report was as follows:

" ...Conscious Sedation: The patient received IV Versed and fentanyl while undergoing continuous noninvasive hemodynamic monitoring by the radiology nurse. The exact dosages will be found in the nurses notes along with additional details of the anesthetic record. Sedation duration: 30 minutes ..."

MD #121 confirmed the electronic signature to be his on the final report for Patient #86.


A review of medical records was conducted in the Administrative offices on 7/23/2021 after 8:00 AM. 9 (Patient #83, #84, #85, #86 X2, #87, #88, #89, #90) of 10 records reviewed revealed PAs ordered all moderate sedation for the cases performed in the IR Department.


Patient #83

A review of the document titled, "SEDATION/VITAL SIGNS/ORDER RECORD"
For Patient #83 was as follows:

Patient #83 was having a procedure in the IR Department on 7/7/2021.

PA #100 gave a verbal order to RN #76 for Versed and Fentanyl. (Exact dose is illegible).

MD #121 electronically signed the document on 7/21/2021.


Patient #84

A review of the document titled, "SEDATION/VITAL SIGNS/ORDER RECORD"
For Patient #84 was as follows:

Patient #84 was having a procedure in the IR Department on 7/01/2021.

PA #100 gave a verbal order to RN #76 for Versed and Fentanyl. (Exact dose is illegible).

MD #122 electronically signed the document on 7/10/2021.



Patient #85


A review of the document titled, "SEDATION/VITAL SIGNS/ORDER RECORD"
For Patient #85 was as follows:

Patient #85 was having a procedure in the IR Department on 7/02/2021.

PA #100 gave a verbal order to RN #76 for Versed and Fentanyl. (Exact dose is illegible).

No MD had co-signed the document.



Patient #86

A review of the document titled, "SEDATION/VITAL SIGNS/ORDER RECORD"
For Patient #86 was as follows:

Patient #86 was having a procedure in the IR Department on 6/02/2021.

PA #101 gave a verbal order to RN #77 for Versed 1mg and Fentanyl 50mcg.

MD #121 electronically signed the document on 6/21/2021.



Patient #86

A review of the document titled, "SEDATION/VITAL SIGNS/ORDER RECORD"
For Patient #86 was as follows:

Patient #86 was having a procedure in the IR Department on 7/16/2021.

PA #101 gave a verbal order to RN #76 for Versed and Fentanyl. (Exact dose is illegible).

MD #122 electronically signed the post procedure note on 7/16/2021.



Patient #87

A review of the document titled, "SEDATION/VITAL SIGNS/ORDER RECORD"
For Patient #87 was as follows:

Patient #87 was having a procedure in the IR Department on 5/05/2021.

PA #62 gave a verbal order to RN #77 for Versed and Fentanyl. (Exact dose is illegible).

MD #122 electronically signed the post procedure note on 5/05/2021.



Patient #88

A review of the document titled, "SEDATION/VITAL SIGNS/ORDER RECORD"
For Patient #88 was as follows:

Patient #88 was having a procedure in the IR Department on 7/13/2021.

PA #100 gave a verbal order to RN #77 for Versed and Fentanyl. (Exact dose is not written).

No MD had co-signed the document.



Patient #89

A review of the document titled, "SEDATION/VITAL SIGNS/ORDER RECORD"
For Patient #89 was as follows:

Patient #89 was having a procedure in the IR Department on 7/16/2021.

PA #101 gave a verbal order to RN #76 for Versed, Fentanyl, and Zofran. (Exact dose is illegible).

No MD had co-signed the document.



An interview with Staff #123 was conducted on 7/23/2021 at 1:50 PM. Staff #123 was asked if he was aware that Physician Assistants are doing moderate sedation in radiology that they are not credentialed to do. Staff #123 stated, "I didn't know that was happening."


Staff #56, #57, #84, and #123 confirmed the findings.

Based on observation, interview, and record review, the facility failed to ensure nursing services was sufficiently organized. The facility failed to:

A. ensure sufficient numbers of nursing staff on 5 of 7 units reviewed for staffing (6 South, 6 North, Neuro Intensive care unit, Cardio-vascular intensive care unit and 2 North).

The facility failed to ensure sufficient Registered nurses (RN), Licensed vocational nurses (LVN) and Patient care assistants/technicians (PCA/PCT).

Refer to tag A0392 for additional information.


B. ensure nursing staff evaluated care. The facility failed to ensure nursing staff followed hospital policy to reassess pain after a pain medication or discharge from the ED. This was found in five (5) of 17 records that were reviewed, for pain reassessment after administration of a pain medication (Patient #'s 30, 31, 33, 34 and 43).

Refer to tag A0395 for additional information.


C. ensure individualized care plans in 9 of 9 patients reviewed for care plans (Patient #'s 1, 40, 43, 45, 46, 47, 57 58, and 93).

Patient #1 was self-administering medications and was on a bi-level positive airway pressure (BiPAP) ventilator assist system and there were no individualized care plans with interventions.

Patient#'s 40, 43, 45, 46, 47, 57 58, and 93 who were identified as critical care patients did not have complete individualized nursing care plans.

Refer to tag A0396 for additional information.

D. ensure medications were administered as ordered by the physician in 5 of 90 sampled patients (Patient #'s 2, 4, 5, 10 and 12).

The facility failed to ensure nurses followed physician ordered parameters for intravenous drips.

The facility failed to ensure medications were administered timely and nurses properly witnessed the administration of insulin.

Refer to tag A405 for additional information.


E. ensure physician orders were complete for blood transfusions. They failed to ensure post transfusion vital signs were completed and followed upon when out of range.

This deficient practice was found in 2 of 4 charts reviewed for blood administration (Patient #'s 50 and 51).

Refer to tag A0410 for additional information.


F. ensure 1 of 1 patients sampled for self-administration of medications received physician's orders, education, competency evaluation, and monitoring prior to self- administrating medications (Patient #1).

Patient #1 was self- administering eye drops withouBased on observation, document review, and interview the Medical Staff failed to ensure that 5 (PA #62, #100, #101, #102, and #103) of 5 Physician Assistant's (PAs) were granted privileges to order Moderate Sedation.

PAs were routinely ordering moderate sedation in the Interventional Radiology Department. The supervising Physician denied moderate sedation was being ordered by the PAs despite countersigning the Post Procedure Note where the orders were documented. Without the proper credentialing and delineation of privileges approved by the Medical Staff, the PAs placed all patients receiving moderate sedation at great risk for patient harm and possible subsequent death.


It was determined that these deficient practices posed an Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, impairment and /or subsequent death.


Cross Refer to Tag A0341
t having physician orders or an prior evaluation. One of the eye drops that Patient #1 was administering was not listed on the medication administration record.


Refer to tag A0413 for additional information.

Based on observation, interview and record review, the facility failed to ensure sufficient numbers of nursing staff on 5 of 7 units reviewed for staffing (6 South, 6 North, Neuro Intensive care unit, Cardio-vascular intensive care unit and 2 North).

The facility failed to ensure sufficient Registered nurses (RN), Licensed vocational nurses (LVN) and Patient care assistants/technicians (PCA/PCT).

This deficient practice had the likelihood to cause harm on all the units reviewed.

Findings include:



6 SOUTH

During an observation on 07/19/2021 at 11:22 a.m., a staffing board was posted at the nursing station with the following staffing for the day:

Four (4) nurses were listed on the board. Three (3) nurse had 6 patients and one (1) nurse had 2 patients.

The PCA had all 20 beds that were listed on the board.

During a confidential interview it was confirmed there was only 1 PCA working the unit.


During an observation on 07/21/2021 at 1:23 p.m., a staffing board was posted at the nursing station with the following staffing:

Four (4) nurses were listed on the board. Three (3) nurse had 6 patients and one (1) nurse had 1 patient.
There was no PCA listed on the board.


Review of staffing assignment sheets, daily assignment sheets, and the staffing matrix from 07/05-07/18/2021 with RN #60 on 07/21/2021 at 1:26 p.m. revealed the following:


O7/05/2021- short by 1 RN and .6 PCT on days. Short by .6 PCT on nights.
O7/08/2021- short by 1 RN and .6 PCT on nights.
O7/09/2021- short by 1 PCT on days and nights.
O7/10/2021- short by 1 nurse and .6 PCT on days.
O7/11/2021- short by .6 PCT on days. Short by 1 nurse and .6 PCT on nights.
O7/12/2021- short by 1 RN and .6 PCT on days. Short by 2 nurses and .6 PCT on nights.
O7/13/2021- short by 1 RN on days. Short by 1 nurse on nights.
O7/14/2021- short by 1 nurse on nights.
O7/15/2021 -short by 1 PCT on days. Short by 1 PCT on nights.
O7/16/2021 -short by 1 nurse on days. Short by 1 PCT on nights.
07/17/2021 -short by 1 nurse and .6 PCT on days.
O7/18/2021- short .6 PCT on nights.

RN #60 confirmed the staffing numbers.




6 NORTH

During an interview on 07/19/2021 at 2:20 p.m., RN #8 said they try to average 8 RN's and 3 PCT's on both shifts. RN #8 said she had a 36 bed unit and currently had 31 patients. RN #8 said she staffed her own unit.

Review of staffing assignment sheets, daily assignment sheets and the staffing matrix from 07/05-07/18/2021 with RN #8 revealed the following:

O7/05/2021- short by 1 RN on night shift.
O7/08/2021- short by 1 PCT on day and night shift.
O7/09/2021- short by 1 RN and 1 PCT on days. Short by 1 PCT on nights.
O7/10/2021- short by 1 RN and 2 PCT on days. Short by 3 PCT on nights.
O7/11/2021- short by 1 RN and 1 PCT on days. Short by 1 PCT on nights.
O7/12/2021- short by 1 RN days.
O7/13/2021- short by 1 RN and 1 PCT on days. Short by 1 RN on nights.
O7/14/2021- short by 2 RN and 1 PCT on days. Short by 1 PCT on nights.
O7/15/2021 short by 1 PCT on days. Short by 1 PCT on nights.
O7/16/2021 short by 1 RN and 1 PCT on days. Short by 1 PCT on nights.
07/17/2021 short by 1 RN and 2 PCT on days.
O7/18/2021 short by 1 RN and 1 PCT on days.

RN #8 confirmed the staffing numbers.




NEURO INTENSIVE CARE UNIT

Review of staffing assignment sheets, daily assignment sheets and the staffing matrix from 07/11-18/2021 with RN #55 on 07/21/2021 after 9:00 a.m., revealed the following:

O7/11/2021- short by 1 PCT on days.
O7/12/2021- short by 1 PCT on days. Short by 1 RN on nights.
O7/13/2021- short by 1 PCT on days.
O7/15/2021 short by 1 RN and 1 PCT on days. Short by 1 PCT on nights.
O7/16/2021 short by 1 PCT on days and 1 PCT on nights.
07/17/2021 short by 1 PCT on days.
O7/18/2021 short by 1 PCT on nights.

RN #55 confirmed the staffing numbers.





CARDIOVASCULAR INTENSIVE CARE UNIT

Review of staffing assignment sheets, daily assignment sheets and the staffing matrix from 07/4-18/2021 with RN #79 on 07/21/2021 after 10:38 a.m., revealed the following:

07/06/2021- On day shift there was 6 RNs and 3 nurses took 1-1 patients. That left 7 patients for the other 3 nurses. The matrix called for 5 RN's.
07/07/2021- On day shift there was 6 RNs and 2 nurses took 1-1 patients. That left 9 patients for the other 3 nurses. The matrix called for 7 RNs.
07/09/2021- On day shift there was 5 RNs and 2 nurses took 1-1 patients. That left 7 patients for the other 4 nurses. The matrix called for 5 RNs.
07/11/2021- There was no PCA on days and the staffing matrix called for one.
07/13/2021- On day shift there was 7 RNs and 4 nurses took 1-1 patients. That left 6 patients for the other 3 nurses. The matrix called for 4 RNs.
07/15/2021- On day shift there was 6 RNs and 2 nurses took 1-1 patients. That left 8 patients for the other 3 nurses. The matrix called for 6 RNs.
07/17/2021- On day shift there was 5 RNs and no PCA. One nurse took a 1-1 patient. That left 9 patients for the other 4 nurses. The matrix called for 7 RNs and 1 PCA.
07/18/2021- There was no PCA on days or night shift and the staffing matrix call for one.

There was no way to tell when patients came off 1-1 status on the staffing sheets being used.

RN #79 confirmed the staffing numbers and said that she was not keeping the information to track when patients were coming off of 1-1 status. RN #79 said generally they do not have PCAs working the dayshift on the weekends.



2 NORTH

Review of staffing assignment sheets, daily assignment sheets and staffing matrix from 07/05-18/2021 with RN #60 on 07/22/2021 after 2:25 p.m., revealed the following:

07/05/2021- short by 1 nurse on days and 1 nurse on nights.
O7/06/2021- short by 1 nurse on days and 1 nurse on nights.
07/07/2021- short by 1 nurse on days and 1 nurse on nights.
07/08/2021- short by 1 nurse on nights.
O7/09-11/2021- short by 1 nurse on days and 1 nurse on nights.
O7/13-17/2021- short by 1 nurse on days and 1 nurse on nights.

RN#60 confirmed the staffing numbers.




During confidential interviews from 07/19-23/2021 the following was stated about staffing:

"We are allowed 1.6 PCT, one comes in at 7 a.m.-7 p.m., one in at 7 p.m.-7 a.m. There is one that comes in from 11 am-11 pm. When there aren't enough PCTs we (nurses) do our own vital signs, they do blood sugars, pass ice and water, answer call lights, take patients to the bathrooms and give baths."

"I am behind this morning" "totals are a lot, 20 patients today and a lot of them need assistance."

"When there are 2 PCAs, the charge nurse can take up the slack. We have one PCA and she is a float".

