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Based on observation during the survey walk-through, staff interview, and document review during the Life Safety code portion of the Full Survey Due to a Complaint conducted August 28-29 2023, the surveyors find that the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags.

Based on observation, document review and interview, it was determined that the hospital failed to comply with the Condition of Participation, 42 CFR 482.42, Infection Prevention Control Antibiotic Stewardship.

Findings include:

1. The hospital failed to ensure the decontamination room contained appropriate sink access and adequate equipment availability to decontaminate instruments and for staff to perform hand hygiene to prevent cross-contamination. See deficiency A-749.

2. The hospital failed to ensure staff performed hand hygiene as required for isolation precautions. See deficiency A-750 A.

3. The hospital failed to ensure that respiratory equipment was changed as scheduled, in accordance with hospital policy prevent the spread of infection. See deficiency A-750 B.

4. The hospital failed to ensure that tube-feeding set (tubing) was changed every 24 hours to prevent bacteria growth, as required. See deficiency A-750 C.

5. The hospital failed to ensure that the biological indicators were completed and documented weekly to determine whether sterilization parameters were met for the sterilization of surgical instuments. See deficiency A-750 D.

6. The hospital failed to ensure that quality control tests were performed and documented for the steam sterlizer, according to manufacturer's instructions. See deficiency A-750 E.

7. The Hospital failed to ensure that visitors wore the appropriate personal protective equipment (PPE) in isolation rooms, in order to prevent cross-contamination of antibiotic-resistant organisms. See deficiency A-750 F.

8. The hospital failed to ensure the staff sanitized equipment in accordance with hospital policy and manufacturer's guidelines. See deficiency A-776.

Based on document review and interview, it was determined that for 3 of 4 (Pt #1, Pt #9, Pt #10) clinical records reviewed for patient rights, the Hospital failed to ensure that the Release of Information form was completed and documented in accordance with policy.

Findings include:

1. The Hospital's policy titled, "Processing of Protected health Information Requests & Maintaining the HIPAA Privacy File", dated 8/2021, was reviewed, and required, " ...The Hospital will respond to all requests for a patient's health information within specified federal and state regulations. Procedure:1. Responding to Requests for PHI. The Hospital employee should provide the appropriate request form. Upon receiving a completed request for, the request is logged into the ROI [Release of Information] web-based application and the request document is scanned to the request ..."

2. The clinical record for Pt #1 was reviewed on 8/28/2023. Pt. #1 was transferred from [another Hospital]'s ED (emergency department) and was admitted to 3 West (adult co-ed behavioral health unit), on 11/14/2022. Pt #1 was discharged on 11/28/2022.

-Pt #1's "Authorization to Disclose/Obtain Information" (Release of Information form), was reviewed. The form was signed by the patient; however, there was no designated person or entity identified who to disclose or release information to (unmarked/left blank). The form required should either be marked as non-applicable or indicate the parties/entity in which information should be disclosed to or obtained from.

3. The clinical record for Pt #9 was reviewed on 8/28/2023. Pt #9 was admitted to the 3 West Adult Behavioral Health Unit on 8/19/2023. Pt #9's clinical record was reviewed with the Director of Behavioral Health (EM #14). The record lacked a Release of Information form. EM #14 acknowledged that the clinical record lacked the required form.

4. The clinical record for Pt #10 was reviewed on 8/28/2023. Pt #10 was admitted to the 3 West Adult Behavioral Health Unit on 8/26/2023. Pt #10's clinical record was reviewed with EM #14. The record lacked a Release of Information form. EM #14 acknowledged that the clinical record lacked the required form.

5. On 8/28/2023 at 10:30 AM, an interview was conducted with a 3 West Charge Registered Nurse (EM #5). EM #5 stated that a Release of Information form is required to be completed upon admission. EM #5 stated that this is required if a patient's family member calls and requests information, the staff would know who to disclose information to. EM #5 stated that this is important to protect the patient's HIPAA rights.

