HospitalInspections.org

Based on observations, record and policy review, and staff interviews, the governing body failed to establish an effective monitoring mechanism to ensure the adequate oversight of the hospital.

Comply with the Condition of Participation for the provision of respiratory services; as a result, placed the health and safety of recipients of care at risk for serious harm. Subsequently, the state agency identified an Immediate Jeopardy relative to the provision of respiratory services, requiring the need for immediate corrective action.

The noncompliance requiring immediate corrective action is as follows:

Failure to...

A. Ensure the organization of respiratory services was appropriate to the scope and complexity of services offered.

B. Establish a mechanism to ensure adequate numbers of respiratory therapists were available to meet the needs of patients.

C. Establish a mechanism to ensure respiratory services were delivered, in accordance with medical staff.

D. Establish a mechanism to ensure respiratory care services were documented, in the patient's medical record, in accordance with the requirements.

E. Establish a mechanism to ensure respiratory staff notified the medical team when prescribed treatments were not administered.

Condition and Standard Level Non-Compliance was identified as follows:

Failure to...

F. Establish a mechanism to ensure that the Quality Assurance and Performance Improvement program measured, analyzed, and tracked quality indicators which assessed processes of care, hospital services and operations.

G. Establish an efficient mechanism for setting quality priorities to ensure performance improvement activities address problem-prone areas.

H. Ensure that safe and hygienic food handling practices were in compliance with state requirements for food service operation standards.

I. Ensure that safe and hygienic infection control practices.

J. Establish a mechanism to ensure nursing staff were skilled to meet patient care needs related to wound assessments.

K. Establish a mechanism to maintain the physical plant and the overall environment in a safe and sanitary manner, to ensure the safety and well-being of patients, visitors and staff.

L. Ensure facilities and equipment are maintained to ensure an acceptable level of quality.


The cumulative effect of these systemic deficient practices resulted in the governing body's failure to comply with the conditions of participation for the Governing Body.

Based on Quality Assessment Performance Improvement (QAPI) Program review, record review, policy review, and staff interview, the hospital failed to set priorities for its performance improvement activities that focus on problem-prone areas related to respiratory care services and infection control that affect health outcomes, patient safety, and quality of care (A-283)


The cumulative effect of these systemic practices resulted in the hospital's failure to comply with conditions of participation in Quality Assessment and Performance Improvement Program.

Based on quality program review and staff interviews, it was determined the hospital failed to implement an effective mechanism for setting quality priorities to ensure performance improvement activities address problem-prone areas, related to respiratory care services and infection control.

Findings included...

During review of the Quality Assessment Performance Improvement (QAPI) Program on 04/18/19 at approximately 2:10 PM, the hospital staff failed to recognize, monitor, measure and track problem-prone areas and issues identified during the complaint investigation survey related to respiratory care services and infection control, to ensure care delivery and process improvement.

The quality and patient safety plan lacked documented evidence of structural, procedural or process changes to achieve sustainable remediation of chronic deficient practices related to patients not receiving respiratory care services and unacceptable dishwasher rinse temperatures. The action plan lacked documented evidence of priorities and process improvement activities related to respiratory care services, and infection prevention for the following identified problem-prone areas:

Failure to ensure respiratory staff delivered respiratory care and carry out physician orders to meet the needs of patients requiring respiratory services. CFR §482.57 (A-1151)

Failure to provide respiratory services relative to the scope and complexity of patient care needs. CFR §482.57 (A-1152)

Failure to provide sufficient personnel available to respond to the respiratory care needs of the patient population. CFR §482.57 (A-1154)

Failure to provide respiratory treatments to include nebulizer medications, metered-dose inhalers and chest physiotherapy CFR §482.57 (A-1160)

Failure to document notification to Medical Staff, when respiratory care treatments are not administered in accordance with physician's orders CFR§ 482.57 (A-1164)

Failure to ensure the hospital staff consistently implemented infection control measures per accepted standards related to the sanitization of dishes; donning/doffing personal protective equipment and the provision of wound treatment as to avoid sources and transmission of infection(s), cross reference CFR §482.42 (A-0747)

During a face-to-face interview on 04/18/19 at approximately 3:00 PM, with Employee #37, Director of Quality, the quality program, and the identified concerns were reviewed and discussed to include the lack of consistent respiratory services and the unacceptable dish machine rinse temperatures. Employee #37 explained that she relied on respiratory and dietary staff to convey findings and concerns; however, neither conveyed any findings or concerns about the findings [identified by the survey team], although they attended the meetings. Employee #37 acknowledged the findings.

Based on medical record review, policy review and staff interviews, the nursing staff failed to follow the plan of care for patient assessments, wound care management, medication administration, and glucose management, in 12 of 13 medical records reviewed (Patients #57, 62, 90, 111, 101, 152, 3, 4, 112, 113, 114 and 115).

Findings included ...

Review of the hospital policy titled, "Pressure Injury Prevention and Treatment," revised 11/2018, showed the following staging system: Stage 1 pressure injury - non-blanchable erythema of intact skin; Stage 2 - partial thickness skin loss with exposed dermis; Stage 3- full thickness skin loss; Stage 4 - full thickness skin and tissue loss; Unstageable - obscured full thickness skin and tissue loss; and Deep Tissue Injury (DTI) - persistent non-blanchable deep red, maroon, or purple discoloration. Pressure injuries should be documented accordingly. Staff nurses collaborate with wound champions to manage Stage 1 and 2 pressure injuries. There should be no down staging or reverse staging ...

The nurse or a physician should place a Wound Ostomy Continence Nurse (WOCN) consult for any wound that doesn't improve over a two week period, or deteriorates. WOCN will be consulted for any Stage 3, 4, unstageable or deep tissue injury unless followed by another service. Pressure injuries will be measured and staged on admission, transfer, discharge, and every Wednesday and documented accordingly. Pressure injuries should be staged using the updated National Pressure Ulcer Advisory Panel (NPUAP) staging system, and there should be no down-staging of wounds.

Review of the treatment protocol attachment to the policy revealed the Wound Ostomy Continence Nurse (WOCN) should be consulted for Stage 3, 4, Unstageable, and DTI wounds; and any wounds that are not improving, within two weeks or deteriorate.

NPUAP guidelines describe an unstageable pressure injury as full-thickness skin and tissue loss in which the extent of tissue damage with the ulcer cannot be confirmed because it is obscured by slough or eschar. A Deep Tissue Pressure Injury can be intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister.

https://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/

The hospital's policy entitled, "Medication Administration" effective 01/16, shows that medications may be administered one hour before or one hour after scheduled dosing times.


A. Review of Patient #57s medical record on 04/15/19 at approximately 12:15 PM, with Employee #59, Registered Nurse, revealed the patient had a pressure injury to the medial buttocks, identified as a Stage 1 pressure injury by nursing staff, on 04/11/19 to 4/12/19. On 04/13/19 at 8:00 PM, nursing staff identified the wound as a Superficial (1st degree) wound and on 04/14/19 at 7:00 AM, the wound was identified as Stage 1 pressure injury.

The practice lacked evidence that the wound characterization recorded as "superfical first degree wound" is consistent with the hospital policy.

During a face-to-face interview with Employee #59, on 04/15/19 at approximately 12:30 PM, she acknowledged the findings.

B. Review of Patient #62's medical record on 04/17/19 at approximately 11:00 AM, in the presence of Employee #56, Registered Nurse, revealed the nursing staff identified a DTI on the patient's left sacrum on 03/19/19 at 8:00 AM; however, the record lacked evidence of a WOCN consult. Additionally, on 03/20/19 at 8:00 PM and 03/21/19 at 6:19 AM, the nursing staff identified the wound as excoriation to the left sacrum.