"Sometimes we can be short of nurses. When we are short PCA's the nurses have to pick up vital signs and any other care. Baths for patients are every day and typically done on day shift"

"Sometimes there are 4 (PCA's) on the floor, but we are not that lucky all the time. Right now we are working with 3 PCA's for the floor. We have to do vital signs, assist with breakfast, change patients, bathe patients, do blood sugars and turn and reposition patients"

"On 7a-7p shift we usually working with 5 (nurses). Lately we have had 6. Staff left the hospital and numerous staff took jobs elsewhere in hospital on other units. On the weekends we are short PCAs"

"The charge nurses help with care when there are no PCAs"

"We have a PCT occasionally to help us. Recently one quit and that keeps us in the patient's rooms longer. We have to answer call lights also for other nurses because of the time they have to spend in patient's rooms."

"We don't have enough staff anywhere."

"Increase of turnovers, economics pulled staff to transfer, contract labor being used to fill vacancies"




Review of the facility's policy named "Nurse Organizational Plan" dated 12/05/2018 revealed the following:

..Staffing levels are based on benchmark data and adjustments are made as necessary on a shift to shift basis by the Nursing Directors, Supervisors, Clinical Managers and/ or charge nurses. Staff adjustments are based on acuity of patients, workload distribution and specialization of the unit.

..Nursing unit have established minimum levels of safe staffing ...
..Unit staffing plan ensure sufficient nursing staff to meet the patient care needs of the individual patients and provide sufficient time for RNs to fulfill their accountability to prescribe, delegate, coordinate and evaluate nursing care. The staffing plan/matrix is available to nurses for their patient care unit at the beginning of each shift ...'

Based on record and interview, the facility failed to ensure nursing staff evaluated care. The facility failed to ensure nursing staff followed hospital policy to reassess pain after a pain medication or discharge from the ED. This was found in five (5) of 17 records that were reviewed, for pain reassessment after administration of a pain medication (Patient #'s 30, 31, 33, 34 and 43).



Findings Included:




1. Patient (ID#31) was admitted to the ED on 07/09/2021 with toe lacerations, and received Norco for a pain of five (5). Patient was discharged without a pain reassessment completed.

2. Patient (ID#34) was admitted to the ED on 07/03/2021 with a pain left ankle, and received hydrocodone for a pain level of 10. Pain was not reassessed at discharge.

3. Patient (ID#33) was admitted to the ED on 07/03/2021 with pain in lower right extremities for pain level of nine (9). She was given Norco at 0006 and discharged at 0010, without a pain reassessment completed.

4. Patient (ID#30), was admitted to the ED on 07/16/2021 with a laceration and a pain level of seven (7). He received Norco at 1940 and was discharged without a pain reassessment completed

Interview on 07/20/2021 at 0945, Nurse manager with RN #49 of the ED who stated "yes, they should reassess pain prior to discharge and it is usually 15 minutes after the medication is given".

5. Patient (ID#43), was admitted on 07/19/2021 to the Medical Intensive Care Unit (MICU) with narcotizing fasciitis of the left groin, and was extubated on 07/22/2021. It was noted that the patient received Tylenol on 07/22/2021 at 1837 for mild pain, with no reassessment not in the record.

Interview on 07/22/2021 at 1050 with RN (ID #21) of the MICU who stated on "I do not see a pain reassessment."


Facility Policy "Pain Management" effective date 04/22/2020 stated;

Reassessment /Evaluation should occur .....within an hour of the administration of oral medication or within a half hour of the administration of intramuscular or intravenous pain medication.

Based on observation, interview and record review, the facility failed to ensure individualized care plans in 9 of 9 patients reviewed for care plans (Patient #'s 1, 40, 43, 45, 46, 47, 57 58, and 93).

Patient #1 was self-administering medications and was on a bi-level positive airway pressure (BiPAP) ventilator assist system and there were no individualized care plans with interventions.

Patient#'s 40, 43, 45, 46, 47, 57 58, and 93 who were identified as critical care patients did not have complete individualized nursing care plans.

This deficient had the likelihood to affect all patients.

Findings include:


Review of a history and physical on Patient #1 revealed she was a 57 -year- old female with an admission date of 07/09/2021. There was documentation that Patient #1 had diagnoses which included glaucoma, sleep apnea, congestive heart failure and chronic obstructive pulmonary disease.


SELF- ADMINISTRATION OF MEDICATIONS
During an observation on 07/19/2021 at 11:07 a.m., Patient #1 was observed to have the following eye drops on her over bed table:

Oxafloxacin antibiotic eye drops
Prednisolone steroid eye drops
Ketorolac non-steroidal anti-inflammatory eye drops

Patient #1 said she was giving herself the drops. Patient #1 explained how she put the drops in everyday and how many times a day.

RN #1 confirmed the observation.



BIPAP
During an observation on 07/19/2021 at 11:07 a.m., Patient #1 was observed with a Phillips resporonics V60 respirator bilevel positive airway pressure (BiPAP) ventilator assist system at the bedside. The mask on the equipment was soiled with a build-up of particles.

Patient #1 said she used the BIPAP every night and sometimes during the day when she slept.

RN #1 confirmed the observation.


Review of the clinical record revealed a physician's order dated 07/09/2021 at 12:31 p.m. for a "BIPAP,RTQ6H&PRN". There were no written settings on the order.


Review of care plans on the chart dating back to 07/09/2021 revealed the following problems;

"Acute-on-Chronic Hypoxemic Respiratory Failure
COPD (Chronic Obstructive pulmonary disease)
Dyspnea
Congestive Heart Failure"

The expected outcomes were:
"Effective Breathing Patterns
Effective Fluid Volume
No Fall"

There was no care-plan with interventions addressing self administration of the eyedrops or the usage of the BIPAP.

During an interview on 07/20/2021 after 8:41 a.m., RN #1 confirmed there were no care plans addressing the self administration of medications or the BIPAP.




Review of a facility's policy named "Assessment and Reassessment -NS-Corp" revealed the following:

"..2) Ongoing assessment as appropriate to the patient:..
f) Care plan is based on needs identified by the patient's admitting diagnosis, assessment/reassessment and diagnostic test results. Care plans are reviewed and updated every shift or more frequently as indicated.."





43549


Surveyor Sarah Wilson


CRITICAL CARE PATIENTS

Patient #57 was admitted 7/19/21 at 9:40 PM with a diagnosis of acute kidney injury, hypertensive urgency/accelerated hypertension (High blood pressure), abdominal pain, nausea and vomiting and dehydration. He was seen with a blood pressure of 208/131. His discharge was 7/21/21 at 1:30 PM.

His care plan dated 7/19/21 was reviewed 7/21/21 at 12:30 PM with RN 20, Infection Control. It identified dehydration, Acute renal Failure and Gastritis as problems. Expected outcomes were

"Effective Fluid Volume - pt. (patient) will not show s/s (signs/symptoms) of dehydration during my shift."
"Effective Mobility - pt. will have increased mobility during my shift."
"No Fall - pt. will not have ground level fall during hospitalization."





Patient #58 was admitted 7/14/21 at 07:49 AM with a diagnosis of acute CVA (Cerebrovascular Accident), aphasia (inability to speak), Essential Hypertension, Severe Mitral Regurgitation and Sick Sinus Syndrome. The patient had not been discharged yet.

Her care plan dated 7/14/21 was reviewed 7/21/21 at 12:35 PM with RN #20, Infection Control. It identified Acute CVA and no safety awareness, with Skin Integrity Impairment added 07/21/21 and Fall added 7/22/21. No falls had been documented.

"Effective Ability to Communicate - Pt. (patient) will be able to communicate with staff while on unit."
"Effective Blood Pressure (BP) - pt. will have BP within parameters set by MD (medical doctor) while on unit."
"Effective Cognition - Pt. will be able to answer cognition questions while on unit."
"No Fall - pt. will not fall while on unit."


The care plans did not include any interventions for reaching the outcomes. They also did not contain nursing problems or measurable goals for the patients.

When interviewed 7/21/21 at 12:41 PM, 20 RN, Infection Control stated interventions were missing from Patient #'s 57 and 58's care plans and there was nothing in the care plan indicating how to progress from problem to outcome. She also conformed the care plan was written as a medical care plan and not as a nursing care plan.



37322


Patient #43 admitted for necrotizing fasciotomy left groin and diabetes, record review of the nursing care plan did not have interventions to address the patient's care.

Patient #93 admitted with a perforated viscous, record review of the nursing care plan revealed the interventions did not address the patients care.

Patient #40 admitted with acute encephalopathy and respiratory failure, with a wound on the right extremity and was also sedated, and restrained. The patients nursing care plan did not address interventions related to his care.

Interview on 07/22/2021 at 1020 with RN (ID#23) who stated "we need to improve".



Patient #45 diagnosed with hypertension, and was on fall precautions. The nursing care plan did not have interventions to address the patient's hypertensions or fall precautions.

Patient #46 diagnosed with intracerebral bleed, did not address interventions that addressed the intracerebral bleed.

Patient #47 diagnosed with renal failure, did not address interventions that addressed the renal failure.

Interview on 07/21/2021 at 1315 with RN (ID#23) who stated yes, "we need to work on that".

Based on observation, interview and record review, the facility failed to ensure medications were administered as ordered by the physician in 5 of 90 sampled patients (Patient #'s 2, 4, 5, 10 and 12).

The facility failed to ensure nurses followed physician ordered parameters for intravenous drips.

The facility failed to ensure medications were administered timely and nurses properly witnessed the administration of insulin.

This deficient practice had the likelihood to cause harm to all patents.

Findings include:




PATIENT #12

Review neurology notes revealed Patient #12 was a 47- year- old male admitted on 07/18/2021 who had diagnoses which included a hemorrhagic stroke and hypertension. According to admitting paperwork Patient #12's arrival time was 4:26 a.m.

Review of the Emergency department records revealed the following blood pressures and medication documentation:

At 4:42 a.m., there was a blood pressure of 162/95.

There was documentation on the medication administration record of a physician order for the following intravenous blood pressure agent:

"NICARDIPINE 20 MG IN SALINE (CARDENE 20 MG IN SALINE) Intravenous;Starting Dose: 5 mg/hr @TITRATEmL/Hour STAT and then Routine, Clinician Dir:TITRATE BY 2.5 MG/HR EVERY 15 MIN TO KEEP SBP LESS THAN 140 MMHG. MAX DOSE 15 MG/HR. TAPER FOR ACUTE HYPERTENSION BY 2.5 MG/HR EVERY 15 MIN TO A GOAL RATE OF 3 MG/HR NICARDIPINE 20 MG IN SALINE (CARDENE 20 MG IN SALINE) 200 ML"


Nursing documented administration of the medication at 5:03 a.m.

At 5:30 a.m., the blood pressure was 150/91.
At 6:00 a.m., the blood pressure was 143/87.
At 6:30 a.m., the blood pressure was 158/92.
At 6:45 a.m., the blood pressure was 146/82.
At 7:12 a.m., the blood pressure was 152/90.

At 7:13 a.m., Patient #12 was admitted to the intensive care unit.

At 7:18 a.m., over 2 hours later there was documentation that the Cardene was increased to 7.5 milligrams in intensive care notes.

At 7:30 a.m., the blood pressure was 156/91.

At 7:45 a.m. the blood pressure was 150/86.

At 8:00 a.m., the blood pressure was 143/89 and the Cardene drip was at 7.5 milligrams.

At 8:45 a.m., the Cardene drip was increased to 10 milligrams.


During an interview on 07/20/2021 at 2:32 p.m. the following was stated;

RN #24 confirmed the documentation that was in the Emergency room portion of the chart. RN #24 confirmed the time and dosage of the Cardene initiation. RN #24 confirmed there was no documentation of an increase in the medication as ordered by the physician. RN #24 said that if there was other documentation the nurses would have free texted in the notes. There was no free text notes found showing the medication was increased in the emergency department.

RN #22 confirmed the intensive care unit documentation of the chart and the rate at which the medication was increased. RN #22 said they did not decrease the drip to keep the systolic blood pressure less than 140. It would cause the blood pressure to drop too low. They try to keep it below 160.

During an interview on 07/23/2021 at 9:24 a.m., RN #61 said she was the nurse that was taking care of Patient #22 when he came from the emergency department. RN #61 said the Cardene was at 7.5 milligrams and there was no order change it. RN #61 said a Resident came up to her and said the physician wanted the systolic blood pressure range to be between 140-160. RN #61 said she told the Resident that if the physician wanted that they needed to change the orders. RN #61 said she went and read the neurologist notes and it read keep below 160. There was no written order by the physician. RN #61 said the order that was written on 07/18/2021 at 1:27 p.m. and it was written by the Resident. RN #61 said they had problems with the doctors giving parameters. The doctors put things in their notes, but do not write the order for them.




PATIENT #10

Review of the emergency department record on Patient #10 revealed he was a 67- year- old male who presented to the emergency room on 07/17/2021. Patient #10 presented with diagnoses which included altered mental status, frontal headache and visual changes.

Patient #10 was triaged at 2:19 p.m. At 2:54 p.m. Patient # 10 was administered the blood pressure medication hydrazaline and seized after the medication.

At 2:54 p.m., Patient #10 was intubated.

There was documentation that the anesthetic agent Propofol was at 30 micrograms/kilogram/min (16.9 cc). The only documentation that could be found in the emergency department ED) notes related to the Propofol was at 7:15 p.m.

At 9:00 p.m., Propofol was at 30 micrograms/kilogram/min (16.9 cc). Patient #2 had a RASS (Richmond Agitation Sedation Scale) score of 2

According to the record Patient #10 went to the intensive care unit at 9:02 p.m.