Based on document review and interview, it was determined that for 1 of 2 patients' records (Pt. #42) reviewed for non-violent restraints, the Hospital failed to ensure that orders were renewed as required by hospital policy.

Findings include:

1. The Hospital's policy titled, "Physical Restraints (Violent and Non-Violent Behavior) and Seclusion" (dated 06/2023), was reviewed and required, "A physician or LP [licensed practitioner] order for Non-violent restraint use may not exceed seven (7) calendar days following the calendar day the order was obtained. The patient must be assessed at least daily by an RN [registered nurse] to determine if the restraints may be removed..."

2. The clinical record of Pt. #42 was reviewed on 8/28/2023. Pt. #42 was admitted on 6/28/2023, with a diagnosis of acute and chronic respiratory failure. Physician's orders for left soft limb (wrist) restraints were ordered on 7/10/2023 (order expired Day 7 = 7/16/2023) and 7/20/2023 (ordered expired Day 7 = 7/26/2023), with the next restraint renewal on 8/1/2023 (12 days later - changed type of restraints to bilateral wrists). Restraint flowsheets indicated that Pt. #42 was in restraints on 7/17/2023, 7/18/2023, and 7/27/2023-7/31/2023 (5 days) without a renewed order, and flowsheets did not include the type of restraints used.

3. An interview was conducted with the Nursing Supervisor (EN#13) on 8/28/2023, at approximately 2:30 PM. EN#13 stated that non-violent restraint orders should be renewed every 7 days. EN#13 confirmed there were no renewal orders in Pt. #42's chart to account for the missing days. EN#13 stated that the flowsheet does not include a space to write down the type of restraints used and stated, "I hope they used what was ordered, but we aren't sure since it's not documented."

A. Based on observation, document review, and interview, it was determined that for 1 of 2 patients (Pt. #26) observed for turning and repositioning, the hospital failed to ensure that the patient was turned and repositioned every hour, in accordance with hospital policy.

Findings include:

1. On 08/29/2023 between 9:30 AM - 12:40 PM, an observational tour of the 3rd floor -medical surgical unit was conducted. During the tour the following was observed:

- At 9:35 AM, Pt. #26 in room #310, bedridden on an air mattress with sacral decubitus and bilateral knee pressure ulcer, was seen laying on bed, turned to right side supported by pillows.

-Between 9:35 AM through 12:35 PM, Pt. #26 in room #310 was not turned or repositioned.

2. On 08/29/2023, Pt. #26's clinical record was reviewed. Pt. #26 was admitted to the hospital on 06/29/2023, with the diagnoses of end stage renal disease, sacral decubitus, and dementia. Pt. #26's clinical record included a physician order, dated 06/30/2023, turn and reposition the patient every 2 hours, and wound care nurse on consultation.

Pt. #26's weekly wound care assessment note included documentation of hospital acquired wounds as follows:

- On 07/26/2023 at 8:19 AM, Left Lateral heel intact blister, single blister measurements: Length 0.9cn (0.4 inches) and width: 0.6 cm (0.2 inches).
- On 08/25/2023 at 6:34 PM, Intact blister, Left Lateral thigh ...weekly wound assessment, measurements: Length: 0.8 cm (3 inches) and width: 3.8 cm (1.5 inches), depth: 0.1 cm (0 inches), ruptured blister, light serosanguinoeous drainage.

Pt. #26's nursing flowsheets indicated patient turning and repositioning exceded 2 hours on the following dates/times:

-On 08/16/2023 at 10:33 AM: Turned to left side.
-On 08/16/2023 at 12:00 PM: Turned to left side.
-On 08/16/2023 at 16:00 [4:00 PM]: turned to right side.
-On 08/17/2023 at 13:59 [1:59 PM]: turned to right side.
-On 08/17/2023 at 17:05 [5:05 PM]: turned to right side.
-On 08/17/2023 at 18:49 [6:49 PM]: turned to left side.
-On 08/17/2023 at 20:03 [8:03 PM]: turned to left side.
-On 08/28/2023 at 14:00 [2:00 PM]: turned to right side.
-On 08/28/2023 at 15:46 [3:46 PM]: turned to right side.
-On 08/28/2023 at 17:28 [5:28 PM]: turned to right side.