The practice lacked evidence that the nursing staff followed the hospital's policy for wound staging as evidence by characterization of the sacral wound as DTI on 03/19/19 and excoriation the following two days. Additionally, there was no evidence that the WOCN was consulted once the patient was assessed with a DTI of the sacrum.

During a face-to-face interview with Employee #56, on 04/17/19 at approximately 11:30 AM, she was asked to provide the WOCN consult information for the identified DTI. She could not provide the requested information and she acknowledged the findings.


C. On 2G Intensive Care Unit (ICU), review of the wound assessment completed by a staff nurse on 03/30/19 showed that Patient #90, had moisture related skin damage to her bilateral sacral area with surrounding excoriation. On 04/02/19 at 10:00 AM, the WOCN documented that the wound on the bilateral sacral area was a Deep Tissue Pressure Injury, measuring 2 centimeters (cm) in length by 1 cm in width.

On 04/04/19, nursing staff documented that the wound was now a stage 2 pressure injury; the assessment included no characteristics or measurements. The nursing assessment documented 04/06/19 showed that the wound measurements were 6 cm in length and 4 cm in width.

The medical record lacked documented evidence that the nursing staff followed the hospital policy to obtained a WOCN consult when the wound deteriorated.

The surveyor conducted a face-to-face interview with Employee #71, Patient Care Manager, on 04/08/19 at 11:45 AM, regarding the wound care assessments for Patient #90. She acknowledged the findings.

D. On 2G Intensive Care Unit (ICU), review of the medical record for Patient #111 showed that on 03/25/19 at 3:00 PM, the WOCN identified an alteration in skin integrity, located on the bilateral sacrum, as a Deep Tissue Injury (DTI), evolving into an unstageable wound. The measurements of the wound were 2.5 centimeters (cm) in length by 3 cm in width on the right sacrum; and 4cm in length by 4 cm in width on the left sacrum. The wound bed was described with necrotic tissue.

Review of the wound assessment completed by the bedside nurse on 03/28/19 at 8:00 PM showed the that wound was a DTI. The next assessment on 03/29/19 at 9:00AM described the wound as a DTI.

Further review of the clinical record lacked evidence that the nursing staff assessed Patient #111 sacral wound during of 04/04/19 through 04/08/19.

The medical record lacked documented evidence that nursing staff consistently assessed the progression of the patient's sacral wound and followed hospital policy related to wound assessement and documentation.

The surveyor conducted a face-to-face interview, with Employee #71, Patient Care Manager, on 04/08/19 at 11:45 AM, regarding the wound care assessments for Patient #111. She acknowledged the findings.

E. On Unit 2E Intermediate Care Unit (IMC), a review of the WOCN note dated 03/24/19 at 2:00 PM showed that Patient #101 had a Stage 2 pressure injury, on the sacrum extending to the bilateral buttock. On 03/26/19 at 11:00 AM, the WOCN documented that the bilateral buttock wound was moisture associated skin damage [MASD].

Review of the nursing assessment dated 03/28/19 at 8:00 AM showed the nurse described the bilateral buttock wound as a skin tear. On 04/04/19 the nurse documented the wound as a pressure ulcer.

The medical record lacked documented evidence that the nursing staff were skilled in wound assessment and characterization.

The surveyor conducted a face-to-face interview on 04/08/19 at 3:30 PM, with Employee #52, Clinical Specialist, regarding the annual education and competency provided to nursing staff. He stated that the nursing staff completes National Database of Nursing Quality Indicators (NDNQI) education on wound identification and staging, during onboarding. However, there is no annual training related to wounds.

The surveyor conducted a review of wound care education provided to nursing staff from unit 2G ICU. Out of 23 nurses, four had not completed the training at all. The other 19 nurses completed the training but there was no date indicated for completion. The surveyor was provided with the wound education for nursing staff on 2EIMC. Out of 12 nurses, three did not complete the NDNQI training. Two of those were float pool nurses. Five nurses have not had the training since 2016 or before; two completed the training in 2018; and two completed the training on 04/08/19, the day of the record review.

The surveyor conducted a face to face interview on 04/18/19 at 2:10 PM with Employee #7, Vice President of Nursing Excellence, #37 Director of Quality, and #36, Vice President of Quality and Safety, regarding wound care concerns. They acknowledged the findings.

F. Review of the medical record showed that Patient #152 was admitted on 04/10/19 with a "Head Medial" wound identified as a "pressure injury stage 2." On 04/10/19 through 04/12/19, the staff nurse documented that the wound was a pressure injury stage 2. On 04/13/19, the wound was described as "raised, pink scar-healed."

Review of the nursing assessments lacked documented evidence of measurements, of the head medial wound from 04/10/19 through 04/13/19. Additionally, there was no staging of the head medial wound on 04/13/19.

The practice lacked evidence that staff performed wound staging and measurements in accordance with hospital policy.

The surveyor conducted a face-to-face interview on 04/15/19 at 2:10 PM with Employee #76, Wound Ostomy Consult Nurse, and #52, Director of Wound Care, regarding the aforementioned findings. After reviewing the medical record, they acknowledged the findings.

The hospital's policy entitled, "Medication Administration" effective 01/16, shows that medications may be administered one hour before or one hour after scheduled dosing times and before administration of any type pf medications, verify: correct patient, correct medication, correct dose, correct route, correct time and correct frequency.

G. The surveyor conducted a medical record review for Patient #3 on 04/08/19, at approximately 2:30 PM, with Employee #125, Nursing Director and #126, Registered Nurse. The physician admitted Patient #3 with diagnoses to include Diabetes Mellitus and Hypertension.

The prescribed antihyprtensive medications that included Hydralazine 25 milligrams (mg) by mouth three times a day, and Metoprolol 75 mg three tabs a day. Both medications required the nursing staff to hold medication if the systolic blood pressure is less than 100 (millimeters of mercury) mmHg, and to call the physician.

A review of the electronic medication administration record (eMAR) revealed the medication was administered on on 04/06/19 at 10:00 PM, and 04/07/19 at 6:23 AM or 1:48 PM, The record lacked evidence nursng staff assessed blood pressure prior to medication administration.

The practice lacked evidence that the nursing staff checked the blood pressure to ensure the correct parameters for the administration of medications for blood pressure.

At the time of the finding, both Employees acknowledged the findings.


H. Patient # 4, admitted for Hypertension and Diabetes Mellitus.

Review of the medical record showed a physician order for blood glucose monitoring with correctional dose insulin coverage, three times a day.

Correctional dose insulin coverage for Finger Stick Blood Glucose (FSBG) was as follows: FSBG 150 milligrams per deciliter (mg/dl) to 199 mg/dl give one unit; 200 mg/dl to 249 mg/dl, give two units; 250 mg/dl to 299 mg/dl, give three units; 300 mg/dl to 349 mg/dl, give four units; greater than 349 mg/dl, give 5 units.

A review of Patient #4 electronic medication administration record (eMAR), showed that on 04/07/19 at 5:20 PM, her FSBG was 159 mg/dl, and the staff nurse administered one unit of Lispro low scale correctional insulin at 6:30 PM.

The practice lacked evidence that nursing staff administered correctional dose insulin coverage in a timely manner and in accordance with the hospital policy.


The surveyor conducted a face-to-face interview with Employees #127, Nursing Director, and #128, Registered Nurse, on 04/09/19 at approximately 11:00 AM. Both Employees acknowledged the findings.

I. Patient #112, admitted for Chronic Systolic Heart Failure and Diabetes Mellitus.

Review of the medical record showed a physician order for blood glucose monitoring with correctional dose insulin coverage, every six hours.

Correctional dose insulin coverage for Finger Stick Blood Glucose (FSBG) was as follows: FSBG 150 mg/dl to 199 mg/dl give one unit; 200 mg/dl to 249 mg/dl, give two units; 250 mg/dl to 299 mg/dl, give three units; 300 mg/dl to 349 mg/dl, give four units; greater than 349 mg/dl, give 5 units.