Review of a physician's order dated 07/17/2021 at 9:21 p.m. revealed the following order;

"PROPOFOL (10 MG/ML)(DIPRIVAN) Intravenous ; Starting Dose:5 mcg/kg/min @titrate..Routine," TITRATE BY 5 MCG/KG/MIN EVERY 5 MIN UNTIL RASS OF -2 TO 0 OR MAP LESS THAN 65 MMHG MAX DOSE 50MCG/KG/MIN.."

At 10:00 p.m., it was at the same rate of 16.9 cc and the RASS score was 2.

At 11:00 p.m. and 12 midnight it was at the same rate of 16.9 cc and the RASS score was 2.

At 1:00 a.m., there was a change in the rate. It was decreased to 25 micrograms (14.1 cc).

During an interview on 07/20/2021 after 2:30 p.m. and 07/21/2021 after 9;00 a.m., RN #23 confirmed the rate and the missing RASS scores. RN #23 said the Propofol was started in the emergency department. The only documentation that could be found was the 7:15 p.m. entry. RN #23 confirmed that each hour the RASS score was 2 it was not within the range the physician wanted it be at. RN#23 said he could not find where the rate had changed or a reason documented as to why it was not changed during that timeframe.


Review of the facility's RASS assessment tool revealed some of the following documentation:

"..+2 Agitated-Frequent non purposeful movement or patient ventilator dyssynchrony
+1 Restless- Anxious or apprehensive but movements not aggressive or vigorous
0 Alert and Calm
-1 Drowsy-Not fully alert, but has sustained(more than 10 seconds) awakening, with eye contact, to voice
-2 Light Sedation- Briefly (less than 10 seconds) awakens with eye contact to voice.."



PATIENT #2

Review of an Emergency department history and physical dated 07/17/2021 revealed Patient #2 was a 66- year- old male with a history of end stage renal disease.

Review of lab results dated 07/17/2021 at 4:45 p.m., revealed Patient #2 had a low potassium level of 3.4 with reference ranges being 3.5-5.1.

Review of lab results dated 07/19/2021 at 5:36 a.m., revealed Patient #2's potassium level had decreased to 2.9 with reference ranges being 3.5-5.1.

Review of physician orders dated 07/19/2021 revealed Patient #2 was to receive one dose of potassium chloride 40 MEQ at 10:15 a.m.


During an observation on 07/19/2021 at 11:54 a.m. (over 1.5 hour later), RN #74 pulled up 4- 750 milligrams tablets of potassium chloride 10 milliequillivents and administered them Patient #2. After administration of the medication RN#74 went back to document the administration. RN#74 said the medication was actually due at 10:15 a.m., but she was unable to see her medications on the medication administration record because of problems with the computer system. RN #74 said the physician was called to get another order for the medication to be given at 12:00 p.m. instead.


During an interview on 07/20/2021 at 10:21 a.m., RN #6 said that some of the nurses had problems with not being able to get into One-chart (facility's computer charting system) for about an hour on yesterday morning.


Review of a facility's undated "Medication Scheduling Guidelines" revealed the following:

"*ONE TIME NOW orders are to be verified and sent for administration within 60 minutes or the time the order is reviewed in the pharmacy. An exception to this are orders which require pharmacy clarification from the prescriber prior to verification. In this instance, medications will be verified and sent when the order is clarified by the prescriber.
General rule for "now and routine" doses: If the time of the entered order is prior to 50 % of administration interval, verify order as "now and routine". If the time of the entered order is past 50 % of the administration interval, verify order as "routine"."



PATIENT #4

During an observation on 07/19/2021 at 12:33 p.m., RN#6 asked RN#5 to witness on a dosage of insulin for Patient #4. RN#6 showed RN#5 a syringe and they signed off.

RN#5 confirmed she had not seen what medication that was drawn up in the syringe. RN#5 confirmed she only confirmed the amount in the syringe.



PATIENT #5

During an observation on 07/21/2021 at 9:45 a.m., RN #64 was observed to draw up a dose of Lantus insulin into a syringe for Patient #5. The vial of insulin was placed back into the refrigerator and RN #64 went directly into a patient's room. RN #64 did not get a witness when drawing up the insulin.

During an interview on 07/21/2021 at 3:50 p.m., RN#64 said she only got a nurse to look at the amount of insulin that was in the syringe. RN #64 said the nurse that witnessed the amount in the syringe was sitting next to entry of Patient #5's door.



Review of a facility's policy named "Medication Administration-Nursing-NS" dated 06/18/2019 revealed the following:

..2) Observe the five rights in administering medication:

a) Right Patient, utilizing two identifiers; patient name and account number
b) Right Time/Frequency
c) Right Medication/drug
d )Right Dose
e) Right Method of Administration/Route

Based on interview and record review, the facility failed to:

A. ensure physician orders were complete for blood transfusions.

B. ensure post transfusion vital signs were completed and followed upon when out of range.

This deficient practice was found in 2 of 4 charts reviewed for blood administration (Patient #'s 50 and 51) and had the likelihood to cause harm in all patients who received blood transfusions.



Findings include:

Review of an admission assessment report dated 06/03/2021 revealed that Patient #50 was a 39- year- old female who had a chief complaint of post partum hemorrhage.


Review of a physician's order dated 06/05/2021 revealed staff were to "Transfuse LRBC (leukoreduced red blood cells) None 1 unit". There was no documentation of the rate of infusion on the order.

The pre-transfusion vital signs were documented as being blood pressure 129/49, pulse 78, respirations 18, and temperature of 98.5 degrees Fahrenheit.


Review of the blood administration record revealed Patient #50 was given a unit of blood on 06/05/2021 starting at 10:20 a.m.

The next vital signs were at 10:36 a.m. and were documented as being blood pressure 97/47, pulse 92, respirations 16, and a temperature of 98.4 degrees Fahrenheit.


According to the blood administration record the unit of blood was stopped at 11:47 a.m.

A set of post vital signs were documented one minute later at 11:48 a.m. and they were documented as being blood pressure 110/66, pulse 101(elevated), respirations 16, and a temperature of 99.0 degrees Fahrenheit.

There was no documentation of what was done about the elevated pulse. The next assessment of Patient #50's vital signs was at 4:12 p.m. (over 4 hours later). They were documented as being blood pressure 134/96, pulse 98 ,respirations 16, and a temperature of 97.9 degrees Fahrenheit.





According to a blood transfusion record Patient #50 received another unit of blood on 06/07/2021.

The pre-transfusion vital signs were documented as being blood pressure 122/96, pulse 97, respirations 20, and a temperature of 98.7 degrees Fahrenheit.


Review of the blood administration record revealed Patient #50 was given a unit of blood on 06/05/2021 starting at 11:15 a.m.

According to the blood administration record the blood was stopped at 12:15 p.m.

A set of post vital signs were documented on the form as being blood pressure 131/68, pulse 76, respirations 20, and a temperature of 98.4 degrees Fahrenheit.

The set of vital signs documented on the form were taken at 12:00 p.m., which was prior to stopping the blood.

The next set of vital signs recorded on Patient #50 was at 4:14 p.m. over 4 hours later.



During an interview on 07/22/2021 after 10:30 a.m., RN #13 confirmed the physician orders and the vital signs. RN #13 compared the vital signs written on the blood administration with the vital sign flow record. RN #13 said she knew the vital signs were taken at 12:00 p.m. because they were taken from a vital sign reading from the monitor.





Review of an admission assessment report dated 06/09/2021 revealed that Patient #51 was a 36 -year -old female who was admitted for a vaginal delivery.


Review of a physician's order dated 06/09/2021 revealed staff were to "Transfuse LRBC Special need. None 1 unit." There was no documentation of the rate of infusion on the order.


The pre-transfusion vital signs were documented as being blood pressure 122/80, pulse 76, respirations 18, and a temperature of 97.6 degrees Fahrenheit.

Review of the blood administration record revealed Patient #51 was given a unit of blood on 06/05/2021 starting at 11:57 a.m..


The next vital signs were at 12:18 p.m.. and were documented as being blood pressure 114/77, pulse 81, respirations 18, and a temperature of 98.2 degrees Fahrenheit.


According to the blood administration record the blood was stopped at 3:01 p.m.

A set of post vital signs were documented one minute later at 3:01 p.m. and they were documented as being blood pressure 142/80, pulse 72 ,respirations 18, and a temperature of 98.1 degrees Fahrenheit.

The post vital signs were taken at the same time the blood was stopped not afterwards.





Review of the facility's policy named "Blood and Blood Products Administration" dated on 05/04/2021 revealed some of the following:


"..8)Administration..

b) Patients will be continuously assessed at the bedside for signs and symptoms of transfusion reactions during the first 15 minutes of the transfusion. Life threatening reactions can occur after the infusion of only a small volume of blood. Patients will be reassessed with each set of vital signs.

c) Vital signs will be taken and recorded prior to transfusion(within 30 minutes prior to initiation ) and 15-20 minutes after beginning of transfusion.

d) Additional vital signs during the transfusion are per unit routine or more frequently as condition warrants.

e) Document the date and time the transfusion was stopped. A final set of vital signs will be taken and recorded in the EMR within 30 minutes of the conclusion of the infusion.

g)i)RBCs should be infused within 4 hours from issuance per American Association of Blood Banks (AABB) due to the danger of bacterial growth.

1)RBCs can be infused over 1-2 hour unless otherwise specified by provider.

Review of the facility's policy named "Transfusion Reactions-NS" dated on 06/18/2019 revealed some of the following:


"..Policy: All patients receiving blood/blood components shall be monitored for a transfusion reaction. The most severe, life-threatening reactions usually start within the first fifteen minutes of the transfusion. During the transfusion, the patient should be observed for:

..4) Temperature elevation of 1.8 degrees above previous temperature reading
5) Sudden change in blood pressure or pulse.."

Based on observation, interview and record review, the facility failed to ensure 1 of 1 patients sampled for self-administration of medications received physician's orders, education, competency evaluation, and monitoring prior to self- administrating medications (Patient #1).


This deficient had the likelihood to affect all patients who self- administered their medications.

Findings include:




Review of a history and physical on Patient #1 revealed she was a 57- year- old female with an admission date of 07/09/2021. There was documentation that Patient #1 had diagnoses which included glaucoma.


During an observation on 07/19/2021 at 11:07 a.m., Patient #1 was observed to have the following eye drops on her overbed table:

Oxafloxacin antibiotic eye drops
Prednisolone steroid eye drops
Ketorolac non-steroidal anti-inflammatory eye drops


Patient #1 said she was giving herself the drops. Patient #1 explained how she put the drops in everyday and how many times a day. Patient #1 said she placed the one with the gray top (Ketoralac) in her eyes at 9 a.m., 1 p.m., 5 p.m. and 9 p.m..

Staff #1 confirmed the observation.




Review of the clinical record on Patient #1 revealed physician orders for the Oxafloxacin and the Prednisolone eyedrops. There was no order on the chart for the Ketorolac eyedrops. There was no physician's order for Patient #1 to self administer her medications.


Review of the chart revealed no evaluation or competency for self-administration of medications.

Review of the chart revealed no careplan addressing self administration of the eyedrops.






Review of the facility's policy named "Self Administration of Drugs by Patients.." revealed the following:

"Policy: Self- administered medications are administered safely and accurately.

Procedure:
1) Self-administration of medications is discouraged. However, if self-administration is determined to be necessary and appropriate for a specific patient and/ or medication, the following elements must be met:
a) An order must be obtained by the appropriate prescriber stating that self-administration of a medication is allowed.
b) Medications may NOT be stored in the patient's room unless the storage location is considered "secure"..
c) The patient, patient family or the non-staff member care giver must be educated regarding:
i) Medication name, type, and reason for use;
ii) How to administer medication, including process, time, frequency, route and dose;
iii) Anticipated actions and potential side effects of the medication administered;
iv) Monitoring the effects of the medication
d) The competency of the patient to safely self-administer the medication must be documented before the patient is allowed to self-administer medication.."

Based on document review and interview the facility failed to follow their own policy and ensure that all verbal orders were authenticated, dated, and timed within 96 hours in 5 (Patient #77, #78, #79, #80, and #81) of 5 medical records reviewed.

This deficient practice had the likelihood to cause harm to all patients receiving medical treatments. Verbal orders for patient care should be reviewed and authenticated for accuracy by the ordering provider to ensure patient health and safety.

Findings include:


Patient #77

A review of Patient #77's medical record revealed a verbal order was given by CRNA #72 to RN #67 on 10/23/2020 at 10:01 AM. The verbal order was as follows:

" ...100mcg/ml q 1min Neosynephrine in PACU prn MAP <60 ..." (Neosynephrine is a medication used to treat low blood pressure that may occur during surgery).

CRNA #72 authenticated the verbal order on 7/19/2021. This verbal order was signed greater than 8 months after it was verbally given to RN #67.


Patient #78

A review of Patient #78's medical record revealed a verbal order was given by CRNA #71 to RN #68 on 3/24/2021 at 5:21 PM. The verbal order was as follows:

" ...NALAXONE (NARCAN) 0.2MG=0.5ML Intravenous ONE TIME STAT for 1 doses, Clinician Dir, ONCE IN PACU ..." Naloxone is a medication used as a reversal agent on some opioids used during surgery).

On 7/22/2021, a review of the medical record for Patient #78 revealed the verbal order given by CRNA #71 had not been authenticated.


Patient #79

A review of Patient #79's medical record revealed a verbal order was given by CRNA #71 to RN #68 on 3/31/2021 at 8:17 AM. The verbal order was as follows:

" ...FENTANYL (SUBLIMAZE) 25mcg=0.5 ML Intravenous ONCE PRN MILD PAIN (PAIN SCALE 1-4) STAT and then routine for 1 Days ..." (Fentanyl is a Schedule 2 Narcotic used to treat pain).

On 7/22/2021, a review of the medical record for Patient #79 revealed the verbal order given by CRNA #71 had not been authenticated.