3. On 08/29/2023, the hospital's policy titled, "Clinical Guidelines for Pressure Related Wounds" dated 06/2022, was reviewed and indicated, "...RNs [registered nurse's] roled in initial and routine patient skin and wound assessments ...ii. Consideration turning schedule of Q1 [every one-hours] if patient is unable to turn and reposition self, has poor nutrition, multiple wounds, a recent change in condition ...poor cognition, skin is moist or at risk for friction/shears injury ..."

4. On 08/29/2023 at 11:45 AM, during the observational tour, the wound care specialist (EN #6) was interviewed. EN #6 stated that patient must be turned every 2 hours. EN #6 stated that at 8:00 AM, all patients are turned to the right side, at 10:00 AM, all patients are turned to left side, at 12:00 Noon, all patients are placed in supine position, and again at 2:00 PM to the right side and the cycle contines. EN #6 stated that patient (Pt. #26) came in with sacral pressure ulcer, and later on on 07/26/2023 and 08/25/2023, patient (Pt. #26) developed two blisters to her left lateral thigh and left heel, that are not considered a pressure injury, only blisters.

5. On 08/29/2023 at 11:55 AM, the Director of Nursing (EN #4) was interviewed. EN #4 stated that patient should have been repositioned every two hours.

6. On 08/30/2023 at 1:45 PM, the Chief Operations Officer (EN #11) was interviewed. EN #11 stated that we discussed about patient acquired pressure injuries during their hospital stay, and the corrective action plan was to turn and reposition the patient every one hour.



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B. Based on document review and interview, it was determined that for 2 of 4 (Pt #9, Pt #10) clinical records reviewed for medication administration, the Hospital failed to ensure that a registered nurse re-assessed the effectiveness of a medication following administration, as required.

Findings include:

1. The Hospital's policy titled, "CORE: Administration of Oral Medications" (dated 6/2022), was reviewed, and required, "This procedure establishes a system by which medications will be administered to patients safely, accurately, and effectively by qualified personnel...Documentation. Effectiveness/post-assessment of medications will be documented in the medical record for PRN [as needed] medications when warranted..."

2. The Hospital's policy titled, "Medication Administration" (2/13/2020, was reviewed, and required, "...Registered Nurse. 9. As Needed Medications: Follow steps for administration of medication. Document reason for as needed medication. Document the results of as needed medication."

3. The clinical record for Pt #9 was reviewed on 8/28/2023. Pt #9 was admitted to the 3 West Adult Behavioral Health Unit on 8/19/2023. Pt #9's clinical record was reviewed with the 3 West Charge Registered Nurse (EM #5).

- On 8/26/2023 at 12:15 PM, Pt #9 received Lorazepam (anti-anxiety medication) IM (intramuscular), as needed due to patient being anxious and agitated. The re-assessment or the evaluation of the effectiveness of the medication was not documented until 4:54 PM (4 hours and 42 minutes after administration).
- On 8/26/2023 at 12:43 PM, Pt #9 received Haloperidol (anti-psychotic medication) oral, as needed due to patient punching another patient in the face. The re-assessment or the evaluation of the effectiveness of the medication was not documented until 4:55 PM (4 hours and 12 minutes later).

4. The clinical record for Pt #10 was reviewed on 8/28/2023. Pt #10 was admitted to the 3 West Adult Behavioral Health Unit on 8/26/2023. Pt #10's clinical record was reviewed with (EM #5).