A review of the electronic medication administration record (eMAR) for Patient #112 showed that on 03/30/19 at 4:35 PM, her FSBG was 177, and the nurse administered one unit of Lispro correctional insulin at 6:00 PM.

On 03/31/19 at 11:45 AM, her FSBG was 169, one unit of insulin was administered at 12:55 PM; on 04/02/19 at 9:16 PM, her FSBG was 303, two units of insulin were administered at 10:39 PM: and on 04/06/19 at 12:27 PM, her FSBG was 258, three units of insulin were administered at 1:49 PM.

The practice lacked evidence that nursing staff administered the correct dose of insulin coverage, and administered insulin in a timely manner and in accordance with the hospital policy.

The surveyor conducted a face-to-face interview with Employees #125, Nursing Director, and #126, Registered Nurse, on 04/08/19 at approximately 2:00 PM. Both employees acknowledged the findings.

J. Patient #113, admitted for Wound care and Diabetes Mellitus.

Review of the medical record showed a physician order for blood glucose monitoring with correctional dose insulin coverage, three times a day.

Correctional dose insulin for Finger Stick Blood Glucose was as follows: FSBG 150 mg/dl to 199 mg/dl give one unit; 200 mg/dl to 249 mg/dl, give three units; 250 mg/dl to 299 mg/dl, give five units; 300 mg/dl to 349 mg/dl, give seven units; greater than 349 mg/dl, give eight units.

A review of the electronic medication administration record (eMAR) for Patient #113 showed that on 04/05/19 at 8:29 AM, his FSBG was 362 mg/dl, and the nurse administered seven units of Lispro medium scale correctional insulin at 10:53 AM; on 04/05/19 at 11:23 AM, her FSBG was 235, three units of insulin was administered at 1:54 PM.

The practice lacked evidence that nursing staff administered the correct dose of insulin coverage, and administered insulin in a timely manner.

The surveyor conducted a face-to-face interview with Employees #127, Registered Nurse (RN), and #128, RN, on 04/10/19 at approximately 11:45 AM. Both Employees acknowledged the findings.

K. Patient #114, admitted for Abdominal Pain and Diabetes Mellitus.

Review of the medical record showed a physician order for blood glucose monitoring with correctional dose insulin coverage, every six hours.

Correctional dose insulin coverage for Finger Stick Blood Glucose was as follows: FSBG 150 mg/dl to 199 mg/dl give one unit; 200 mg/dl to 249 mg/dl, give three units; 250 mg/dl to 299 mg/dl, give five units; 300 mg/dl to 349 mg/dl, give seven units; greater than 349 mg/dl, give eight units.

A review of the electronic medication administration record (eMAR) for Patient #114, showed that on 04/13/19 at 4:53 PM, her FSBG was 286 mg/dl, and the staff nurse administered five units of Lispro medium scale correctional insulin at 6:00 PM; on 04/15/19 at 7:07 AM, her FSBG was 240 mg/dl, three units of insulin was administered at 8:17 AM.

The practice lacked evidence that nursing staff administered correctional dose insulin coverage in a timely manner.

The surveyor conducted a face-to-face interview with Employees #125, Nursing Director, and #126, Registered Nurse, on 04/08/19, at approximately 2:00 PM. Both employees acknowledged the findings.

L. Patient #115, admitted for Congestive Heart Failure and Diabetes Mellitus.

Review of the medical record showed a physician order for blood glucose monitoring with correctional dose coverage, three times a day.

Correctional dose for Finger Stick Blood Glucose was as follows: FSBG 150 mg/dl to 199 mg/dl give zero unit; 200 mg/dl to 249 mg/dl, give two units; 250 mg/dl to 299 mg/dl, give three units; 300 to 349, give five units; greater than 349, give six units.

A review of Patient #115 electronic medication administration record (eMAR), showed that on 04/10//19 at 4:29 PM, his FSBG was 174 mg/dl, one unit of insulin was administered at 6:38 PM; on 04/10/19 at 8:53 PM, his FSBG was 202 mg/dl, one unit of insulin were administered at 11:02 PM: on 04/11/19 at 4:35 PM, his FSBG was 193 mg/dl, one unit of insulin was administered at 5:47 PM; and on 04/11/19 at 8:34 PM, his FSBG was 248, one unit of insulin was administered at 10:07 PM.

The practice lacked evidence that nursing staff administered the correct dose of insulin coverage, and administered insulin in a timely manner and in accordance with the hospital policy.


The surveyor conducted a face to face interview with Employees #72, Quality, #121, Registered Nurse, and #44 Director of Behavioral Health on 04/15/19 at approximately 11:35 AM. All employees acknowledged the findings at the time of the record review.

Based on the review of facility documents, Pyxis (Automated Dispensing Machine) [ADM]- Schedule II, III, IV, and V Controlled Substances Activity Report, physicians' orders, patient electronic Medication Administration Record (eMAR), in the presence of Employee #207, the hospital staff did not properly document the administration, wasting, or handling of controlled substances, Additionally, the staff failed to follow physician order and administered medication according to an unsigned order.


Findings included ...

On April 8, 2019, a seventy-two (72) hour report generated by the Facilities Pyxis Machine for controlled substances schedule II-V. The pharmacy staff created a report for all patients receiving a controlled substance from 10:00, April 7, 2019, through 10:00, April 10, 2019. The report was for patient care unit (PCU) 5 E, 2 K, 4 G, 2 C, 2 G, 2 H, 2 NE, 2 NW, 3 G, 4 H, ER (A and B), PACU, LDR and Endoscopy.

The surveyor randomly selected 40 patients for this audit from each unit and the patient's physician orders and electronic medication administration record (eMAR) for review. The surveyor completed the record review with the Pyxis printouts, patient charts and eMAR record review on April 18, 2019, at approximately 1:00 PM.

A. On April 8, 2019, at 09:55, the physician ordered Hydromorphone 1 mg (one milligram) intravenous push every 4 hours as needed for breakthrough pain for Patient # 7, on PCU 2 NE. On April 9, 2019, at 17:08, the nursing staff removed 2mg/ml (millimeter) Hydromorphone from the Pyxis, and 1mg hydromorphone administered to the patient. The wasting of 1mg of hydromorphone occurred one hour and fifty minutes after administration.

B. On April 9, 2019, at 22:00, the physician ordered Oxycodone ER 10 mg every twelve hours for Patient # 10, on PCU 2 NE. On April 10, 2019, at 08:40, the nursing staff removed Oxycodone ER 10mg from Pyxis; however, failed to administer the medication to the patient until 10:03. Over one hour late.

C. On April 8, 2019, at 08: 05, the physician ordered Lorazepam 0.5 mg one-time dose for Patient # 15, on PCU 2 H. The nursing staff administered the dose of Lorazepam at 08:05; however, the nursing staff wasted of the medication at 12:21; over 4 hours after administration.

On April 9, 2019, at 05:41, eMAR documentation showed that 50 micrograms of Fentanyl administered. However, the Pyxis records do not show that the nursing staff removed the Fentanyl injection.

D. On April 9, 2019, at 16:31 and 18:22, Patient # 32 on PCU 3G received one tablet Oxycodone IR 5 mg. The nursing staff administered the medication every two hours instead of every 4 hours as ordered by the physician.

Based on observation, record review, United States Public Health Service 2017, Section 4-501.112 Food Code review, and staff confirmation, the hospital staff failed to maintain dietary services in a safe and sanitary manner to ensure that the safety and well-being of patients and have a mechanism to ensure that foods were prepared and served in a safe and sanitary manner (A-0619); and the Director of Dietary Services failed to ensure safe and hygienic food handling practices, in compliance with state requirements for food service operation standards (A-0620).