Patient #80

A review of Patient #80's medical record revealed a verbal order was given by DO #99 to RN #69 on 1/06/2021 at 5:05PM. The verbal order was as follows:

" ...HYDROCOD-ACETAM 10-325 MG (NORCO 10) 2 TABLET Oral Q6H PRN SEVERE PAIN (PAIN SCALE 8-10)..." (Hydrocodone-Acetaminophen is a medication used to control pain).

On 7/22/2021, a review of the medical record for Patient #80 revealed the verbal order given by DO #99 had not been authenticated.


Patient #81

A review of Patient #81's medical record revealed a verbal order was given by DO #99 to RN #70 on 3/17/2021 at 7:19 AM. The verbal order was as follows:

" ...TAMSULOSIN (FLOMAX) 0.4 MG=1 CAPSULE Oral CAPSR24 Daily ..." (Flomax is a medication used to relax the muscles in the prostate and bladder).

On 7/22/2021, a review of the medical record revealed the verbal order given by DO #99 had not been authenticated.





A review of the policy titled, "Orders Written and Verbal-NS-Corp" Policy Number 40044.2 with an effective date of 09/17/2020 was as follows:

" ...Policy:
9) Verbal and Telephone Orders:
a) It is the responsibility of the physician, leadership, and department director to ensure that:

vi) All verbal/telephone orders should be dated, timed, and signed within your State's regulations by the prescriber or practitioner who is responsible for the care of the patient.

C) All verbal/telephone orders must be authenticated/signed, dated and timed by the provider who gave the order within 96 hours ..."


An interview was conducted on 7/19/2021 at 10:05 AM with Staff #30. Staff #30 was asked how the verbal orders were monitored to ensure they were authenticated, dated, and timed according to facility policy. Staff #30 stated, "Well, actually Nursing and Quality look at those records. I run a report and look at them, but the other departments do the chart audits to make sure that they are being completed." Staff #30 was asked if the Medical Records Department was notified if the verbal orders had not been authenticated according to facility policy. Staff #30 stated, "No, they just fall off the list. I do not compare the current list to the previous list and we only send out delinquent notices to providers if the chart is 30 days past the discharge date. We do not include the delinquent verbal orders on the report that is sent to the Medical Staff Office." Staff #30 was asked about the verbal orders from the Certified Registered Nurse Anesthetist (CRNA) and how was that communicated to the Anesthesia Department. Staff #30 stated, "The Anesthesia Department was a contracted service and the new Lead CRNA does not communicate to the other CRNA's that they have outstanding unsigned orders. The one lady that used to be the Lead CRNA kept up with it and told them they had records to sign."

Staff #29 confirmed that verbal orders were not monitored on a regular basis in the Medical Records Department. Staff #29 stated, "We run a Delinquent Records report monthly and send out letters to the providers that are on the list every Thursday. If the providers are over 30 days delinquent, we send notification to the Medical Staff Office. Verbal orders are not included on the delinquent records report."

An interview was conducted on 7/21/2021 after 9:00 AM with Staff #28. Staff #28 confirmed that the Medical Staff Services was not informed of any verbal orders not being authenticated, dated, or timed according to facility policy.


Staff #29 and Staff #30 confirmed the findings.

Based on observation, and interview, the facility's Pharmaceutical Services failed to ensure the safe storage, dispensing, tracking and control of a patient's refrigerated medication once returned to the pharmacy for credit.

Findings include:

During a tour of the pharmacy on 07/21/2021 at 2:10 PM observed numerous bags of antibiotics and mixed intravenous fluids in a red bin. The intravenous bags and antibiotic bags were being returned to the pharmacy for patient credit.

Observed medications had been returned to the pharmacy and not refrigerated on 7/21/21. The bags of medication were at room temperature and stored in red bin with a sign over the bin labeled "Refrigerated IV". The medication process was the medication had been thawed and labeled for patient usage sent to the floor and refrigerated and then returned to the pharmacy when no longer prescribed or discontinued for patients. The issues were that the medication was now at room temperature. The process for picking up medication when patients' medications are discontinued; was that the pharmacy technician makes rounds at 6:30 AM and picks up medication and places them in the red bin. The surveyor was in the pharmacy at 2:10 PM and observed the medication had remained in the red bin and the medication was at room temperature.

The following Medication was observed at 2:10 in the red bin on 07/21/2021 at room temperature.

Zosyn - 8 bags returned not refrigerated
Cubcin - 1 bag returned not refrigerated
Vancomycin - 5 bags returned not refrigerated
Azithromycin - 2 bags returned not refrigerated
Phosphorus - 1 bag returned not refrigerated
Doxycycline - 1 bag returned not refrigerated

An interview with the Pharmacist #106 on 7/21/21 at 2:10 PM confirmed there were numerous bags of antibiotics and mixed intravenous fluids sitting in the red bin that were at room temperature. Also, Pharmacist #106 confirmed the medication had been in the red bin since 6:30 AM in the pharmacy area.

Based on observation, interview, and record review, the facility failed to ensure pharmaceutical services involving compounding, packaging, or dispensing of drugs and biologicals were performed consistently with state and federal laws.

These deficient practices of having the compounding doors not closing to Chemotherapy room and compounding medication rooms had the likelihood to become chemically or microbiologically contaminated, resulting in deviating or lethal consequences for patient who received them.

Findings include:

The facility's pharmacy department failed to ensure and report that the aluminum doors to the 2 compounding rooms remain closed. There was a 2-inch gap on each door. The door that led out to the maim pharmacy was cracked and broken on the top left side. The aluminum doors were very flimsy. There was positive pressure in the first compounding room, but the pressure was strong it kept the flimsy aluminum door 2-inches open. The second flimsy aluminum door was where the negative pressure was used for mixing chemotherapy medication and the pressure was strong and it was keeping door 2-inches open.


An Interview with the Pharmacist #106 and RN#2 confirmed the compounding doors were 2 inches open and not closing securely. This issued needed to be addressed immediately and confirmed with Pharmacist #106 and RN#2.

According to the United States Pharmacopoeia<797> Resource Guide, dated 2013 revealed the following:

Page 19
"Since compounding sterile preparations requires manipulation of the manufacturer's products, the date beyond which the CSP (Compounded Sterile preparation) can be used is different from the expiration date. CSPs must be labeled with a beyond-use date, which is determined by the compound being prepared and the temperature at which it will be stored."

Based on observation, interview and record review, the facility failed to ensure medications were kept secure and not accessible to unauthorized personnel on 3 of 8 units checked for medication storage (6 South, Labor/Delivery and Neuro Intensive care unit).


This deficient practice had the likelihood to affect all patients on these units.



Findings include:


6 SOUTH

During observation on 07/19/2021 at 10:26 a.m., a medication cart was found unlocked. There were medications stored on top of the medication cart and inside drawers on the cart. They were accessible to anyone passing in the hallway. Some of the medications that were accessible were bags of antibiotics, antifungals medications, respiratory medications, blood pressure medications, eyedrops and boxes of albumin.


A cabinet at the nurse's station was unlocked and bags of antibiotics were stored in it.



RN #1 confirmed the observations and said that they should be locked up.



During an interview on 07/19/2021 at 11:11 a.m., Staff #4 (Pharmacist) said the reason the medication was being placed on top of the medication carts was because they were having a challenge with space.




Review of a facility's policy named "Medication Administration-Nursing -NS" dated 06/18/2019 revealed the following:


"..Any multidose vials (MDV's) must have a new expiration date placed on the vial when opened. Unless otherwise specified by the manufacturer, this expiration date should be 28 days from the date of opening.."






NEURO INTENSIVE CARE UNIT

During an observation on 07/21/2021 at 10:08 a.m., unlocked cabinets were found behind the nurses station which contained patient medications.

Staff #1 confirmed the observation.




LABOR AND DELIVERY

Supply room near the temporary waiting room

During an observation on 07/22/2021 at 9:42 a.m., an emergency response bag was found stored in a supply room. The bag contained such medications as Atropine, Epinephrine, and Sodium bicarbonate.

RN #11 confirmed the observation and said that the housekeeping staff and scrub techs had access to the room.

On 07/22/2021 at 9:46 a.m., Staff #116 (material tech) came into the room and delivered supplies. Staff #116 said she had keys to the room too.


Supply room adjacent to room #4508

During an observation on 07/22/2021 at 10:10 a.m., another emergency response bag with medications was found stored on a shelf. The bag contained such medications as Atropine, Epinephrine, and Sodium bicarbonate.

There were open plastic bins on another shelf in the supply room which contained bags of intravenous Magnesium sulfate and vials of Lasix.

RN #'s 1, 11, 12 and 13 confirmed the observations.





Review of the facility's policy named "Obtaining and Storage of Pharmaceuticals" dated 04/02/2020 revealed the following:

"..Drugs are stored in an orderly manner in well-lighted cabinets,shelves, drawers or carts of sufficient size to prevent crowding.Whenever possible, drugs outside of the Pharmacy will be stored in the PYXIS cabinets or locked in cabinets on the unit.."

Based on observation, interview and policy review, the facility failed to:

A. ensure unusable drugs were not available for patient use because a multi-dose vial was found in a drawer of the Procedure Cart with a needle sticking in the rubber diaphragm which provided a portal of entry for organisms.

B. ensure unusable drugs were not stored in medication carts and crash carts with medications that were currently being used.



Findings Include:

Respiratory Department

An observation tour of the respiratory therapy department on 07/19/21 beginning at 11:38 a.m. accompanied by Staff #5 and Staff #6 revealed the following:

A multi-dose vial of Lidocaine with NDC 0409-4277-17 for infiltration and nerve block had a needle sticking in the rubber diaphragm and was sitting in a thin paper box lid inside the 4th drawer of a procedure cart.

Staff #5 and Staff #6 confirmed the above findings at the time of the observation.

The hospital policy #41987.1 entitled, "Proper Use of Multidose Vials and Single Use Containers-DIV-MM," was reviewed on 07/23/21 and stated the following in part:

Policy: The pharmacy assures the safe use of multidose vials (MDVs) of medications,"

Procedure:
1) Multi dose vial (MDV) use should be minimized. opened multidose vials (MDV's) will be treated according to the following CDC guidelines:
a) Store multidose vials after they are opened according to manufacturer's recommendations.
c) Cleanse the rubber diaphragm of multidose vials with alcohol before inserting the needle into the vial.
d) Use a sterile needle and syringe each time a multidose vial is accessed and avoid touch contamination of the needle (and diaphragm) prior to penetrating the rubber diaphragm.




10135


6 South

During observation on 07/19/2021 at 10:26 a.m., a medication cart revealed the following:


One of the drawers on the medication cart had an open vial of sterile water in it. There was no open date recorded on the vial. There was documentation on the vial that it was single dose and contained no anti-microbial.


One drawer had a bottle of Alphagan eye drops stored in it. The eye drops had been opened and had no open date recorded on it.


Another drawer had a bag of antibiotic Cefepime in which the vial had already been activated. There was no expiration date written on the label or a beyond use date since it had already been activated.


RN#1 confirmed the observations.


During an interview on 07/19/2021 at 11:11 a.m., Staff #4 (Pharmacist) said the multi-dose vials should be discarded after 28 days.

Review of a facility's policy named "Proper Use of Multidose Vials and Single Use Containers.." dated 08/08/2020 revealed the following:

"..1)Multi dose vial (MDV) use should be minimized. Opened multidose vials (MDV's) will be treated according to the following CDC guidelines:

iv) All MDV's must be labeled with a beyond use (BUD) which is 28 days from the date opened unless other factors necessitate an earlier expiration date..

2) Single dose vials (SDV's) are intended for one-time use on one patient.
a) SDV's are to be appropriately destroyed or discarded after one patient treatment event..






During an observation of a crash cart, a box of the anti-chlolinergic agent Atropine was found which expired June 2021.

Review of the July 2021 "CRASH CART CHECKLIST" revealed no documentation of checks for expired medication.

Review a sticker on the top of the crash cart revealed that the next medication would expire in the cart on 11/01/2021. There was no documentation on the cart about the Atropine expiring.

During an interview on 07/19/2021 at 11:37 a.m., Staff #4 (Pharmacist) confirmed the medication was expired. Staff #4 (Pharmacist) said that the sticker dated 11/01/2021 was placed on the cart by pharmacy personnel. They had missed the expired Atropine.

Review of the facility's policy named "Obtaining and Storage of Pharmaceuticals" dated 04/02/2020 revealed the following:


..Any drugs past their expiration will be quarantined in pharmacy for subsequent disposal according to applicable rules and regulations ...

..7) Drugs unusable for any reason are isolated from stock until they can be disposed of properly ...

..12) Inventory will be inspected periodically for out of date drugs.
a) When an out of date drug is found it will be quarantined in the out of date section in the back room of the pharmacy.."

Based on observation, interview and record review, the facility failed to maintain supplies and equipment at an acceptable level of safety and quality. An ENT tacklebox with a lighter was stored in cabinet with sterile supplies, expired medical supplies and Magill Forceps in wrinkled peel pouches including 1 with a visible tear in it were available for patient use in a crash cart with dusty debris. Saline irrigation for patient use was stored in a refrigerator used to store lab medium and an ATP test swab, expired Cidex strips were available for staff use. Caulking was peeling away from the backsplash in a soiled equipment room, paint was chipped off wire racks and bags of solution used for inhalation were stored in shelves below extension cords and equipment.

Findings Include:

An observation tour of the respiratory therapy department on 07/19/21 beginning at 11:38 a.m. accompanied by Staff #5 and Staff #6 revealed the following:

SCOPE ROOM
A cabinet in the room where bronchoscopes are stored housed a yellow tacklebox labeled Consult and identified by staff as belonging to ENT, contained a cigarette lighter, 2 cotton balls and some alcohol preps.