-On 8/26/2023 at 9:05 AM, Pt #10 received Lorazepam IM, as needed due to patient being anxious, agitated, attempting to go into nursing station, and threatening staff. The re-assessment or the evaluation of the effectiveness of the medication was not documented until 12:00 PM (2:55 minutes after administration).
- On 8/26/2023 at 9:05 AM, Pt #10 received Haloperidol IM, as needed due to patient being agitated, attempting to go into nursing station, and threatening staff. The re-assessment or the evaluation of the effectiveness of the medication was not documented until 12:00 PM (2:55 minutes after administration).
- On 8/27/2023 at 2:15 AM, Pt #10 received Lorazepam oral, as needed. The re-assessment or the evaluation of the effectiveness of the medication was not documented until 7:21 AM (5 hours and 6 minutes after administration).

5. On 8/29/2023 at 10:05 AM, an interview was conducted with EM #5. EM #5 stated that if a patient receives medication either intravenous or intramuscular, the nurse should re-assess for the effectiveness within 30 minutes. EM #5 stated that when patients receive medication orally, the re-assessment should be within the hour after administration.






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C. Based on document review, observation and interview, it was determined that for 2 of 2 crash carts on the medical surgical unit, the hospital failed to ensure the crash carts were checked daily, as required.

Findings include:

1. On 8/31/2023, the hospital's policy, titled "Emergency Medications" (released 06/2021) was reviewed and required, "Documentation ...Patient care units are responsible for checking the integrity of the emergency cart at least daily..."

2. On 8/28/2023, during a tour of the hospital's 3 East and 3 West medical surgical units, The 3 East crash cart had a label that indicated that supplies (intubation box) had expired on 8/9/2023 which was confirmed after opening the crash cart. The Emergency CPR [cardiopulmonary resuscitation] Cart Checklists (05/1/2023 - 08/28/2023) for the 3 West crash cart were reviewed. The Checklists lacked daily checks on 5/25/2023, 6/30/2023, 7/1/2023, 7/2/2023, and 7/12/2023.

3. On 8/28/2023 at approximately 11:00 AM, an interview was conducted with the Registered Nurse (RN/EN #8). EN #8 stated that the crash carts should be checked daily and documented on the checklist.

Based on document review and interview, it was determined that the hospital failed to ensure that medical records were completed within 30 days, as required.

Findings include:

1. On 8/30/2023, the Hospital's policy titled, "Physician Notification of Incomplete and/or Delinquent Medical Records and the Suspension Process" (dated 6/2022) was reviewed and required, "...A complete medical record has all required documentation present in the medical record within 30 days..."

2. On 8/30/2023, EM #1 (Chief Clinical Officer) presented an attestation letter that included there were 8 delinquent records that were not completed within 30 days of discharge.

3. On 8/30/2023 at 2:30 PM, an interview was conducted with E #1. E #1 stated that all medical records should be completed within 30 days.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety code portion of the Full Survey Due to a Complaint conducted August 28-29, 2023, the surveyors find that the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags.

Based on observation, document review, and interview, it was determined that for 1 of 2 decontamination rooms observed, the hospital failed to ensure the decontamination room contained appropriate sink access and adequate equipment availability to decontaminate instruments and for staff to perform hand hygiene to prevent cross-contamination

Findings include:

1. On 8/29/23 at approximately between 9:55 AM to 10:20 AM, an observational tour was conducted of the decontamination room, located adjacent to the central supply department. In the decontamination room, there was one plastic single tub laundry style sink with a standard faucet. The sink was not labeled to be used only for pre-cleaning of surgical instruments. There were no visible decontamination supplies or any accessories/tools needed to clean and decontaminate surgical instruments. There was no other clean sink available for staff to perform hand hygiene in this area.

2. The hospital's policy titled, "Cleaning and Decontamination of Instruments" (revised 2/2021) was reviewed and required, "3. The area should contain ... d. Access to water of appropriate quality for rinsing instruments. 4. Stock the decontamination area with the accessories and supplies needed to clean and decontaminate instruments in accordance with the manufacturer's written IFU (instructions for use) including: a) brushes ... b. enzymatic and non-enzymatic detergent. C Soft, low-linting cloths ..."