The hospital lacked a policy to instruct dietary staff on proper sanitization when the dish machine fails to operate.

The cumulative effect of these systemic practices resulted in the hospital failure to comply with conditions of participation for Dietary Services.

Based on observation and staff confirmation during the survey, the dietary services were not adequate to ensure that foods were prepared and served in a safe and sanitary manner. The observations were in the presence of Employee #129, Director of Dietary Services, on 04/08/19 between 9:30 AM and 4:00 PM.

Findings included ...

1. During a tour of Cooler #0, a large container of carrots was not labeled and lacked an expiration date and use by date.

2. A large container of Eye Round Cooking oil, stored on a shelf in Cooler # 0, was not covered and unlabeled.

3. Three containers of chicken wings and mixed chicken parts were held beyond the use by date. The preparation date was 04/04/19; the use by date was 04/07/19.

4. Two containers of Salisbury steak, were held beyond the use by and expiration dates of 04/04/19.

5. Ceiling surfaces were soiled with dust, in front of eight compressor fans, located in Cooler #0.

6. The shelf surfaces of three carts, in the Produce Refrigerator, were soiled with food spillages; and floor surfaces were damaged and soiled at the entrance to the unit.

7. Floor tile surfaces at the entrance to the Walk in Freezer, were torn, damaged and separated from the floor; and floor surfaces were soiled with spillages, in Cooling Box #6.

8. Slices of bread were improperly disposed of, in a regular trash receptacle, near the Sandwich Preparation Area.

9. Floor surfaces were marred and soiled, in front of the steamer in the Main Kitchen.

10. A scoop used for dispensing rice, was improperly stored, in the bin.

11. Floor surfaces, in the Pot and Pan Wash Area, were marred, damaged and the paint was peeling; and floor surfaces in the Main Storage Room were soiled.

12. The shelf surfaces of racks in the Main Storage Room were soiled; paper products were on floor surfaces in the Caged Area; and sprinklers heads were soiled with dust.

13. Coffee cups were not thoroughly cleaned, during the washing cycle. Residual coffee stains were on the interior of coffee cups, in 16 of 48 instances.

14. The interior and bottom surfaces of cooking vessels, washed in the Pot and Pan Wash Area, were not thoroughly cleaned of food residue; 6 X 4 inch pans, in five of 10 observations, and 14 X 14 inch pans were soiled in eight of 10 observations.

15. Foods stored in the Grill Refrigeration Unit #55 were held above 41 degrees Fahrenheit in the following instances: Pickles -80 degrees; Tomatoes - 62 degrees; Cheddar Cheese - 48 degrees; Pepper Jack Cheese- 50 degrees; Uncooked Chicken and Uncooked Hamburger Meat -53 degrees.

16. In the Cafeteria Grill Area, the refrigeration unit was soiled with debris on the interior surfaces; cooking hood filters were soiled with dust and grease; sprinkler head surfaces were dusty; and ceiling tiles were soiled with dust and grease.

17. The following cold foods were stored above 41 degrees Fahrenheit in the Pizza Area: Shrimp - 55 degrees; Cheddar Cheese - 47 degrees; Parmesan Cheese - 48 degrees; Black Beans - 47 degrees; Chick Peas - 47 degrees; Celery - 43 degrees; Carrots - 54 degrees; Mushrooms - 44 degrees; Boiled Eggs - 42 degrees; and Cucumbers - 49 degrees.

18. The following cold food temperature were elevated above 41 degrees Fahrenheit, in the Sushi Area: Rice - 59 degrees; Tuna - 44 degrees, and Salmon - 45 degrees.

19. Doors and doorjamb surfaces were marred and scarred throughout the Dietary Department and supporting areas.

20. The following food temperatures were elevated, above 41 degrees Fahrenheit, in the Cafeteria Deli Bar: Swiss Cheese - 47 degrees; Provolone Cheese - 47 degrees; Pepper Jack Cheese - 48 degrees; American Cheese - 48 degrees; Guacamole - 47 degrees; Cucumbers - 44 degrees; Parmesan Cheese - 56 degrees; and Cheddar Cheese - 55 degrees.

21. The inner panels and areas below burners of deep fryers were soiled with grease and food deposit, in two of two observations, in the Main Kitchen.

The practice lacked evidence the Director of Dietary Services ensured that the organization of dietary services were met. Employee #129 acknowledged the findings.

Based on observation and staff confirmation, the Director of Dietary Services failed to ensure safe and hygienic food handling practices that were in compliance with state requirements for food service operation standards.

Findings included ...

A reviewof the Food Code, Food and Drug Admionistration (FDA), United States Public Healthe Service, 2017, Section 4-501.112 stipulates, the temperature of the fresh water sanitizing rinse, as it enters the manifold, should be 82 degrees Celsius (°C) or 180 degrees Fahrenheit (°F).

During tour of dietary services on 04/08/19 at approximately 9:30 AM, the surveyor observed that the rinse temperature of the dish machine was operating, during the rinse cycle, at 173 °F, which is below the required 180 °F temperature.

Between 3:00 PM and 3:30 PM, trays of soiled dishes were sent through the machine several times and the machine failed to reach the required 180°F temperature. The final rinse temperature remained between 173 and 175 °F.

Employee #129, Director of Dietary Services informed the surveyor that the machine would usually operate properly, after the machines water storage tank was drained and refilled. A third observation was made between 5:30 PM and 6:00 PM. Several trays of dishes were passed through the machine and the final rinse temperature remained between 173 and 175°F.

Employee #129 instructed staff to discontinue using the machine to clean soiled dishes, and use disposable ware; until the final rinse temperature issue was resolved. Log Sheets were requested for the month of April; however, the records were not readily available, for review at the initial time requested at 3:30 PM. The Daily Dish Machine Logs provided later in the evening revealed the final rinse temperature was below 180 °F, on 15 occasions during the month of March 2019 and on 10 occasions between the period of 04/01/19 through 04/08/19.

The practice lacked evidence that the Director of Dietary Services ensured effective, sustaining corrective measures, once it was determined final rinse temperatures repeatedly failed to meet minimum temperature requirements.

During a face-to-face interview with Employee #129, he acknowledged that the hospital lacked a corrective action plan or alternative plan to sanitize dishes, when the dish machine malfunctions. Documentation of corrective actions were not in place to address the issue.

Employees #129, 130, Chef Manager, and #150, Assistant Vice President of Facilities stated that the dietary staff would convert to manual washing of dishes via the 3-compartment sink on occasions that final rinse temperatures were inadequate. However, the leadership was not able to provide documented evidence of the corrective measures that were taken on each of the occurrences of inadequate final rinse temperatures.

The practice lacked evidence that the Director of Dietary Services ensured effective management of dietary services for safe and hygienic food handling practices.

1. Based on observations, interview, and a review of the MedStar Washington Hospital Center Energy Plant Generator/ATS (Automated Ttransfer Switch) Test Logs, the hour meters lacked a column to record in tenths of an hour, to verify that the generators are exercised for a full 30 minutes.

Findings included ...


Review of the National Fire Protection Association (NFPA) Standard for Emergency and Standby Power Systems, 2010 Edition, Section 8.4.2 showed that the generator should be exercised 30 minutes each month, under load, to ensure proper operation, in the event of an emergency.

According to Log sheets on 01/08/19, it was determined that the generator operated for 30 minutes in actual time, between 5:12 AM and 5:44 AM; however the hour meter failed to change to verify that the generator was operated under load for thirty minutes.

On 02/25/19, Generator #2, was operated between 5:13 AM and 5:45 AM; however the Hour Meter reading failed to change during the 15 minute interval and remained at a reading of 1827; which failed to verify the run time of an between 5:29 AM and 5:45 AM.