BRONCHOSCOPY ROOM
There was dusty debris on the cardiac monitor on the crash cart bronchoscopy room. The crash cart contained three (3) 10 ml single use syringes of 0.9% sodium chloride injection NDC/00338-0048-02 for flush that expired on 2021-07-01. Two (2) wrinkled peel pouches including one (1) with a visible tear in the packaging contained Magill forceps available for patient use.

Staff #5 and Staff #6 confirmed the above findings at the time of the observation. Staff #9 from Central Supply came to the room and retrieved the items.

At least 9 bottles of 250 cc 0.9% Sodium Chloride irrigation for patient use was stored in a refrigerator with an ATP Test Swab identified by staff as used to test for ATP in the scopes and 9 glass tubes of Thioglycollate identified by staff as a medium.

An opened knife with a cover over the blade was being stored in a drawer in the Procedure Cart. The cart had rust on the top of the drawer pulls.

SOILED EQUIPMENT PROCESS ROOM
Cidex OPA Solution Test Strips with an expiration date of 06/28/21 were available for staff use.

The caulking was brownish and separating from the backsplash.

CLEAN ROOM
Black paint was chipped off wire racks.

A metal cart housed extension cords and equipment above bins with bags of sterile solution for patient use for inhalation.

Staff #5 and Staff #6 confirmed the above findings.

The hospital policy #50713.1 entitled, "Inventory Procedures-DIV-SC," was reviewed on 07/23/21 and stated in part: "6 b) i) Excess inventory items, which will spoil before usage or have expired, or other obsolete items, should be physically separated from inventory which is to be counted."

The hospital policy #42021.1 entitled, "Obtaining and Storage of Pharmaceuticals-DIV-MM," with an "effective date of 04/02/2020," and stated in part: 4) Test agents, germicides, disinfectants and other household substances will be stored separately from drugs."

An FDA report on NDC/00338-0048 Sodium Chloride Irrigation was reviewed on 07/23/21 and revealed in part that it was identified as a "Human Prescription Drug."

Based on record review, observation, and interviews the facility failed to maintain a sanitary environment placing patients at risk for contracting and spreading infections and communicable diseases in 16 departments and areas of the hospital ( Dietary Department, 3rd Floor Medical ICU, Pharmacy, Laboratory, Radiology, 6 South, Labor and Delivery, Central Supply Warehouse, Emergency Room at Broadway, Emergency Room Main Emergency Room Main- West, 3N Orthopedic Department, 4WA and B -COVID Telemetry/ICU, Linen and Laundry, and 3rd floor IMC Medical/Surgical Unit.)

The facility failed to ensure the dietary department had properly working dishwasher to prevent excessive condensation dripping from the ceiling onto clean dishes and cookware for two weeks. The dishware was unable to be dried properly and stored to prevent food borne illness or bacterial growth that could spread such as Legionnaires Disease. The hospital administration nor infection control was aware of the issue.

Refer to Tag A0749

Based on review, observation, and interviews the facility failed to maintain a sanitary environment placing patients at risk for contracting and spreading infections and communicable diseases in 16 departments and areas of the hospital ( 3rd Floor Medical ICU, Pharmacy, Laboratory, Radiology, 6 South, Labor and Delivery, Central Supply Warehouse, Emergency Room at Broadway, Emergency Room Main Emergency Room Main- West, 3N Orthopedic Department, 4WA and B -COVID Telemetry/ICU, Linen and Laundry, and 3rd floor IMC Medical/Surgical Unit.)

The facility failed to ensure the dietary department had properly working dishwasher to prevent excessive condensation dripping from the ceiling onto clean dishes and cookware for two weeks. The dishware was unable to be dried properly and stored to prevent food borne illness or bacterial growth that could spread such as Legionnaires Disease. The hospital administration nor infection control was aware of the issue.

This deficient practice was determined to pose an Immediate Jeopardy to patient health and safety and placed all patients in the facility at risk for the likelihood of harm, serious injury, and possibly subsequently death.


Findings include;

Dietary Department

On 7/19/2021 during the initial touring of the dietary department, the following observations were made. The clean dish room, where the end of the dish washing process occurs, was observed with a high density of humidity consuming the entire space of the room. Visibility was decreased and moisture was dripping from the ceiling vents. Moisture was beading on clean dishes. This created an environment where clean dishes and utensils could not dry and be kept dry for sanitary storage. Food born bacteria could not be ruled out or other moisture born illnesses such as Legionnaires Disease.

Interview with the Dietary manager, staff #2, confirmed this environment had been present for 2-3 weeks. The Manager further confirmed that he had submitted work orders to the plant operations department to investigate and provide interventions or repair if needed. Staff #2 confirmed the inability to maintain a dry environment prior to storage of the "clean utensils". Staff #2 agreed the clean room resembled a sauna.

On 7/20/2021 an interview with plant operations staff #40 revealed the plant engineering had not been able to divert or reduce the flow of steam exiting the dish machine. They (Plant operations) had notified the manufacture numerous times without improvement observed, other than steam being rerouted from exiting on the intake (dirty) side, to now exiting into the clean side where dishes were to be removed, as dry and stored.

A request was made for a policy that guided sanitary drying and storage of eating and cooking utensils, none was provided.

The engineer confirmed an exhaust fan and conduit had been installed in the dirty room ceiling to try to remove the buildup of trapped steam vented into room, but the plant operations staff had not acted to remove and correct the venting of steam into the clean room.

On the morning of 7/21/2021 the administration of the hospital was requested to observe the environmental conditions of the clean dish room. During the observation, steam which vented into the clean dish room accumulated at the ceiling. Moisture collected and was observed dripping steadily from the air conditioning vents in the ceiling. The drips fell onto stainless steel shelving which held "clean" eating utensils and large stainless mixing and serving bowls. The observation lasted 15-20 minutes. The fog created by the venting of steam diminished only when exit doors were opened as employees entered and exited the room.


Other observations in the dirty dish room included, mildew visible on the ceiling calk where the walls and ceiling met in the dirty dish room. Small points of rust were visible on the ceiling support frame.


Other dietary department findings included:

Six of Six, front opening two-door ovens were observed in use with visible damage from leaking door seals, evidenced by baked on oils observed on the interior surface between the oven's double pane glass doors. There was significant debris at the base of the doors, caught between the double pane as well.

One bag of breaded frozen vegetable was found to be torn open at the corner and not resealed for freshness and sanitation.

1 gallon of Kikkoman soy sauce was observed with heavy sticky residue from drips and had been replaced on condiment storage tray without cleaning the residue.

3 open gallons of milk were not dated with date opened or use by date in the café refrigerator.
The thermostat in the café cooler was found with one thermometer not working and the second thermometer measuring a temperature of 42 degrees, 1 degree above maximum for safe use of 41 degrees. The cooler temperature had been recorded for the day as 41 degrees on the morning check list. The manager was asked, how was maximum temperature monitored to ensure the cooler range did not rise above the safe maximum. There was no process identified. The above observations were confirmed by the manager staff #2.


Third Floor NEURO ICU (Intensive Care Unit)

Flooring in the hallway outside the nurse's station was worn to below the brown coloring and pattern of flooring, down to a bald white area. A Supply cart on Neuro floor with visible cracks in the bumper coverings with black sediment in cracks resembling spider veins. Both the floor and the cracked bumpers could no longer be sanitized with the surface broken.



Third Floor Medical ICU

Doorway floors, leading into patient rooms, were observed with visible dirt (grit) and debris (hair, colored thread, tape) which was stuck to the floor. A patient room being cleaned was observed. The housekeeper wet mopped the floor without dry mopping it first. All debris captured by the mopping process was wet mopped to outside the threshold of the patient room. It was then swept using a broom into a dustpan. The wet residue was left on the floor to dry, trapping any dirt and debris not collected in the dustpan, to remain stuck to the floor. This was observed by the unit RN.


3 North
A Corner wall at the door of patient room on left side of the East hallway plaster was missing with the exposed metal form visible beneath the missing plaster. This doorway was no longer able to be sanitized.

Visible dark gray black discoloration on the wall where a large rectangle shaped object had been removed, possibly a white marker board.

Handrails were observed with varnish worn down making sanitation of bare wood unlikely.
A recessed valve shut off was visible with heavy dirt and gray dust-bunnies easily visible behind the glass door.

Numerous "dings" where paint had been knocked off the door facings leaving bare surface which could not easily be disinfected.



29191

Main Pharmacy Area:

During a tour of the main pharmacy on 07/21/2021 at 1:19 PM there was a red rolling cart labeled "COVID Vaccine Clinic" that was covered in hair, dust, and dirt particles. The cart was located with the crash carts.

An interview with the Pharmacist #106 on 07/21/2021 at 1:19 PM reported that the process was that all carts go to material management for the cleaning process and that the "COVID Vaccine Clinic" cart did not make it through the proper process.


43549

Radiology- Main Campus

During the tour on July 21, 2021 at 10:07 AM of the main hospital radiology department with employee # 51 and employee # 56 the Assistant Director of Radiology Cat Scan (CT) rooms one and two five were observed. The top crescent and arms of the CT in room number two all were felt for dust. Heavy grayish white dust bits fell to the floor from all areas touched. The dust resembled dryer lint as it was in a blanketing formation.

The CT Scanner in CT room one of the main hospital radiology department was observed July 21, 2021 10: 20 AM during the same tour. The top crescent and arms of the CT in room number two all were felt for dust. Grayish white dust bits fell to the floor in light flakes from all areas touched.

The countertops in CT room number two were soiled and slightly gritty to the touch. Employee #56 called into the room Employee #54 the CT Coordinator to answer questions. Employee 54 explained there is a cleaning schedule that radiology staff preform. He produced a schedule that did not include cleaning the tops or arms of the CTs. When Employees #54 and #56 were asked when the last time the top and arms of the CT were dusted or cleaned, they both stated they did not know.
This surveyor asked Employee # 56 to look at and feel the gritty soil on the countertop. After doing so he stated, "I think that's just how they are." This surveyor took a paper towel from the sink dispenser in the room, wet it with water and wiped the counter in a small area. Another paper towel was used to then dry the countertop. Employee #56 felt the cleaned countertop area and stated, "it feels smooth now." He confirmed it looked cleaner/whiter too.

Upon interview July 21, 2021 10: 20 AM Employee #56 confirmed there was no schedule for cleaning the tops and arms of the CT scans.


Laboratory- Broadway

Based on observation and interview the facility failed to maintain the freezer frost free in the Broadway Emergency Room Laboratory. During a tour on 07/19/21 at 12:54 PM of the on-site laboratory within the Broadway ER with two surveyors and Employee #31 RN, Infection Preventionist the Emergency room Laboratory under counter freezer was observed to be caked with thick frost on the freezer insides, inner top, inner bottom, inner door shelves and rising up approximately ½ to ¾ inches on test tubes stored on all shelves in the freezer.

Employee #49 a Medical Laboratory Technician was asked what the freezer contained. She stated it contained chemistry controls, Covid tests that can be used and sent to the Clinical Pathology Laboratory, chemistry calibrators, chemistry and cardiac controls and machine proficiency tests. She was asked how long the freezer had been with this amount of frost. She responded it had been that way for the 30 days she had been working at the site. When questioned about how to rectify the ice she stated the process was to put in a Biomedical work order and tell the manager. She was asked if that had occurred and she responded she knew a work order had been put in because in the past 30 days a workman came, looked at the freezer, checked the temperature and said it was alright because the temperature was within normal range. He did not address the frost. Employee #49 added that the Laboratory Technicians could not defrost the freezer because there was no where to store the freezer contents in the lab and keep them frozen while this freezer would defrost.

When interviewed on 07/19/21 at 12:57 PM of the on-site laboratory within the Broadway ER, Employee #31 RN, Infection Preventionist confirmed the freezer and contents were covered in frost and stated there was so much frost "You definitely have to hold it to shut it, " with her hand on the freezer door.



10135

6 South

During an observation on 07/19/2021 at 10:35 a.m., the bottom bin of the 6 South Pyxis had bags of intravenous solution stored in it. The bin was soiled with black debris.

During an interview on 07/19/2021 at 11:11a.m., RN #1 and Staff #4 (Pharmacist) confirmed the observation. Staff #4 (Pharmacist) said they were responsible for cleaning the inside of the Pyxis. There was no documentation of when it was last cleaned and they did not have a cleaning schedule yet.



During an observation of the main supply room on the unit there was no separation of clean and sterile supplies. Some of the supplies in the room were sterile suction catheters, syringes of saline flush, sterile dressing kits, Foley catheter trays, sterile pediatric lumbar puncture trays, bins of respiratory supplies, bed pans, toilet seats, and diapers. The supply room also was the storage place for clean linen.

RN #1 confirmed the observation.





Labor and Delivery


Alcove

Three wheelchairs were parked in an alcove on the unit and had tapes on them that indicated that they were clean. One had a basket that was soiled with trash. The wheels on the chair and the lower frames were soiled with dirt, dust and soiled tape.


Equipment/Storage room


Had shelves of supplies stored on it which had no identifying label on it to signify it was clean equipment. Some of the supplies on the shelves were wall mount blood pressure monitors, wall mount oxygen regulators, oxygen flow meters, and suction canisters.


RN #'s 1, 11, 12 and 13 confirmed the observations.





32143

Findings include:

The Central Supply Warehouse

The Central Supply Warehouse was in a separate building and location from the hospital. Supplies are received there, processed, unpacked, stored, and delivered to the different units of the hospital in a covered truck as needed. The warehouse had three sections, receiving, dirty, and clean.

The receiving area was located by the loading dock. This was where the boxes of supplies were delivered and checked in by staff. The products are still in the shipping boxes and sealed.

Dirty holding area continued to be supplies that are still in the shipping boxes or supplies that are not patient used such as, paper supplies for offices, cleaning products, or non-sterile items. The boxes are placed on shelves, protected from the elements, and temperature controlled.