3. On 8/29/23 at approximately 10:30 AM, an interview was conducted with the scrub technician (EM#6). EM#6 stated that for instruments used in procedures (mosquito forceps, clamps, or tracheotomy dilators), EM#6 collects the used instruments in a covered tray from the operating room nurse and brings the tray to the decontamination room. EM#6 brings supplies needed, such as the enzymatic detergent and brush and cloths, to the decontamination room from another area. EM#6 stated that after EM#6 has washed the instruments, EM#6 runs the water in the sink to flush any blood clots or debris, then brings the tray to the room where the steam sterilizer is kept. EM#6 stated hand hygiene is performed at the same sink where instruments are pre-cleaned. EM#6 stated EM#6 does not know who else uses this sink. At the time of the observational tour, there was a soiled sponge on the sink. EM#6 stated EM#6 did not know who used the sponge since this area is also used by the staff in the central supply department.

A. Based on observation, document review, and interview, it was determined that for 1 of 1 (Certified Nursing Assistant/CNA EN #1) observed for isolation precautions, the hospital failed to ensure that staff performed hand hygiene. This has the potential to cause cross-contamination.

Findings include:

1. On 08/29/2023 between 9:30 AM - 12:40 PM, an observational tour of the 3rd floor -medical surgical unit was conducted. During the tour the following was observed:

- At 11:45 AM, the certified nurse asssistant (CNA) (EN #1) was seen entering room #310 - contact isolation room for clostridium difficile (C-diff - transmittable bacterial infection which causes inflammation of the colon). EN #1 was observed donning gown and gloves after using the hand sanitizer; went by Pt. #26's bedside; and completed point of care blood glucose testing. After blood glucose testing, EN #1 then removed the dirty gloves, donned another pair of clean gloves, and walked out of the isolation room, without performing hand hygiene.

2. On 08/29/2023, Pt. #26's clinical record was reviewed. Pt. #26 was admitted to the hospital on 06/29/2023 with the diagnoses of end stage renal disease, sacral decubitus, and dementia. Pt. #26's physician order, dated 06/30/2023, included, "...place patient on contact precautions for clostridium difficile ..."

3. On 08/29/2023, the hospital's policy titled, "Clostridioides difficile (C.diff)" was reviewed and required, " ...Hand hygiene with soap and water should be performed exiting the room of a patient ..."

4. On 08/29/2023 at 11:55 AM, the CNA (EN #1) was interviewed. EN #1 stated that she was not aware that Pt #26 was on c-diff isolation. EN #1 stated that EN #1 forgot to wash their hands.

5. On 08/29/2023 at 12:15 PM, the Director of Nursing (EN #4) was interviewed. EN #4 stated that the nurse assistant should have washed her hands before coming out of the room, since the patient was on c-diff isolation.

B. Based on observation, document review and interview, it was determined that for 4 of 6 patients (Pts. #26, #27, #44, and #45) observed for respiratory care, the hospital failed to ensure that respiratory equipment was changed as scheduled, in accordance with hospital policy prevent the spread of infection.

Findings include:

1. During a tour of the 3 West Medical Surgical Unit on 8/28/2023, the following was observed:

- At approximately 10:30 AM in room #302, Pt. #44 was lying in bed with a tracheostomy (artificial airway) connected to a ventilator. There was a nebulizer set (used for breathing treatments) hanging on the wall that was not labeled with the date it was changed.

- At approximately 12:00 PM in room #309, Pt. #45 was lying in bed, and a Respiratory Therapist (EN#2) was present suctioning the patient's tracheostomy. There was a nebulizer connected to the patient's ventilation tubing; however, the nebulizer set with storage bag were not labeled with the date it was changed.

2. On 08/29/2023 between 9:30 AM - 12:40 PM, another observational tour of the 3 West Medical Surgical Unit was conducted, and the following was observed:

-At 10:45 AM, in room #308, Pt. #27 was seen lying in bed with tracheostomy collar to ventilator breathings in progress. The respiratory therapist (EN #2) was seen providing breathing treatment via the trach-collar. Pt. #27's heat moisture exchange (HME) was not labeled with the date it was changed.