On 03/12/19 Generator #3, operated for 30 minutes in actual time; the hour meter indicated a reading of 1827 at 5:29 AM; at 5:40 AM the hour meter remained at 1828, and failed to verify the run time and the time of operation.

On 04/09/19 Generator # 4, operated for 30 minutes in actual time; the hour meter indicated a reading of 1829 at 5:09 AM, and at 5:25 AM; the Hour Meter was 1830 at the end of the exercise; the Hour Meter was at 1830, and failed to verify the actual run time in tenths of an hour.

The surveyor conducted a face to face interview on 04/17/19 at approximately 11:00 AM with Employees #152 Chief Facilities Engineer, and #150 Assistant Vice President of Operations regarding the generator tests. Both acknowledged the findings.


2. Based on observation during the survey, the housekeeping and maintenance services failed to ensure that the hospital was maintained in a safe and sanitary manner.

Findings included...

The following findings were observed, during an inspection conducted from 04/08/19 thru 04/18/19 in the presence of Employees # 132, Director of Safety, 133, Director of Engineering, and 150 Assistant Vice President of Operations.

1. The following findings were observed, during a tour throughout the hospital.

A. Emergency Department: Walls marred in rooms 4G6, 4G10, and 4G22, Fast Track Area, Green Team Pyxis Room, floor marred and soiled; Atrium entrance area, worn furniture. Dust accumulation in rooms 4G10, 4G12, 4G15, 4G6, 4G22, 4G21, 4D26, 4D30, 4D10, 4D2, laboratory room 1, Fast Track Bay 9, Rooms 16B, 12, and 10, heating ventilation air conditioning unit covers loose in rooms : 4D26, 4D30, 4D10, 4D2, Fast Track

B. Operating Room: soiled sterile processing, steam sterilizer area, Accumulated dust in Rooms 2, 3, and 21
C. Endoscopy Center: Accumulation of dust in Procedure Rooms
D. Water temperature below 105 º Fahrenheit /loose faucet in Fast Track, Scrub Sink outside room #21 and Cardiac catheterization Laboratory.

E. Exposed wires: Nursing Station in Fast Track area, room 109 in Emergency Department, main operating room #3.

F. Stretchers needing repair in Cardiac catheterization Laboratory room 6, Main operating room #2, Endoscopy Suite, Bay #10 Emergency Department.


2. The following was observed during a tour of the MedStar Emergency Department:

A. Room 2105: clogged sink.

B. Diamond plate walkway on the outside of the hospital not secured with screws.

C. Soiled stretchers stored on the grounds outside of the hospital.

D. Floors soiled, cracked, and damaged, in the storage and control rooms.

E. X-ray Room 2: spoiled stretcher.

F. Day Room #3: damaged venetian blinds.
G. Laminated cover front of the nursing station damaged.

H. Upper portion of one medical gas container cracked.

I. Walls marred in staff break room.

J. Clean linen room faucet leaks, and the linen cart not covered.

K. Soiled utility room: Hopper Sink leaks and floor soiled

L. Bay #5 floor soiled.

Based on observation, record review, policy review, and staff interviews, the hospital staff failed to consistently implement infection control measures in accordance with accepted standards of practice as it relates to donning and doffing personal protective equipment (PPE) and wound treatment practices to ensure infection prevention (A-0749); and the hospital leadership failed to implement successful and sustaining corrective measures when it was determined that the dish machine repeatedly failed to reach minimum acceptable temperatures to ensure sanitization of dishware as to promote infection prevention (A-0756).

The cumulative effect of these systemic practices resulted in the hospital's failure to comply with conditions of participation for Infection Control.

Based on observation and staff interview, the hospital staff failed to ensure that staff followed acceptable standards related to donning and doffing personal protective equipment (PPE), as to prevent the spread of infection four of nine observations. (Patient #54, 55, and 56)

Findings included...

1. Review of The Center for Disease Control and Prevention's guidance, "Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Setting," showed that standard precautions include a group of infection prevention practices that apply to all patients, regardless of suspected or confirmed infection status, in any setting in which healthcare is delivered. These include hand hygiene, and use of gowns, gloves and mask. Healthcare personnel, caring for patients on Droplet Precautions wear gown, gloves and mask, for all interactions that may involve contact with the patient. Donning PPE (Personal Protective Equipment) upon room entry and discarding before exiting the patient room is done to contain pathogens; the following sequence to apply Personal Protective Equipment (PPE), "...1. Gown ...2. Mask or respirator ...3.Googles or face shield ...4. Gloves ..."
https://www.cdc.gov/hai/pdfs/ppe/PPE-Sequence.pdf

Record review of the hospital's policy titled, "Standard Precautions," dated 03/20/19, showed the sequence for staff to don PPE as follows: gown, mask or respirator, goggles or face shield, and gloves.

During a tour of the Emergency Department on 04/10/19 at approximately 2:30 PM, with Employee #197, Clinical Manager, the surveyor observed Employee #205, Physician, exiting, Patient #155's room (who was on droplet precautions). He exited the room, with his mask under his chin, talking on a cell phone, without sanitizing his hands. Upon re-entering the patient's room, he proceeded to don the contaminated mask over his nose, and proceeded to examine the patient, without sanitizing his hands.

During a face-to-face interview on 04/10/19 at approximately 3:38 PM, the surveyor queried Employee #197 regarding the practice. She explained the physician should have removed his mask, and sanitized before and after exiting the patient's room.

The practice failed to demonstrate that the physician followed acceptable standards of infection prevention practices.

Employees' #197, Clinical Manager and #195, Clinical Specialist, acknowledged the findings at the time of the observation. Employee #197, further stated the physician was a "contracting physician."

2. During a tour of the 3NW unit on 04/17/19 at approximately 3:35 PM, with Employee #49, Clinical Specialist, the surveyor observed Employee #58, Occupational Therapist, exiting Patient #55's room (who was on droplet precautions), with her mask in place. When she saw the surveyor, she sanitized her hands, removed the mask, and discarded it three doors down the hallway, in the trash can in Patient #56's room (who received a Heartmate 3 Implant on 04/02/19).

During a face-to-face interview on 04/17/19 at approximately 3:38 PM, the surveyor queried Employee #58, regarding the practice. She explained the patient was on droplet isolation and she was not exiting the room, without wearing the mask. When queried regarding the hospital's policy and acceptable standards of practice, she reiterated her statement, and further explained that she discarded the mask in the other patient's room because she did not cross the patient's curtain, so she was not considered in the room.

The practice failed to demonstrate that the occupational therapist followed acceptable standards, infection prevention practices, or the hospital's policy.

Employees #49 and 58 acknowledged the findings.

3. On 04/09/19 at approximately 11:30 AM the surveyor conducted a tour of unit 4G Intermediate Care Unit. The surveyor observed Employee #181, Nutrition Services, prepare to enter a room of a patient on Droplet precautions. She donned the mask and entered the room, she exited the room without removing her mask and without sanitizing her hands. Employee #181 then retrieved another lunch tray from the cart in the hallway, and entered the next patient room wearing a mask.

The practice lacked evidence that dietary staff prevented the spread of infection.

The surveyor conducted a face to face interview on 04/09/19 at 11:40AM, with Employee #181, regarding infection control practices. She stated that she didn't know she had to remove her mask. She acknowledged the findings.

4. During a tour of the 3NW unit on 04/17/19 at approximately 3:30 PM, with Employee #49, Clinical Specialist, the surveyor observed Employee #54, Registered Nurse, apply his gloves before applying his mask, to enter Patient #54's room, who was on droplet precautions.

The practice failed to demonstrate that nursing staff followed acceptable standards, infection prevention practices, or the hospital's policy.

Employee #49 acknowledged the findings.