The Clean Storage was patient supplies that have been unboxed from their shipping boxes, placed in bins, and ready for distribution to the hospital. Once the hospital departments place an order for their needs the workers would collect the supplies on clean carts then transfer the items in a gray large plastic bin with folding lids. The bins would be placed on metal rolling carts and taken to the truck for delivery to the hospital departments.

A tour of the warehouse was conducted on 7/19/21 with Staff #124, 79, and RN #31. The tour revealed the following;
The gray bins used to transport clean supplies were stored in the receiving side of the warehouse. The bins were stacked on dirty wooden pallets. The bins were stacked inside of each other with tops open. The bins were exposed to heavy dust and dirt. The inside of the bins were dirty, dusty, and soiled. Staff #124 stated the bins that were stacked in the dirty receiving area was considered clean and ready for use. Staff #124 looked into the bins and confirmed the bins were visibly soiled. Staff #124 confirmed the bins on the dirty pallets were being taken into the clean storage areas and filled with clean and sterile patient supplies. Staff #124 stated the bins were wiped down between uses but did not have a cleaning schedule or written process to ensure how the bins were to be cleaned or stored.

In the receiving area across from the storage bins was a shop vacuum, tools and a dirty trash can with trash in it. The items and the floor were heavily soiled with dust and dirt. An open box of full soap containers that goes in patient rooms was sitting open on a dirty floor in the receiving area.

Metal carts used in the dirty and clean area to transport bins were found to be soiled with dirt, dust, rust, and peeling surfaces on the bottom of the cart. The carts were unable to be cleaned properly.

In the dirty holding area rolls of tape used on patients were unboxed and exposed to dirt and dust. The ends of the tape rolls have adhesive material on them, and they had collected dust particles that cannot be removed.

Shelving in all rooms revealed the floor underneath revealed heavy dirt, dust, and debris. Patient supplies were found overflowing the holding containers, resting on the dirty shelves, and floor.

Three-tiered plastic rolling carts were used to collect clean supplies while going down the aisles and filling the items request list. The items on the cart were then placed in the gray bins. Three out of three carts visualized were heavily soiled with dirt, dust, and dried spilled liquids. Old tape and tape residue were found all over the carts. The carts were not cleaned properly.

In the dirty holding area dozens of bottles of Glucerna and Ensure used for tube feeding was unboxed and sitting on the shelves. The bottles were covered in dust. These bottles are used as nutrition for patients and are taken directly to the patient rooms when used. The feedings should have stayed boxed in the dirty area or unboxed in the clean room.
An old medicine cabinet was found in the clean supply room with empty shelves and canisters inside. The outside of the cabinet was soiled with dirt and dust. Staff #120 stated the cabinet was not used for anything and needed to be discarded.

Six tiles on the floor in the clean supply room was broken. The floor was unable to be cleaned properly. There were visibly soiled floors by the trash can and in the open area of the clean supply room. Staff #79 stated they do not have enough staff to clean properly and needed a shop vacuum that would work. Staff #124 stated that housekeeping came "maybe once a month to mop" and that is the only time the floors are mopped. Staff #120 and 79 stated they were just using dry dusters when cleaning. Staff #79 confirmed the dry dusters just stir the dirt up. Staff #120 confirmed there was no written process or polices on cleaning the environment properly.

The large rolling trash can in the clean room was visibly full of trash, dirty on the outside with spilled dried liquids, and old tape. The trash cans were not being cleaned regularly.

Emergency Room at Broadway

A tour was conducted on 7/19/21 at 11:50AM of the Emergency Room (ER) on Broadway street. The tour was conducted with RN #31 and RN #30. The following issues are as follows:
The ER desk in the entrance area where patients check in was soiled with dust, old tape, and tape residue on the counter space. Multiple signs were taped to the desk and the tape edges were rolled up and heavily soiled. The desk was unable to be cleaned properly.

2-chairs in the ER waiting room were torn and unable to be cleaned properly.

In the triage room a cabinet was found holding opened 4x4 bandages. The bandages were lying loosely on a soiled shelf.

In the triage area the portable blood pressure monitor cart has an attached metal basket on a stand with wheels. The stand had a blood pressure machine on top. The base of the stand was soiled with dirt, dust and hair. The basket had tape and tape residue all around it. The portable blood pressure monitor cart was not properly cleaned between patients.

The metal linen cart had wheels. The wheels were rusted and unable to be cleaned in 2 of 2 carts observed.
The Pyxis (medication cabinet) was heavily soiled on the outside and inside with dirt, dust, hair, and dried spilled liquids. Inside the refrigerator medication sat in opened containers. The containers were soiled with dust and hair. Staff #43 was filling the Pyxis during the tour. He stated that the pharmacy should be cleaning the carts. He was unable to tell me a process for cleaning the carts or if they were on a schedule.


Emergency Room Main

A tour was conducted on 7/20/21 at 9:45AM with RN #31, LVN #40, and RN #24.
In the triage area of the main ER the nurse was found eating a hamburger and drinking in the triage room. The room smelled strongly of onions.

In the triage room the ophthalmoscope and audiscope were visibly dusty and the ophthalmoscope light was not working.

The green reclining vinyl chair in the triage room was laid back and the seat was visibly soiled with debris, dust, and hair.

Medical Room #7, #8, and #9 was considered a trauma room that had negative pressure. The rooms have the capability to be used as an isolation room for COVID patients or any patient with an infectious disease. They are called negative pressure rooms because the air pressure inside the room is lower than the air pressure outside the room. This means that when the door is opened, potentially contaminated air or other dangerous particles from inside the room will not flow outside into non-contaminated areas.

Medical Room #7, #8, and #9 had glass doors. The rubber stripping down the side of the glass door was broken and half of it was missing on all doors. The doors were unable to seal properly. There were no electronic sensors outside the door to show that the room was ready with negative pressure. LVN #40 was asked how the staff knew the negative pressure was working. LVN #40 stated that he was not sure but presented the state surveyor with a Vaneometer. The Vaneometer is developed for industry to measure air velocity. This air velocity together with the volume of the room and the surface of openings through which air enters the room, provide the inputs to calculate the ACH (air changes per hour). LVN #40 stated that he was not sure how to use the Vaneometer and he believed that Plant Operations were testing the rooms.

An interview with Plant Operations Staff #68 was conducted in the morning of 7/20/21. Staff #68 stated that he had not been testing the rooms, but he thought they were being tested. Staff #68 was not aware of the missing stripping on the doors.

An interview was conducted in the afternoon with Staff #117 on 7/23/21. Staff #117 confirmed that Plant Ops did not have any logs of testing the isolation rooms nor any processes for testing the rooms.

Emergency Room Main- West

The ER west side is closed at night and reopened in the mid-morning time or sooner if the main ER is full. During a morning tour on 7/20/21 the west ER was still closed from the night before. The public patient bathroom in the ER West was soiled. The floor had paper debris. The toilet was dirty with urine and hair.

Exam Room 10 had a broken cabinet door under the sink. The cabinet door was unlocked, and the cabinet was heavily soiled with rust debris and dust. The floor was soiled with dust, hair and dried footprints. Patient supplies were found sitting on the windowsill that was dusty. The bedside table was soiled with tape and tape residue. The ER stretcher was soiled with dust and an old sticker was half worn off and heavily soiled.


3N Orthopedic Department

The Equipment Room was found to have a broom and dirty dustpan stored in the room. A pair of clean patient crutches were found sitting in the dirty dustpan. 2-IV pumps were visibly soiled with dust spilled liquids and excessive amounts of tape and tape residue. 4 IV poles were found soiled with dust, rust, tape and tape residue. 2 portable blood pressure monitor carts were found soiled with dust, hair, and tape.

The freezer in the clean patient supply room is used for ice packs for the patients. The inside of the freezer was caked in sheets of ice and was unable to be cleaned properly. The bottom of the freezer was soiled with hair, dirt debris, and ice.

Medication room had a medication destroyer in a bracket holder on the wall. The wall and cabinet behind the bracket were heavily soiled with dirt and dust.

Nurses were found to have multiple syringes of normal saline sticking out of their pants pockets. Nurses were going in and out of different patient rooms exposing the individual patient medications.

An isolation cart with open drawers were found with PPE (personal protective equipment) in the patient room hallway. 6 syringes of normal saline were found lying among the PPE.

Patient Room 3507 was designated a terminally cleaned room. Terminally cleaned means the room was overturned and cleaned thoroughly for use by a new patient. In the room a portable blood pressure monitor cart was found soiled with dust, hair, and tape. The bottom of the portable blood pressure monitor cart was missing paint and was peeling paint. The faux window shutters were dusty and paper candy wrappers were found lying on the shelf under the shutters and window.

Patient room 3524 was designated as terminally cleaned and waiting for a new patient. The counter under the window was dusty and a syringe cap stopper was found lying on the counter. The bottom sheet on the bed was soiled with tape and an old band aide was stuck on the "clean sheets". The wooden bumper (chair rail) on the wall was visibly soiled with dust and dirt. The bumper was wiped with a cleaning cloth and clumps of dirt and dust was wiped off the wall.

A Posey sitter monitor was found in a drawer. The device was not wrapped in plastic and there were no identifiers that the monitor had been cleaned. The housekeeper stated that there was already in the room and was it should have been taken out. The housekeeper could not confirm the device had been cleaned. Staff #31 confirmed the finding.

4WA and B -COVID Telemetry/ICU

The clean linen was in a closet hallway. The linen was not covered. A ventilation vent was above the linen.
Isolation carts were found in the hallway outside patient rooms. Three carts were found broken on the bottom and were unable to be cleaned properly.

Patient Room 4441 was terminally cleaned and ready for a patient. There was trash in the trash can. The shelving under the hand sanitizer was found to have dried buildup of had sanitizer. The shelf had not been wiped down. The shelf behind the bed sat a telemetry monitor. The shelf was soiled with debris and dust. The shelving had not been wiped down. The counter under the faux shutters had a spilled dried orange substance. A substance was easily cleaned with a wipe used by the surveyor.

The toilet in room 4441 was leaking from the flush valve and the toilet and floor was wet. The bathroom floor threshold was missing a section of tile and was heavily soiled with a black substance, dirt and debris. The grout on the bathroom floor was black and mildewed. The surveyor was able to clean a section and the grout cleaned to a light gray. The pillowcase on the bed had a large tear. The mattress was lifted, and the metal part of the bed was soiled with a thick brown dried substance.

In the clean supply room three rolling carts were found with medical supplies on them. The carts were dusty, and staff could not confirm or deny if the carts were moved in and out of the room. The metal shelving up against the walls held medical supplies. The metal shelving's were heavily soiled in dust and hair. The floor under the shelving was soiled with dust and dirt. The bins holding the patient supplies were soiled with debris and dust.


Linen and Laundry

A tour was conducted on 7/21/21 at 2:00PM with Staff #94, Staff #95 and RN #31. The following items were identified;

The threshold floor between the loading dock and hospital hallway was missing tile on the floor. The floor was heavily soiled.

A linen cart was found on the loading dock with trash in it and a cleaning bucket with cleaning supplies hanging on it. A sticker was on the cart to identify it as a linen cart. The cart was being used by the hospital plant ops as a trash can.

Staff #94 confirmed the hospital staff were using the cart for their own trash cart "because they don't have one." Staff #94 could not ensure the dirty trash cart would not be mistaken and used as a linen cart.

On the clean side of the laundry holding area 8 bins were found holding laundry bundles that were delivered and ready to be dispersed. Since the bins have no covers, the laundry shall be kept wrapped in plastic until the laundry can be placed in a clean covered area. 5 out of 8 bins had laundry that was delivered to the facility unwrapped and uncovered. Staff #94 confirmed the laundry should have been wrapped.

The bins used to deliver the linen was soiled with dust, debris and was covered in tape and tape debris. 8 out 8 bins were broken and unable to be cleaned properly.

a cart of blankets and bedspreads were found on a cart uncovered. The items were covered in dust. Staff #94 confirmed the items were purchased several months ago. Staff #94 stated he was not sure what the hospital was going to do with the items.

Metal laundry carts were found against the wall holding clean laundry. One of the carts bottom shelves had a dirty and soiled plastic barrier. 5 metal racks holding scrubs had no barrier on the bottom exposing these scrubs to dirt and dust from the floor. There was no barrier to prevent dirty mop water from penetrating the scrubs.

Two large rolling covered trash cans were found in the clean linen room. The barrels were marked "soiled linen." Staff #94 stated he was not sure why the barrels were in the laundry room.

A covered linen cart was found in radiology in the hallway in an alcove. The cart had a green bag attached full of laundry. The bag read, "Reject Linen." Half of the bag was lying on the floor. Something red and green was seen under the cart. The cart was removed from the alcove and a torn green linen bag, a red rag and string was found lying in heavy dust, hair and debris.

Review of the Policy and Procedure Linen Management Program Policy Number: 48366.2 stated ,
" Procedure:
1) all linen delivered to the facility will arrive by cart, bagged, and covered.
6) Storage of Linen within Facility
a) all clean linen stored within the clean storage room will be organized in a fashion that ensures the integrity of clean linen. All linen will be covered at all times. Any linen that touches the floor at any point will be discarded as soiled/ contaminated.
15) Infection Control Rounding
a) The facility Infection Control Department will round and inspect both the clean and soiled rooms not less than once monthly. The rounds will be documented per the attached EOC rounding document."

An interview was conducted on 7/22/21 at 9:40AM with RN #31, RN #59 and Staff #117. RN #31 and #59 both confirmed they do surveillance rounds for infection control year-round but only twice a year for each department. Staff #31 confirmed the infection control rounds were not being done in the linen and laundry every month. Staff # 117 stated that she had just recently had the Linen and laundry department placed under her for supervision. Staff #117 stated that she is currently looking at the contracted service and realizes that changes need to be made.