-At 10:50 AM, in room #310, Pt. #26 was seen lying in bed with oxygen via nasal cannula. Pt. #26's humidifier bottle was not labelled with the date it was changed.

3. On 08/29/2023, the hospital's policy titled, "Respiratory Care Routine Responsibilities" dated 06/2021, was reviewed and indicated, "Equipment Change Schedule: Aerosol equipment every 7 days ...Heat Moisture Exchange (HME) every 48 hours ..."

4. Interviews were conducted with the Respiratory Therapist (EN#2) on 8/28/2023, at approximately 12:10 PM, and on 08/29/2023 at 10:55 AM. EN#2 stated that nebulizers are changed every week on Fridays. EN#2 assumed it was changed last Friday; however, stated that it's possible it could have been missed and without a date on the set, EN#2 could not be sure if it was changed as scheduled. EN #2 stated that she was not sure why the HME was not dated, and that she did not know when they initiated the HME for the patient.

5. On 08/29/2023 at 11:10 AM, the director of respiratory therapy (EN #5) was interviewed. EN #5 stated that therapists should have labelled the HME and the humidifier bottle, because it can develop the fungus growth and cause infection.


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C. Based on observation, document review, and interview, it was determined that for 2 of 2 patients' (Pt. #26 and Pt. #27) observed for tube-feeding, the hospital failed to ensure that tube-feeding set (tubing) was changed every 24 hours to prevent bacteria growth, as required.

Findings include:

1. On 08/29/2023 between 9:30 AM - 12:40 PM, an observational tour of the 3rd floor -medical surgical unit was conducted. During the tour the following was observed:

-At 10:10 AM, Pt. #27 in room #308 was observed with naso-gastric tube feeding nepro 1000 ml (milliters) bag infusing at 40 ml/hr (milliliters per hour) via the infusion pump with no date and time label on the tube feeding set.

- At 10:15 AM, Pt. #26 in room #310 was observed with gastrostomy tube feeding nepro 1000 ml (milliliters) bag infusing at 45 ml/hr (milliliters per hour) via the infusion pump with no date and time label on the tube feeding set.

3. On 08/29/2023, the hospital's policy titled, "Administration of Enteral Nutrition" dated 06/2023, was reviewed and required, "...Change of administration set: change feeding administration set with new formula bag not to exceed every 24 hours ..."

5. On 08/29/2023 at 10:30 AM, the Registered Nurse (EN #8) was interviewed. EN #8 stated that she forgot to label the date and time on the tube feeding set for both the patients.

6. On 08/29/2023 at 10:40 AM, the Director of Nursing (EN #4) was interviewed. E #4 stated that the feeding tube set must be dated and labeled to avoid any type of infection.

D. Based on document review and interview, it was determined that for 1 of 1 steam sterilizer log reviewed, the hospital failed to ensure that the biological indicator tests were completed and documented weekly to determine whether sterilization parameters were met for the sterilization of surgical instuments. This has the potential to affect any patients receiving surgical services.

Findings include:

1. The Steam Sterilizers Manufacturer's Operating Manual (undated) was reviewed and required, "2.4 Control Measures for Verifying Sterilization Process. A live spore test ... is the most reliable form of biological monitoring ... refer to AAMI guidelines (per the Association for the Advancement of Medical Instrumentation- biological testing should be conducted at least weekly)."

2. The hospital's policy titled, "Sterilization of Surgical Instruments and Equipment" (revised 6/2021) was reviewed and required, "16. a) Trained staff shall use Biological indicators to: i. Monitor sterilizer efficacy at least weekly and recommended daily."

3. The instructions for use for "Verify Dual Species Self-Contained Biological Indicator (SCBI)" was reviewed and required, "13. Biological controls are performed weekly."