34093

Based on observation, policy review, standards of care review, and staff interview, the nursing staff failed to follow standards of care and the hospital policy, related to left ventricular assistive device (LVAD) driveline exit site care, in one of one observation (Patient #54).

Findings included...

Record review of the hospital's policy titled, "MCS [Mechanical Circulatory Support] Driveline Exit Site Care," dated 05/11/18, showed that during the sterile procedure, staff are to close the door; discard the old dressing and donned gloves; re-wash hands and don sterile gloves and a gown; prior to disinfecting the driveline exit site.

Review of the Centers for Disease Control and Prevention (CDC)'s recommendations for hand hygiene, showed that hands are to be washed for at least 15 seconds.
https://www.cdc.gov/handhygiene/providers/index.html

Review of the CDC's recommendations for the use of Personal Protective Equipment (PPE), showed the gowns are to be fastened in the back of the neck and waist.
https://www.cdc.gov/hai/pdfs/ppe/PPE-Sequence.pdf

Review of Patient #54's medical record on 04/17/19 at approximately 9:30 AM, revealed the patient underwent Heartware Ventricular Assistive Device placement, for which the physician ordered driveline exit site care Monday, Wednesday, and Friday, starting 03/18/19 at 3:01 PM.

During the dressing change on 04/17/19 at approximately 3:40 PM, Employee #54, Registered Nurse, performed the exit site care. He failed to close the door, prior to the dressing change; and he failed to change his gloves, after removing the old dressing, prior to cleaning the site. When Employee #54 removed the gloves, he only washed his hands for seven seconds, and proceeded to don his gown, leaving it open at the neck and waist. Employee #49, Clinical Specialist, offered assistance to close the gown and fastened it at the waist; however, the neck was left unfastened.

The practice lacked evidence that the nursing staff followed the hospital's drive line exit site procedure to ensure proper dressing changes, or that the nursing staff followed acceptable infection control standards for hand hygiene and the use of PPE to prevent the spread of infection.

During a face to face interview with Employee #49 on 04/17/19 at approximately 4:30 PM, she acknowledged the findings.




35226

Based on observation, policy review, standards of care review, and staff interview, the hospital leadership failed to implement successful and sustaining corrective actions and/or evidence thereof, to promote continuous infection prevention practices when it was determined that the dishwashing sanitizing rinse temperatures failed to meet minimum standards to ensure dishes were sanitized adequately.

Findings included ...

Based on observation, record review, United States Public Health Service (FDA) 2017, Section 4-501.112 Food Code review, and staff confirmation, the hospital staff failed to maintain dietary services in a safe and sanitary manner to ensure that the safety and well-being of patients and have a mechanism to ensure that foods were prepared and served in a safe and sanitary manner (A-0619); and the Director of Dietary Services failed to ensure safe and hygienic food handling practices, in compliance with state requirements for food service operation standards (A-0620).

The cumulative effect of these systemic practices resulted in the hospital failure to comply with conditions of participation for Dietary Services.

During tour of dietary services on 04/08/19 at approximately 9:30 AM, the surveyor observed that the rinse temperature of the dish machine was operating, during the rinse cycle, at 173 °F, which is below the required 180 °F temperature. Between 3:00 PM and 3:30 PM, trays of soiled dishes were sent through the machine several times and the machine failed to reach the required 180°F temperature. The final rinse temperature remained between 173 and 175 °F.

Employee #129, Director of Dietary Services, informed the surveyor that the machine would usually operate properly, after the machines water storage tank was drained and refilled. A third observation was made between 5:30 PM and 6:00 PM. Several trays of dishes were passed through the machine and the final rinse temperature remained between 173 and 175°F.

Employee #129 instructed staff to discontinue using the machine to clean soiled dishes, and use disposable ware; until the final rinse temperature issue was resolved. Log Sheets were requested for the month of April; however, the records were not readily available, for review at the initial time requested at 3:30 PM. The Daily Dish Machine Logs provided later in the evening revealed the final rinse temperature was below 180 °F, on 15 occasions during the month of March 2019 and on 10 occasions between the period of 04/01/19 and 04/08/19.

The practice lacked evidence that the Director of Dietary Services ensured effective, successful corrective measures, once it was determined final rinse temperatures repeatedly failed to meet minimum temperature requirements.

During a face-to-face interview with Employee #129, he acknowledged that the hospital lacked a corrective action plan or alternative plan to sanitize dishes, when the dish machine malfunctions. Documentation of corrective actions were not in place to address the issue.

Employees #129, #130, Chef Manager, and #150, Assistant Vice President of Facilities stated that the dietary staff would convert to manual washing of dishes via the 3-compartment sink on occasions that final rinse temperatures were inadequate. However, the leadership was not able to provide documented evidence of the corrective measures that were taken on each of the occurrences of inadequate final rinse temperatures.

The surveyor conducted a face-to-face interview with Employees #36, Vice President of Quality and #210, Director of Infection Control, on 04/18/19 at approximately 1:10 PM, regarding the failure of the dietary staff to maintain the dish machine at an acceptable final rinse temperatures to sanitize the china/dishware and utensils. Employee #210 stated she was not aware that the dishwasher machine was malfunctioning. The infection control department does not oversee dietary services. Employee #36, further stated, there had been a transition of vendors in mid- December, and new leadership for support services. The support services leadership did not convey the findings to the infection control staff or quality assurance performance staff.

Based on observations, medical record and policy review, and staff interviews, it was determined that the hospital failed: ensure the organization of respiratory care services was appropriate to the scope and complexity of the services offered(1152); failed to ensure adequate numbers of respiratory therapists were available to meet the needs of patients (1154); failed to ensure respiratory services were delivered, in accordance with medical staff directives (1160); and failed to ensure all respiratory care services orders were documented, in the patient's medical record, in accordance with the requirements (1164).

The cumulative effect of these systemic practices resulted in the hospital's failure to comply with conditions of participation for Respiratory Services.

1. Based on medical record review, staffing review, respiratory treatment care report review, respiratory record review, and staff interview, the hospital failed to ensure respiratory staff and other qualified staff, to include nursing, provided respiratory services relative to the scope and complexity of patient care needs, in 51 of 114 patients with confirmed missed respiratory treatments.

Findings included...

The surveyor conducted respiratory personnel staffing review on 04/12/19 at approximately 11:30 AM. Review the staffing matrix showed the required number of staff for scheduled treatments from 04/03/19 to 04/11/19:

04/03/19 - day shift staffing required per staffing matrix is 21.5 therapist, available staff 19, actual staff members 15.

04/03/19 -night shift Staff required 20, available staff 14, Actual staff 14.

04/04/19 - day shift staff required 21.57, staff available is 17, actual staff 16.

04/04/19 - night shift staff required is 18, available staff 17, actual staff 17.

04/05/19 - day shift required staff 21.4, available staff 18, actual staff 16.

04/05/19 - night shift, total staff required 19.8, available staff 16, actual staff 16.

04/06/19 - day shift - required staff, 21.2, available staff 16, actual staff 16.

04/06/19 - night shift - required staff 17.4, available staff 11, actual staff 12.

04/07/19 - day shift - required staff 20, available staff 11, actual staff 10.

04/07/19 - night shift - required staff 18, available staff 15, actual staff 15.

04/08/19 - day shift - required staff 19.5, available staff 16, actual staff 16.

04/08/19 - night shift - required staff 18.3, available staff 12, actual staff 12.

04/09/19 - day shift - required staff 20, available staff 19, actual staff 17.

04/09/19 - night shift - required staff 17.9, available staff 13, actual staff 9 from 7:00 PM to 11:00 PM, and 11 from 11:00 PM to 7:00 AM.

04/10/19 -day shift - required staff 19.9, Available staff 18, actual staff 15.

04/10/19 - night shift - required staff 18.5, available staff 15, actual staff 15 until 9:30 PM, 16 from 9:30 PM.