3 rd floor IMC Medical/Surgical Unit

An open 4 tier metal cart on wheels was found holding medical supplies in the hallway alcove. The metal shelving was rolled out and the floor was soiled with dust, dirt, and a dead roach.

An interview was conducted on 7/22/21 at 9:40AM with RN #31, RN #59 and Staff #117. RN #31 and #59 both confirmed they do surveillance rounds for infection control year-round. Staff #31 stated that they used to do rounds with other people from other departments but that ended about two years ago. Staff #31 stated that infection control preventionist do the rounding. Staff #117 stated the departments were supposed to do their own rounding then report to QAPI or Infection Control as needed. The infection control preventionist look at each department 2 x a year ( the last documented observation was on 11/5/2020). Staff #117 was made aware of the infection control findings and stated that those issues should have been found and reported.

Based on review and interview the Governing Board (GB) failed to approve the pharmacist to the interim position for the stewardship.

An interview was conducted with Staff #93 on 7/21/21. Staff # 93 stated that she was asked to take the Antibiotic Stewardship in March of 2020 after the previous person resigned. Staff #93 was not aware if GB had appointed her in the GB meeting minutes.

Review of the March/April/May 2021 GB meeting minutes revealed there was no mention of the approved interim position held by Staff #93.

Based on observation, document review, and interview the facility failed to:

A. ensure a clean and sanitary environment was provided for the provision of surgical services in 4 (Digestive Disease Center, Day Surgery, Main Operating Room, Sterile Processing Department) of 5 areas observed.


B. ensure the temperature in the Operating rooms (OR) and Sterile Storage areas in Day Surgery was within acceptable standards to inhibit microbial growth, reduce the risk of infection, promote patient comfort and assure the physical safety of all patients in 8 (OR Room A, OR Room B, OR Room C, OR Room D, and OR Room E, Viewing Room, Consignment Room, Sterile Storage Room) of 8 areas observed. The facility also failed to follow their own policy.


C. ensure a current roster listing each practitioners privileges and a current roster of practitioners suspensions were available to all schedulers.

Cross Refer to A0945


D. ensure the operating room register was complete and up to date in 2 (Main OR and Day Surgery) of 2 areas observed.

Cross Refer to A0958




Findings Include:



A. Sanitary Environment


Digestive Disease Clinic

During an observation tour on July 20, 2021 at 9:45 AM with RN #35, and Staff #107 the following was observed:



In the Pre-op area, it was noted that 2 (two) portable computers on wheels were heavily soiled with dirt, dust, and debris. The keyboards were heavily soiled with dirt and dust. On the base of the rolling stand it was noted to have small black pieces of debris. The sink for staff in the pre-op area was visibly soiled with dirt and dust. A tall cabinet with a rolling door was observed in front of Bay 11. Inside the cart was IV Pumps and Patient monitors. 1(one) IV pump was covered with a clear plastic bag and the other was not. One patient monitor was covered with a clear plastic bag and the other was not. RN #35 stated that a clear bag over the equipment indicates the equipment was clean but, RN #35 could not confirm or deny if the uncovered patient equipment was clean or dirty.

Also, in the Pre-op area a Sonosite was observed uncovered and readily available for patient use. The probe for the Sonosite was also uncovered and RN #35 could not confirm nor deny if the probe had been cleaned after the last patient use. RN #35 was asked what the equipment was used for. RN #35 stated, "We use the Sonosite for difficult IV's." On the tray of the Sonosite there is a white paper ruler that is taped down with scotch tape and visibly dirty. There are four white holders for different probes that are heavily soiled with dirt, dust, and debris on the inside. The base of the portable Sonosite was soiled with a dried liquid and dust. The portable EKG machine was noted to be dirty with dust, debris, and gloves.

Inside a room where the "Mobile Equipment" was stored was a portable cart used to hold the procedure equipment. The cart was noted to have dirt, dust, and debris on each shelf. On the bottom of the cart was towels, a notebook, and extra supplies. The shelves where the towels and extra supplies were stored was heavily soiled with dirt and dust. The cart had 3 drawers. In the 1st drawer there was 2 opened bottles of betadine (an antiseptic). Each bottle was 2 fluid ounces. Neither bottle had an opened date or expiration date written on the outside of the bottle. A bottle of Instant Gas Relief drops was noted to be expired 6/09/2021. One 10 ml of Epinephrine was expired 7/01/2021. These items were readily available for patient use. RN #35 was asked when and what the equipment was used for. RN #35 stated, "We carry this equipment to the Main OR, or to the patients room if a procedure needs to be done. This equipment is not kept in the Main OR and so if there is a procedure, they have to come here to get the equipment or we transport it over."

In the hallway outside the Scope Room was an Anesthesia Emergency Cart. On the top of the cart was 3 (three) Bougie Endotracheal Tube Introducers. 2 (two) expired 4/11/2021 and one expired 09/2019. These introducers are used to aid in the intubation of someone in an emergency situation. One 14-gauge IV Catheter expired 4/30/2021 and 2 (two) 16-gauge IV Catheters expired 10/31/2020.

The C-Arm in Procedure Room 1 was visibly soiled with dirt and dust.


In Procedure Room 7 a procedure cart was observed. The cart contained the following:

On top of the procedure cart was an opened and partially used 1000 cc bottle of sterile water for irrigation with a label that stated, "Single unit container. Discard unused portion."

Five (5) loose plastic ampules of Eleview with an "EXP: 202106" were available for patient use.

During an interview with RN#35 on 07/20/21 at 11:09 a.m. the above findings were confirmed.

A review of Package Insert for Eleview was conducted on 07/23/21 at 10:40 a.m. in a conference room in administration and stated in part, "Submucosal injectable composition 10 ml. To facilitate endoscopic resection procedure 10 ml per ampoule," and " ...store the unused ampoules inside the aluminum pouch into the folding box."


RN #35 and Staff #107 confirmed the findings.




Day Surgery

During an observation tour on 7/21/2021 at 9:20 AM with RN #36 the following was observed. The patient stretchers in Pre-op Bay #9 and #11 was noted to have dirt and dust on the base of the stretcher. A bear hugger (a warming device for patients) was heavily soiled with dirt, dust, and debris.

In an anesthesia workroom it was noted that no temperature or humidity was monitored. This room also stores patient medical supplies and medications. Multiple shelves and drawers are noted that store supplies and medication. The base of the shelves and base of the drawers were dirty and dusty. The floor was noted to have chipped and broken tile. The tile floor was not sealed. The tile floor cannot be properly sanitized to prevent cross contamination and hospital acquired infections. Staff #113 confirmed the Anesthesia Workroom was not monitored for temperature and humidity.


Main Operating Room

An observation tour was conducted on 7/22/2021 after 1:00 PM with RN #33, #34, and #63. This surveyor observed in the Trauma Room, OR4, IV Fluids had been spiked and placed in a pressure bag with the intent to use on the next patient. No staff could determine when the IV fluids had been spiked. On the floor beneath the head of the bed, there was dried white fluid. The mobile computer and keyboard in the room was noted to be soiled with dirt and dust. This surveyor removed all linens from the OR Table for inspection. The mattress was noted to have old tape adhesive on the mattress. Under the mattress there was tape on the removable frame of the bed and a blue cap that was used to cover IV tubing ports. The metal frame was heavily soiled with dirt and dust and when the Kidney rest was flexed, there was a red dried liquid. This surveyor used a Sani wipe to easily remove the dried liquid. RN #33, #34, or RN #63 could not confirm nor deny if the dried red colored liquid was blood from the previous surgical case. In the anesthesia cart there was a 10 ML syringe with a label of Ephedrine 10 mg/ml. There was no date that it was drawn up, no expiration date, and no name of the staff that drew the medication up.

An interview was conducted with RN #33 on 7/22/2021 at 1:45 PM. RN #33 was asked if the provider delivering the anesthesia was aware the bag of fluids could not be spiked prior to a Surgical case. RN #33 stated, "Yes they are well aware of that and they are also aware they cannot prefill syringes and leave them unattended as they did in here. We can obviously see that the housekeeping team will need more education on terminal cleaning of a room. We always keep this room set up for trauma cases and turn it over as soon as we are through."

There was clean equipment stored in the hallway of the Surgical Department. There was no indication if the equipment was clean or dirty and the equipment was readily available for patient use. The "BrainLab" equipment was a portable piece of equipment that could be used for any neurological surgical case. It is a navigation device to assist with guidance in small areas. The base of the equipment was so heavily soiled in dirt and dust, this surveyor could draw a line in the dust. RN #33 stated, "We do not even use this equipment and I do not know why it is even in this department. It should have been removed a long time ago."

RN #33, RN #34, and RN #64 confirmed the above findings.




B. The facility failed to ensure the temperature in the Operating room (OR) in the Day Surgery Department was within acceptable standards to inhibit microbial growth, reduce the risk of infection, promote patient comfort and assure the physical safety of all patients.

A review of the temperature logs for June 2021and July 1-21, 2021 was as follows:





A review of the documents titled, " ...UTHealth East Texas
Temperature and Humidity Log for Clean/Sterile Storage
Location______________Month/Year______________
Temperature Range:______Max75_____Humidity Range:_____Max 60%__

If temperature or humidity are not within range notify BioMed at 68745. Document actions taken (i.e. adjusting thermostat, close door, etc.) and then re-measure after 30 minutes to assure that the affected parameter is within the acceptable range ..."




June 2021

OR A - The temperature was documented out of range 6 of 30 days. June 26-27, 2021 no documentation was completed for temperature or humidity.

OR B - The temperature was documented out of range 4 of 30 days. June 26-27, 2021 no documentation was completed for temperature or humidity.

OR C- The temperature was documented out of range 4 of 30 days. June 26-27, 2021 no documentation was completed for temperature or humidity.


OR D - The temperature was documented out of range 6 of 30 days. June 26-27, 2021 no documentation was completed for temperature or humidity.


OR E - The temperature was documented out of range 3 of 30 days. June 26-27, 2021 no documentation was completed for temperature or humidity.

Viewing Room - The temperature or humidity was not documented 6 of 30 days.

Sterile Supply - The temperature or humidity was not documented 2 of 30 days.

Consignment Room - The temperature or humidity was not documented 2 of 30 days.


There was no documentation on the log to indicate corrective action taken or the temperature upon follow up after corrective action was completed.




July 2021

OR A - The temperature was documented out of range 9 of 21 days. July 17, 2021 was documented "temp adjustment" but no re-measure was documented. Humidity was out of range 1 of 21 days.

OR B - The temperature was documented out of range 4 of 21 days. July 17, 2021 was documented "temp adjustment" but no re-measure was documented. Humidity was out of range 1 of 21 days.


OR C- The temperature was documented out of range 9 of 21 days. July 17, 2021 was documented "temp adjustment" but no re-measure was documented. Humidity was out of range 1 of 21 days.

OR D - The temperature was documented out of range 8 of 21 days. July 17, 2021 was documented "temp adjustment" but no re-measure was documented. Humidity was out of range 1 of 21 days.


OR E - The temperature was documented out of range 8 of 21 days. July 17, 2021 was documented "temp adjustment" but no re-measure was documented. Humidity was out of range 1 of 21 days.


Viewing Room - The temperature was documented out of range 7 of 21 days. The temperature or humidity was not documented 4 of 21 days. There was no re-measure of the temperature after corrective actions were taken in 7 of 21 days.


Consignment Room - The humidity was documented out of range in 1 of 21 days. There was no re-measure of the humidity after corrective actions were taken.




A review of the AORN Perioperative Standards and Recommended Practices,

" ...Temperature should be maintained between 68 degrees F to 75 degrees Fahrenheit (20 degrees to 23 C) within the operating room suite. General work areas in sterile processing should be maintained between 68 degrees to 73 degrees F.

Relative humidity should be maintained between 20% and 60% within the perioperative suite, including operating rooms, recovery area, cardiac catheterization rooms, endoscopy rooms, instrument processing areas, and sterilizing areas and should be maintained below 60% in sterile storage areas.

Low humidity increases the risk of electrostatic charges, which pose a fire hazard in an oxygen-enriched environment or when flammable agents are in use and increases the potential for dust. High humidity increases the risk of microbial growth in areas where sterile supplies are stored, or procedures are performed.

Temperature should be monitored and recorded daily using a log format or documentation provided by the HVAC (heating, ventilation, and air conditioning) system..."



A review of the facility policy titled, "Humidity/Temperature Control SS" Policy Number 1700.036 with an approval date of 11/21/2018 was as follows:

" ...Policy: To provide guidelines for the environmental control systems in the operating rooms, Sterile Processing Department, and other areas where a large bulk of sterile items are stored.

Purpose: These rooms will be designed and maintained in accordance with the American Institute of Architects (AIA). The AIA/Association of Operative Registered Nurse (AORN) recommends that the Operating Room (O.R.) temperature be maintained between 20C and 24C (68 F and 75 F) and the relative humidity maintained between 20% and 60%. AORN recommends that Preparation and Packing areas (Sterile Processing Department Assembly area) should have a controlled between 22 C and 26 C (72F and 78F). The temperature in the sterile storage area (Staging) may be as high as 26 C (78F). The relative humidity in all Sterile Processing Department areas should be controlled between 20% and 60% except the sterile storage area (Staging) where the relative humidity should not exceed 60%.


Procedure:
1. Relative humidity/temperature levels will be monitored and recorded daily ..."