4. The AMSCO (steam sterilizer) Sterilization logs from 1/4/2023-8/17/2023 were reviewed on 8/29/2023 and indicated that the biological indicator testing was not conducted weekly as required for the following dates:
1/11/23, 1/24/23, 1/31/23, 2/7/23, 2/15/23, 3/1/23, 3/24/23, 3/31/23, 4/25/23, 5/4/23, 5/11/23, 6/7/23/, 6/14/23, 7/4/23, 7/13/23, 8/1/23, and 8/24/23.

5. On 8/29/23 at approximately 1:40 PM, an interview was conducted with the scrub technician (EM#6). EM#6 stated that the biological indicator monitoring is run only on days when surgeries are scheduled and not weekly. There are times that there are no surgeries scheduled for 1 to 2 weeks at a time.

6. On 8/29/23 at approximately 3:30 PM, an interview with the Chief Clinical Officer (EM#1) was conducted. EM#1 stated that the staff was not aware that the biological inidcator monitoring should be conducted at least weekly.

E. Based on document review and interview, it was determined that for 1 of 1 steam sterilizer observed, the hospital failed to ensure that quality control tests were performed and documented according to manufacturer's instructions. This had the potential to affect any patient receiving surgical services.

Findings include:

1. The Steam Sterilizers Manufacturer's Operating Manual (undated) was reviewed and required, " ... Dart (Bowie-Dick) Test: Conduct a residual air test (e.g., Bowie-Dick test) at the beginning of each day... Run the Vacuum Leak test cycle daily or weekly. This test measures the integrity of the sealed pressure vessel and associated piping to assure air is not being admitted to the sterilizer during the vacuum draw downs ... A leak rate of greater than 1.0 mmHg (millimeters of mercury) per minute indicates a problem with the sterilizer that must be addressed..."

The hospital's policy titled, "Sterilization of Surgical Instruments and Equipment" (revised 6/2021) was reviewed and required, "b. All physical, chemical, and biological monitoring results, including results from controls, will be interpreted by qualified staff ... and will be included in the sterilization logs."

2. Sterilizer Logs from 1/4/23-8/17/23 for the steam sterilizer in the Sterile Processing Department/SPD were reviewed on 8/29/23. The documentation of Dart (Bowie-Dick) and leak tests being performed were only documented on the load envelope and not on the log. The envelopes indicated that the weekly leak tests were not completed as required.

3. On 8/29/23 at approximately 1:40 PM, an interview was conducted with the scrub technician (EM#6). EM#6 stated that the dart and leak testing are done only on days when surgeries are scheduled, and there are times when there are no surgeries for 1 to 2 weeks. E#6 stated that EM#6 does not document the quality control measures in a log, the results are documented on the envelope.

4. On 8/29/23 at approximately 3:30 PM, an interview with the Chief Clinical Officer (EM#1) was conducted. EM#1 stated that staff was not aware that the dart and leak test should be conducted daily or weekly.



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F. Based on observation, document review, and interview, it was determined that for 2 of 2 visitors observed for patients (Pts. #42 and #43) on isolation precautions, the Hospital failed to ensure that visitors wore the appropriate personal protective equipment (PPE) in order to prevent cross-contamination of antibiotic-resistant organisms.

Findings include:

1. During a tour of the 3 West and 3 East Medical Surgical Units on 8/28/2023 the following was observed:

- At approximately 10:37 AM, Pt. #43 was in room #303 with an enteric precautions sign on the doorway that required anyone entering the room to wash hands and put on a gown and gloves prior to entering the room. The daughter of Pt. #43 was standing right next to the bedside and was not wearing a gown or gloves. There was also a staff member in the room at the time.

- At approximately 11:13 AM, Pt. #42 was in room #352 with a contact precautions sign on the doorway that required anyone entering the room to put on a gown and gloves prior to entering. The aunt of Pt. #42 (ZPt. #42) was sitting at the bedside and was not wearing a gown or gloves. ZPt. #42 stated that ZPt. #42 has been here for months visiting Pt. #42 daily, and they [hospital staff] never told ZPt. #42 that a gown and gloves needed to be worn when in the room with the patient. ZPt. #42 stated that today ZPt. #42 has been there the whole morning and nobody mentioned anything about putting on a gown and gloves.