04/11/19- day shift - required staff 23, available staff 21, actual staff 19.

04/11/19 - night shift required staff 20.6, 14 available staff, actual staff 14.

The practice lacked evidence that the hospital provided adequate respiratory staffing to furnish the respiratory services to meet the patient's needs. Additionally, there was no documented evidence that the nursing staff administered respiratory care treatments.

The surveyor conducted a face-to-face interview on 4/11/19 at approximately 4:00 PM with Employee #12, Vice President of Operation, and #40, Director of Respiratory Therapy, regarding the inadequate staffing according to the department-staffing matrix. Employee #40 stated that the department currently has 89 positions; however, only 82.5 are staffed and 6.5 are vacant. Additionally, they utilize a "PRN" (as needed), staffing pool. Employee #12 stated, they are "recruiting heavily for new graduates and consulting with Human Resources every week regarding the application process."

Employees #12 and #40 acknowledged the findings at the time of the interview.


2. Based on medical record review, policy review and staff interview, the governing body failed to ensure that the Pulmonary Services responsible for Respiratory Therapy (RT) services policies and guidelines, included directives to notify the medical staff when the respiratory therapy staff failed to administer medications and complete respiratory treatments as ordered.

Findings included ...

Review of the hospital's policies titled "General Treatment Guidelines," revised 04/02/19; "Staff Responsibilities in General Care "dated 08/0316 and "Respiratory Protocols" presented by Employee #40, Director of Respiratory Service on 04/11/19, showed no evidence for the RT to notify the medical staff for missed medications and treatments.

The surveyors reviewed 51 of 114 medical records on 04/11/19 because of missed respiratory treatments noted during unit rounds on 04/8/19 to 04/10/19 and later from a list of missed respiratory therapies provided by the hospital regulatory, and QAPI (Quality Assurance Performance Improvement) staff.

Further review showed 39 of 51 patients missed respiratory treatments without documentation in the medical record of medical staff notification.


The current guidelines, policies, and protocols lacked directives to notify the medical staff when the respiratory therapy staff failed to administer medications and complete respiratory treatments as ordered.

The surveyors conducted face-to-face interviews on 04/11/19 at approximately 5:00 PM with the hospital administrative staff to include Employee #3, Sr. Vice President (VP) of Medical Affairs/Chief Medical Officer, Employee #7, VP Nursing Excellence, Employee #12, VP of Operations, Employee #37 Director of Quality, Employee#38, Directory of Regulatory Readiness, and Employee #40, Respiratory Therapy Director.

The findings relative to missed medications and respiratory treatment presented to the hospital staff. The staff discussed and acknowledged the findings.

Based on medical record review, staffing review, respiratory treatment care report review, respiratory record review, and staff interview, the hospital leadership failed to provide sufficient personnel available to respond to the respiratory care needs of the patient population, for 114 patients from 04/03/19 to 04/11/19.

Findings included ...

Review of the staffing for 04/03/19, during the day shift, revealed the required staffing, based on the matrix was 21.5 respiratory therapists. Actual staffing for that day was 15 therapists. Patient #1 was scheduled for Duoneb (Albuterol-Ipratropium) treatments every four hours on 04/03/19. The 4:00 PM dose was missed, and the patient's oxygen saturation decreased from 92% (percent) to 80% at 4:57 PM.

Review of staffing for 04/07/19, day shift, showed that the required staffing based on the staffing matrix was 20 therapists, actual staffing was 10 therapists. Patient #2 was scheduled for twice a day Budesonide - Formoterol metered-dose inhaler. The 8:00 PM dose was missed on 04/06/19 and on 04/07/19 the 8:00 AM dose was missed, and subsequently the patient suffered respiratory distress at 9:47 AM.

Additional findings revealed the following inadequate staffing provided to service the respiratory needs of 114 patients, during 04/03/19 to 04/11/19:

4/3/19 Day Shift Total staffing required per staffing matrix 21.5 therapist, Available staff 19 staff members. Actual staff members present for day shift 15.

04/03/19 - Staff required 20, available staff 14 , Actual staff 14.

04/04/19 - Day shift staff required 21.57, staff available is 17 , actual staff 16.

04/04/19 - night shift staff required is 18, available staff 17, actual staff 17.

04/05/19 - day shift required staff 21.4, available staff 18, actual staff 16.

04/05/19 - night shift, total staff required 19.8, available staff 16, actual staff 16.

04/06/19 - day shift - required staff, 21.2, available staff 16, actual staff 16.

04/06/19 - night shift - required staff 17.4, available staff 11, actual staff 12.

04/07/19 - day shift - required staff 20, available staff 11, actual staff 10.

04/07/19 - night shift - required staff 18, available staff 15, actual staff 15.

04/08/19 - day shift - required staff 19.5, available staff 16, actual staff 16.

04/08/19 - night shift - required staff 18.3, available staff 12, actual staff 12.

04/09/19 - day shift - required staff 20, available staff 19, actual staff 17.

04/09/19 - night shift - required staff 17.9, available staff 13, actual staff 9 from 7:00 PM to 11:00 PM, and 11 from 11:00 PM to 7:00 AM..

04/10/19 - day shift - required staff 19.9, Available staff 18, actual staff 15.

04/10/19 - night shift - required staff 18.5, available staff 15, actual staff 15 until 9:30 PM, 16 from 9:30 PM to 7:00 AM.

04/11/19 - day shift - required staff 23, available staff 21, actual staff 19.

04/11/19 - night shift required staff 20.6, 14 available staff, actual staff 14.


The practice lacked evidence that the hospital leadership ensured sufficient staff was available to respond to the respiratory needs of the patient population being served.

The surveyor conducted a face to face interview on 04/10/19 at 11:30 AM with Employee #84, Respiratory Therapist (RT). The surveyor asked the reasons why treatments are missed, he stated that they are really short staffed and sometimes they just aren't able to get to all of the patients.

The surveyor conducted an interview on 04/11/19 at 1:10 PM with Employee #41, Respiratory Therapist, regarding missed doses of respiratory medications. She stated that when an RT documents schedule conflict, it may indicate that there are multiple medications due for different patients at the same time. She went on to say that for the last six months, the Respiratory Department has been working short.

The surveyor conducted a face to face interview on 04/11/19 at 3:15 PM with Employee #40, Director of Respiratory Therapy, regarding missed doses of medication and staffing concerns, he acknowledged the findings.

Employees #84, 41, and 40, acknowledged the findings at the time of the interview.

Based on medical record review, policy review, respiratory treatment care report review, and staff interviews, the respiratory staff failed to meet the needs of patients in accordance with acceptable standards of practice as evidenced by failure to administer respiratory medications, in accordance with physicians orders, in 39 of 51 patient records reviewed (Patients #1, 2, 74, 75, 76, 77, 78, 79, 80, 50, 91, 92, 93, 94, 95, 96, 97, 98, 99, 100, 101, 102, 103, 105, 105, 14, 88, 105, 159, 141, 154, 130, 133, 135, 139, 140, 144, 155, and 151).

An Immediate Jeopardy (IJ) was identified on 04/12/19 at 3:00 PM under Respiratory Services - Code of Federal Regulations (CFR) 482.57 (A1151) - Failure to meet the needs of patients in accordance with acceptable standards of practice.

The hospital's Governing Body provided a removal action plan and compliance was determined on 04/23/19.

Findings included ...

Review of the hospital policy titled, "General Treatment Guidelines," revised 04/02/19, showed that respiratory therapy staff administering medications are responsible for drug knowledge, dosages, actions, side effects and interventions for medication administration. "The plan of care should be updated as goals are met or problems change." They are to perform and document breath sound assessments pre and post therapy, with each treatment.