An interview was conducted with RN #73 on 07/21/21 at 10:30 a.m. in Day Surgery. RN #73 was asked about the temperature/humidity logged for the above areas in Day Surgery that were out of range on 07/17/21.
RN #73 stated, "The temperature and humidity are not electronically monitored in Day Surgery, but a manual log is kept instead. The Day Surgery is closed on Saturday and Sunday. No one works on Saturday and Sunday or monitors temperature/humidity. On Friday the staff hit reset on the temperature and humidity gauge on the wall. On Monday morning the RN, a CST (Certified Scrub Tech), or a PCT (Patient Care Tech) pushes Max/Min on the unit and the Max/Min will flash on the screen and show the maximum temperature and humidity. The staff member presses Max/Min on the unit again, and the minimum temperature and humidity will be shown on the screen."
RN #73 stated, "There is no way of knowing when the temperature and humidity were at the minimum and maximum range just that it was sometime between Friday after close and Monday morning. We don't know when a temp adjustment was made." RN #73 did not complete an incident report and did not contact Plant Services.
Staff #10 confirmed on 07/23/21 in administration that the hospital did not have an incident report for Day Surgery for the temperature/humidity problem on July 17, 2021.

RN #73 confirmed there is no policy for this process and the process was not always followed as evidenced by the review of the document titled Manual Temperature and Humidity Logs for June and July 2021. RN #36 and RN #73 also confirmed the Day Surgery was not on the electronic monitoring of Temperature and Humidity.

RN #33 confirmed on 7/22/2021 after 9:00 AM that no employee reports to Day Surgery on Saturday or Sunday to check the temperature and humidity of the Operating Rooms and Sterile Supply areas.

RN #36 and RN #73 confirmed the above findings.





34617

DIGESTIVE DISEASE CENTER

An observation tour in the Digestive Disease Center on 07/20/21 after 9:40 a.m. accompanied by RN #35 and Staff #107 revealed the following:

PRE-OP AREA

a. A sign on the Blanket Warmer stated, "Maximum temperature 130 degrees Fahrenheit." The temperature reading was 134°. RN#35 was asked for a log book but did not have one.

b. There was debris on the bottom shelf of the Pyxis used to store IV solutions for patient use.

c. A plastic basket used to store sterile specimen cups housed on top of a supply cart in the hall had debris in the bottom of the basket. The 1st drawer of the cart contained a tray with loose 2 x 2's available for patient use.

d. A rolling computer cart in the pre-op area had debris on the keyboard and down in the crevices of the keys, the fabric on the wrist rest was torn, and the work space had sticky tape.

e. A rolling computer cart ISD31342 at the foot of bed 7 had debris on the keyboard and down in the crevices of the keys and a black sticky substance on the work space.

f. A rolling computer cart ISD31335 had debris on the keyboard and down in the crevices of the keys and dirty tape labeled WORKS 4/1.

g. The bottom of the third drawer of a supply cart in Bay 8 contained debris and was used to store primary piggyback sets for patient use. The first drawer contained loose 2 x 2's available for patient use.

h. The bottom of the stretcher for Bay 8 contained dusty debris.

i. There were tears in the plastic linen cart cover.

RN#35 and Staff #107 confirmed the above findings.

PROCEDURE AREA

a. A procedure cart in the hall outside Procedure 7 contained a plastic bin used to store sterile #22 gauge IV catheters had dusty debris in the bottom of it. In addition, an unsterile pair of scissors and an unsterile hemostat were stored with the sterile #22 gauge IV catheters.

b. In Procedure 1 there was a fan plugged into a wall socket with no bio med sticker on it to indicate that it had been tested prior to use. A storage cabinet contained five (5) 500 ml bottles of 0.9% Sodium Chloride Irrigation with an "EXP 1 Feb 2021."
A clear pump container contained reddish brown fluid and a handwritten label that stated only, "Enzymatic Cleaner," but no expiration date was stored on a cart. Two (2) bottles of Fecal Eliminator bottles were in the room with no dates as to when they were opened or an expiration date. A supply cart had a bio hazard sharp container in a rack on the side of it with a Chloro Prep Sterile Solution and a 2 oz Ready Prep PVP stored next to the sharps container.

RN#35 confirmed the findings for the procedure cart in the hall outside Procedure 7 at 12:15 p.m. and Staff #107 confirmed the findings in Procedure 1 at 12:39 p.m.

The hospital policy #55196.1 entitled, "20-806 Medical Equipment Management Plan-Biomed-DIV-PE," with an "effective date of 05/28/2020," stated the following in part, "Objective: ...designed to assess and control the physical and clinical risks of all equipment used in the diagnosis, treatment, monitoring and care of our patients," "Elements of Performance 2) b) All new equipment (life support or non-life support) shall be inventoried and inspected prior to use for patient care or any other use. Equipment that fails electrical safety or other pertinent tests shall not be approved for use until the deficiencies have been corrected.

DAY SURGERY

An observation tour in Day Surgery on 07/20/21 after 9:20 a.m. accompanied by RN #73 and Staff #25 revealed the following:

a. In a sub-sterilizer area between Operating Room C and Operating Room D, an uncovered tray of instruments was sitting on a counter with separation of the caulking from the backsplash. RN#73 was asked about the tray, identified it as a dirty dental tray and stated, they "Just didn't cover it." A headlight battery charger with dusty debris and an open unlabeled specimen cup with about ½ inch of clear fluid and 6 burrs was sitting on the counter. RN#73 was asked about the clear fluid and stated, "One of the DA's (dental assistants) put them there."

b. A Sterile Supply Storage Room housed bins with debris in the bottoms that contained sterile supplies including blue sterile O.R. towels and impervious stockinettes. Seven (7) peel pouches with Stryker drill bits and one (1) peel pouch with a Weitlander Retractor had uncovered tips such that the integrity of the packaging could be breeched. One pouch had a tear in the packaging and was available for patient use.

c. In the Viewing Room there were Sterile Breast Sizers stored about 10 inches away from a Sharps Container attached to the side of a Regional Nerve Block Cart. An anesthesia cart had brown drippage on it. A red wire was hanging over a bucket with Sterile Bag Decanters.

d. Operating Room A had a keyboard with dusty debris, a cracked and peeling patient roller, peeling paint on a window sill, dusty debris in a bin inside the prep table, a right leg holder attached to the operating table with debris in the foot section, a leg holder laying on the floor, and items sticking up from the open biohazardous waste bin. The operating room table pad was flipped over by another Surveyor and the underside was wet. The same Surveyor flexed the operating room table and there was drippage that could be wiped off. An open 7.0 endotracheal tube with a stylet and a syringe attached was on top of the anesthesia cart along with a Bougie that expired 2019-12.

RN#73 and Staff #25 confirmed the above findings.

The hospital policy #48455.1 entitled, "Selection of Packaging Materials-SS" with an effective date "Not Set" was reviewed and stated in part, "Policy: Packing materials will ensure sterility of package contents until opened for use..." and "Procedure: 6)Materials used for packaging will contribute to the maintenance of sterility of contents."

MAIN OPERATING ROOM

An observation tour in the Sterile Processing Department of the Main Operating Room on 07/22/21 beginning at 1:14 p.m. accompanied by Staff #109, Staff #110, and Staff #112 revealed the following:

STERILE SUPPLY ROOM

a. A hard plastic bin with debris inside it and breaks in all 4 corners covered with dirty tape was stored on top of a cart next to sterile items.

b. One (1) discolored peel pouch contained a grasper, four (4) peel pouches contained scissors with only one side of the tip covered, and two (2) peel pouches contained graspers with tip covers loose in the pouch and not covering the tips.

c. An opened and unsterile drape was lying on top of a Sterile Synthes Small Battery Drill.

d. At the opposite end of the Sterile Supply Room was an area shared by another department. Non-sterile Prepping Pads were stored with sterile supplies and confirmed by Staff #114 at 2:51 p.m.

Staff #109, Staff #110 and Staff #112 confirmed the above findings.

STERILE PROCESSING CLEAN AREA

There were 4 Prevac Steam Sterilizers. Sterilizer SN 010360309 had a Steris Chamber Cleaning Services label with a date of 9-24-17 and next service due: Sept 2018. The outside area below the door had pale greenish buildup. A Sterilizer with a Biomedical Services Label 25536 had a Steris Chamber Cleaning Services label but the service date and next service due date were not legible. A Sterilizer with a Biomedical Services Label 25537 had a Steris Chamber Cleaning Services label but the service date and next service due date were not legible. The Sterilizer with Label 25537 had greenish gray deposits and buildup on the door and in the chamber. There was also brownish deposits in the chamber. Dirty debris was in the recessed areas at the bottom of the sterilizer. A Sterilizer with a Biomedical Services Label 50051 had dusty debris that could be wiped off of a black rubber strip on the left side of the outer door. The Sterilizer with Label 50051 had a Steris Chamber Cleaning Services label with a date of 2020 and next service date of Feb 2021.

During an interview of Staff #109, Staff #110 and Staff #112 on 07/22/21 at 3:25 p.m. the above findings were confirmed. According to Staff #110, cleaning of the sterilizers was not scheduled because they are going to replace steam sterilizers 1, 2 and 3. During an interview of Staff #10 on 07/23/21 at 12:16 p.m. in administration, she stated they "follow the manufacturers instructions for cleaning the sterilizer." They do not have a policy. During an interview of Staff #10 on 07/23/21 at 1:20 p.m. in an office in administration, she stated we "are waiting for Ardent to sign the PO for SPD Equipment Replacement."

An e-mail from STERIS on 12/08/20 at 11:43 a.m. to the Division Director, Biomedical Services at UT Health Tyler was reviewed on 07/22/21 at 4:45 p.m. in a conference room and stated in part, "Per my voice mail message, the Steris IMS Chamber Cleanings are now going to be through STERIS Corporation. As the OEM, STERIS does recommend annual cleanings and most accrediting agencies do specify to follow the OEM recommendations. The IMS records show that your last cleaning was done in February, 2020 ...Enclosed is a quote for Chamber Cleaning ...If you are interested, please sign and return the quote along with a purchase order ..." An e-mail from the Division Director, Biomedical Services at UT Health Tyler to Staff #110 on 12/08/20 at 3:25 p.m. that forwarded the above e-mail was reviewed on 07/22/21 at 4:45 p.m. and stated, "We probably need to do this?"

A page from the Operator Manual on Routine Maintenance for the Steris Sterilizer, entitled, "8.3.1," was reviewed on 07/23/21 in a conference room in administration and stated in part, "Important: Professional cleaning of the chamber on a yearly basis (or as required due to local conditions) is suggested to maintain appearance of the chamber interior. Contact STERIS for information regarding this service."

An e-mail dated 07/21/21 at 5:04 p.m. from STERIS to RN#33 and Staff #115 was reviewed on 07/23/21 in a conference room and stated the following in part: "Thank you again for your time on Friday to review and collaborate on the pending SPD project decision," and "I know that --- submitted our approved and updated project quote to you on Monday and I believe you were scheduled to have a meeting Monday afternoon to make a final decision on the vendor selection." An e-mail dated 07/22/21 at 2:13 p.m. from STERIS to RN#33 and Staff #115 was reviewed and stated in part: "I understand that STERIS received verbal notification that UT Tyler intends to proceed with the purchase of the STERIS Capital identified on attached quote ----1271361. The quote referenced was reviewed and included in part AMSCO 600 Prevac Steam Sterilizer Quantity 3.

Based on observation and interview the facility failed to maintain a current roster of each practitioners specific surgical privileges located in the surgery scheduling department. Also, the facility failed to maintain a list of surgeons suspended or surgeons who had restricted surgical privileges.

This deficient practice had the likelihood to cause harm to all patients receiving surgical services if a specific surgeon was suspended from practice or did not have the privileges to perform the surgery that was scheduled.


Findings Include:

A tour of the Main Surgery Scheduling area was conducted on 7/22/2021 after 12:00 PM with RN #33.

An interview was conducted on 7/22/2021 at 3:15 PM in the Main Surgery Department with Staff #108. Staff #108 was asked to provide a list of suspended surgeons. Staff #108 could not do so. Staff #108 was asked if she was informed what surgeons were suspended and what the privileges were for each surgeon. Staff #108 stated, "I do not know that information." Staff #108 was asked if there was a book that was kept in the scheduling area for the schedulers to reference if there was a question regarding a specific surgeons privileges. Staff #108 stated, "No, we do not have a book like that."

RN #33 confirmed there was no book or roster in the Department for the schedulers to review before scheduling a procedure. Weekend and Night staff did not have access to this information. Staff #33 stated, "I communicate with Staff #28, but I do not forward any information to the schedulers."

RN #33 and Staff #108 confirmed the above findings.

Based on document review and interview the facility failed to have a complete and up to date Operating Room Register for 41 of 41 days reviewed.

A review of the document provided by RN #33 was as follows:

A review of the untitled document was conducted on 7/22/2021 and revealed the following:

The facility failed to maintain an operating room register that was up to date and contained the following required elements: Patient's name, Patient's hospital identification number, Date of the operation, Inclusive or total time of the operation, Name of the surgeon and any assistant(s), Name of nursing personnel (scrub and circulating), Type of anesthesia used and name of person administering it, Operation performed, Pre and post-op diagnosis, and Age of patient.

A review of the operating room register revealed that 6 of 14 (Post Op Diagnosis, Surgical/Practitioner Assistant if any, Name of nursing personnel (scrub and circulating), and type of anesthesia used and name of person administering anesthesia) required elements were missing from June 1-July 11, 2021.

An interview was conducted with Staff #33 on 7/22/2021 after 9: 00 AM. RN#33 was asked if the document was the complete OR Register. RN #33 stated well we can run a report and put whatever we want on there. RN #33 was asked if she was aware of all the elements that are required to be on the OR Register. RN #33 stated, "I can get any information on there if I know what is required." RN #33 confirmed that the OR log is not kept current daily and the department just queries a report. The Day Surgery was not on the OR Register and RN #33 confirmed the only surgical cases on the OR Register were from the Main OR.

RN #33 and RN #34 confirmed the findings.