2. The clinical record of Pt. #42 was reviewed on 8/89/2023. Pt. #42 was admitted on 6/28/2023 with a diagnosis of acute and chronic respiratory failure. A sputum (secretions from the airway) culture, dated 7/30/2023, indicated that multiple-drug resistant bacteria was found in the culture (contact precautions).

3. The clinical record of Pt. #43 was reviewed on 8/28/2023. Pt. #43 was admitted on 8/23/2023 with a diagnosis of respiratory failure. Pt. #43 was on enteric precautions for CRE (Carbapenem Resistant Enterobacteriaceae).

4. An interview was conducted with the Infection Control Nurse (EN#3) on 8/28/2023, at approximately 11:20 AM. EN#3 stated that visitors in the room should be reminded by staff to wear the necessary PPE when going in rooms of patients on precautions. EN#3 stated that staff should tell the visitors right away if they see one that is not wearing the appropriate PPE. EN#3 stated that both gown and gloves should be worn if a patient is on contact or enteric precautions.

Based on observation, document review and interview, it was determined that for 1 of 1 (EN #1) staff observed performing bedside blood glucose monitoring, the hospital failed to ensure staff sanitized equipment in accordance with hospital policy and manufacterer's guidelines.

Findings include:

1. On 08/29/2023 between 9:30 AM to 12:40 PM, an observational tour of the 3rd floor medical-surgical unit was conducted and the following was observed:

- At 11:45 AM, the certified nurse asssistant (CNA) (EN #1) was observed entering room #310 - contact isolation room for clostridium difficile (C-diff - transmittable bacterial infection) donning gown and gloves after using the hand sanitizer; went by Pt. #26's bedside; placed the glucometer on patient's bed; then checked the patient's identification band and completed the blood glucose testing. After blood glucose testing, EN #1 removed the dirty strips from the glucometer and threw the used lancets along with dirty strips into the sharps container, and placed the glucometer on the patient's bed. EN #1 then removed the dirty gloves and donned another pair of gloves, picked-up the glucometer from the patient bed; walked out of the isolation room; and placed the glucometer on the cart stationed outside room #310. EN #1 cleaned the glucometer with a sani-cloth bleach germicidal wipe for less than 60 seconds, then removed their gloves and documented the blood glucose level in patient's chart.

2. On 08/29/2023, Pt. #26's clinical record was reviewed. Pt. #26 was admitted to the hospital on 06/29/2023 with the diagnoses of end stage renal disease, sacral decubitus, and dementia. Pt. #26's physician order, dated 06/30/2023, included, "...place patient on contact precautions for clostridium difficile ..." Pt. #26's physician order, dated 08/09/2023, included, "...blood glucose testing six times daily (00, 6, 12, 18) [12:00 AM, 6:00 AM, 12:00 PM, and 6:00 PM] ..."

3. On 08/29/2023, the hospital's policy titled, "Clostridioides difficile (C.diff) ...Hand hygiene with soap and water should be performed exiting the room of a patient ...d. Equipment Sanitation: ...ii The manufacturer's recommended contact time should be used and ideally the bleach agent should be both a cleaner and a disinfectant ..."

4. On 08/29/2023, the manufacturer guidelines for PDI sani-cloth germicidal disposable bleach wipes were reviewed and indicated, "To clean, disinfect, and deodrize: use a wipe to remove heavy soil. Unfold a clean wipe and thoroughly wet surface. Treated surface must remain visibly wet for a full four (4) minutes ...assure continuous 4 minute contact time ..."

5. On 08/29/2023, the CNA (EN #1) was interviewed. E #1 stated that E #1 wipes the glucometer with the sani-cloth bleach wipes and is not aware of the contact time. EN #1 stated that they were not aware that patient was on c-diff isolation. EN #1 acknowledged that the glucometer should have been cleaned inside the isolation room prior to placing it on the cart outside the patient room.