Record review revealed two of 51 patients did not receive respiratory medications and/or treatments as prescribed, sustained a decline in physical status as evidenced by:

The surveyor reviewed the medical record for Patient #1 on 04/11/19 at approximately 10:15 AM with Employee #195, Registered Nurse. The physician admitted Patient #1 with a diagnosis of Chronic Obstructive Pulmonary Disease to the Intensive Care Unit for the management of worsening chronic hypoxic respiratory failure on 04/01/19. The patient was admitted with High Flow oxygen via nasal cannula and ordered Albuterol-Ipratropium (medicine used to open up the air passages in the lungs) 2.5 milligram (mg) via nebulizer every four hours. On 04/03/19 at 4:00 PM, Employee #199, Respiratory Therapist , note on the electronic medical record "not given" for Albuterol nebulizer treatment.

On 04/03/19 at 6:45 PM, Employee #200, Respiratory Therapist, progress note shows "Patient became cyanotic in hands and face, less interactive starting off with questioning ...bagged by RT then returned to oxy mask ..." Addendum by Employee # 200 on 04/03/19 at 8:06 PM states " ...patient was noted to have purplish lips, dusky and modeled fingers, while on high flow nasal cannula, sat [saturation] probe placed in his nose and the sat reading was 80, patient bagged and o2 sats [oxygen saturation] came up to 89%..."

The practice lacked evidence that the respiratory therapist administered respiratory medications as ordered by the medical staff.

The surveyor conducted a face to face interview with Employee #195 Registered Nurse on 04/11/19 at 11:00 AM, who acknowledged the findings.

Patient #2 was admitted with reports of shortness of breath. Review of the history and physical showed that he had a past medical history of Chronic Obstructive Pulmonary Disease (COPD).

Review of the physician orders dated 04/06/19 at 8:00 PM showed that a Budesonide-Formoterol ( medicine used to open up the air passages in the lungs) Metered Dose Inhaler (MDI- A metered dose inhaler is a small device that delivers a measured amount of medication to your lungs), was ordered twice a day. Review of the medication administration record showed that on 04/06/19 at 8:00 PM the dose was not given; the reason given was "schedule conflict." On 04/07/19 at 8:00 AM, the MDI was not administered; the reason given was "schedule conflict."

Review of a list of patients who experienced rapid response showed that a Rapid Response was called on Patient #2, for increased heart rate, on 04/07/19 at 9:47 AM, one hour and 47 minutes after the last missed MDI treatment.

On 4/10/19 at approximately 1:00 PM, the hospital provided the surveyors with a list of patients by unit, with orders for respiratory treatments. On 04/11/19 at 12:00 PM, the hospital provided the surveyors with a list of patients from 04/03/19 to 04/11/19, that missed hospital treatments. The list of patients with missed treatments totaled 114.

Review of patient medication administration records (MAR), randomly chosen during tour and from lists provided, showed that out of 51 patient records reviewed, 39 patients missed respiratory treatments:

Patients #2, 104, 97, 89, 14, 154, 130, 133, 135, and 151 missed a combined total of 19 MDI treatments.

Patients #103, 94, 101, 96, 102, 100, 98, 97, 92, 95, 91, 93, 99, 1, 14, 105, 74, 75, 76, 77, 78, 79, 80, 141, 139, 140, 144, and 145 missed a combined total of 125 nebulization aerosol treatments.

Patients #97, 98, 88, 76, 80, 141, and 155 missed a combined total of 34 chest physiotherapy treatments.

Patients #104, 62, and 50 did not have pre and post treatment assessments performed, in 19 opportunities.

Continued review of the MAR showed that reasons documented by respiratory therapists for missed medications included "scheduling conflict", "not done with another patient". Additionally, the medical record lacked evidence that RT's notified nursing staff, or physicians that ordered medications were not given.

The surveyor conducted a face to face interview on 04/10/19 at 11:30 AM with Employee #84, Respiratory Therapist (RT). The surveyor asked the reasons why treatments are missed, he stated that they are really short staffed and sometimes they just aren't able to get to all of the patients.

The surveyor conducted an interview on 04/11/19 at 1:10 PM with Employee #41, Respiratory Therapist, regarding missed doses of respiratory medications. She stated that when an RT documents schedule conflict, it may indicate that there are multiple medications due for different patients at the same time. She went on to say that for the last six months, the Respiratory Department has been working short.

The surveyor conducted a face to face interview on 04/11/19 at 3:15 PM with Employee #40, Director of Respiratory Therapy, regarding missed doses of medication and staffing concerns, he acknowledged the findings.

Based on medical record review, respiratory treatment care report review, respiratory record review, and staff interview, the respiratory therapy (RT) staff failed to document medical staff notification, when nebulization medications, chest physiotherapy, and metered dose inhalers not administered as ordered, for 51 of 114 patients with confirmed missed respiratory treatments (Patients #1, 2, 74, 75, 76, 77, 78, 79, 80, 50, 91, 92, 93, 94, 95, 96, 97, 98, 99, 100, 101, 102, 103, 105, 105, 14, 88, 105, 159, 141, 154, 130, 133, 135, 139, 140, 144, 155, and 151).

Findings included ...

Review of the hospital policy titled, "General Treatment Guidelines," revised 04/02/19, showed, "The plan of care should be updated as goals are met or problems change."

On 04/11/19 at 12:00 PM, the hospital provided the surveyors with a list of patients from 04/03/19 to 04/11/19 that missed respiratory treatments. The list of patients with missed treatments totaled 114.

The surveyors reviewed 51 randomly selected patient records from the list provided and from the unit tour. The record review showed that the respiratory therapy staff failed to provide documented evidence of medical staff notification following missed respiratory treatments. The record review included the electronic Medication Administration Record (eMAR).

The record review showed that out of 51 patient records reviewed, 39 patients missed respiratory treatments:

Patients #2, 104, 97, 89, 14, 154, 130, 133, 135, and 151 missed a combined total of 19 MDI treatments.

Patients #103, 94, 101, 96, 102, 100, 98, 97, 92, 95, 91, 93, 99, 1, 14, 105, 74, 75, 76, 77, 78, 79, 80, 141, 139, 140, 144, and 145 missed a combined total of 125 nebulization aerosol treatments.

Patients #97, 98, 88, 76, 80, 141, and 155 missed a combined total of 34 chest physiotherapy treatments.

Patients #104, 62, and 50 did not have pre and post treatment assessments performed, in 19 opportunities.

Continued review of the MAR showed that reasons documented by respiratory therapists for missed medications included "scheduling conflict", "not done with another patient", "medication not available in pharmacy".

The medical record showed no evidence that respiratory staff documented medical staff notification to allow medical providers to make the appropriate decisions related to the provision of care for the patients.

The practice lacked evidence that respiratory therapy staff documented medical staff notification, for missed medications and treatments, to ensure appropriate plans of care.

The surveyors conducted a face-to-face interview with Employee #124, Respiratory Supervisor on 04/11/19 at approximately 2:50 PM. Employee #124 stated that she compiles a monthly report relative to respiratory audits to include missed respiratory treatments. She completes the report in percentages and not detailed information regarding the total number of missed treatments. The employee said she shares the information with the director for respiratory, and the director shares the information with the administrative staff responsible for respiratory services.

The surveyors conducted a face-to-face interview on 04/11/19 approximately 3:15 PM with Employee #40, Director of Respiratory Services regarding the missed dosed of medication and failure of the RT not notifying the medical staff when RT failed to administer the medication. The Director acknowledged the findings and confirmed the respiratory monthly percentage report to include missed respiratory treatments. .

The surveyor questioned the Director regarding staffing affecting missed treatments. The Director stated that "6.5 full-time positions are vacant. Supplemental staff utilized through "PRN" (as needed) staffing pool in the hospital and the staffing schedules were completed six weeks in advance; therefore, we have time to fill any vacancies.."