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A. Based on document review and interview, it was determined that for 1 of 1 clinical record (Pt #8) reviewed for pressure ulcer assessment and documentation, the Hospital failed to ensure that a nurse supervised and evaluated the nursing care for each patient by completing a pressure ulcer skin assessment on admission.

1. On 1/9/2023, the Hospital's policy titled, "Skin Wound Assessment and Documentation" (effective 2/9/2022) was reviewed and required, "Braden Risk Assessment (scale for predicting pressure sore risk - mild risk 15-18, moderate risk 13-14, high risk 10-12 and severe risk less than or equal to 9) and Skin assessment and documentation are performed on admission and every shift."

2. On 1/9/2023, Pt #8's clinical record dated 1/8/2023 thru 1/9/2023 was reviewed and indicated:
-Pt #8 was admitted on 1/8/2023 with the diagnosis of CVA (stroke).
-Pt #8's Braden risk assessment score on admission was 14 (moderate risk)
-Pt #8's wound assessment on admission dated 1/8/2023 noted, "coccyx (tailbone) - no measurement or description of the pressure ulcer stage, color of the pressure ulcer or any drainage was documented."

3. On 1/9/2023 at 10:40 AM, an interview was conducted with the Charge Nurse of the Telemetry Unit (E #1). E#1 stated that there should be a wound assessment and description of the pressure ulcer (size, drainage and stage) documented in the admission nursing assessment.


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B. Based on document review and interview, it was determined that for 2 of 2 patients' (Pt. #11 and Pt. #13) clinical records reviewed for blood sugar testing, the Hospital failed to ensure that the registered nurse supervised and evaluated the nursing care for each patient by failing to ensure the physician's orders were followed, as required.

Findings include:

1. On 01/09/2023, the Hospital's "Job Description - RN-ICU (Registered Nurse-Intensive Care Unit)" dated 04/07/2019 was reviewed and included, "...Responsibilities: ...Notes and carries out physician ...orders ...."

2. On 01/09/2023 at 9:35 AM, Pt. #11's clinical record was reviewed. Pt. #11 was admitted to the Hospital's intensive care unit on 01/07/2023 with the diagnoses of sepsis, ventilator associated pneumonia, and chronic obstructive pulmonary disease. A physician's order, dated 01/07/2023 at 7:03 PM, included bedside blood sugar testing AC and HS (before meals and at bedtime) ...Novolog [type of insulin] 20 U [twenty units] TID [three times daily] AC [before meals] SC [subcutaneous] ..."

3. On 01/09/2023 at 9:40 AM, Pt. #11's POC [point of care] glucose testing history was reviewed. Pt. #11's clinical record lacked the bedside blood glucose testing on 01/08/2023 at bedtime and on 01/09/2023 at 6:00 AM before breakfast, as ordered.

4. On 01/09/2023 at 10:00 AM, Pt. #13's clinical record was reviewed. Pt. #13 was admitted to the Hospital's intensive care unit on 01/06/2023 with a diagnosis of amputation of arm. A physician's order, dated 01/07/2023 at 9:01 AM, included, bedside blood sugar testing QID [four times daily] AC [before meals] and HS [at bedtime] ...on Humulin R [type of insulin] sliding scale: BG [blood glucose] 70-180 ...no dose; BG 181- 220: 2 units; ..."

5. On 01/09/2023 at 10:15 AM, Pt. #13's POC glucose testing history was reviewed. Pt. #13's clinical record lacked the bedside blood glucose testing on 01/07/2023 before dinner, and on 01/08/2023 before breakfast, before lunch, and before dinner.

6. On 01/09/2023 at 10:25 AM, the ICU Charge Nurse (E #2) was interviewed. E #2 stated that the physician's order for bedside blood glucose testing should have been carried out for both the patients (Pt. #11 and Pt. #13).

Based on document review, observation and interview, it was determined that for 11 of 11 frozen vegetarian patties, 8 of 8 frozen flourless brownies, and 8 of 8 cups of frozen mashed bananas, that were stored in the kitchen freezer and were readily available for patient use, the Hospital failed to manage the dietary services by ensuring that food items were labeled with a use-by-date and that outdated items were discarded. This had the potential to affect the average daily census of 100 patients receiving meal service.

Findings include:

1. On 01/09/2023, the Hospital's Contracted Dietary Service policy titled "Food Supply and Storage Procedures" dated 12/2017 was reviewed and included, "...label and date unused portions and open packages ...Frozen Storage: ...Discard food past the use-by or expiration date ..."

2. On 01/09/2023 between 1:30 PM - 2:45 PM, an observational tour of Food and Dietary Services was conducted and the following were observed:

- Kitchen Freezer #6: Eleven (11) vegetarian patties wrapped in plastic with no use-by or expiration label.
- Kitchen Freezer #7: Eight (8) flourless brownies in a plastic crate with no use-by or expiration label.
- Kitchen Freezer #8: Eight (8) cups of mashed bananas in a plastic Ziploc bag with use-by label dated 11/26/2022.

3. On 01/09/2023 at 2:30 PM, the Clinical Nutrition Manager (E #9) was interviewed. E #9 stated that those foods should not be in the freezer. E #9 stated that expired food could be contaminated and cannot be used.

4. On 01/09/2023 at 2:40 PM, the findings were discussed with the Director of Food and Dietary Services (E #10). E #10 stated that it is not acceptable to have any food item without a use-by label if the food item had been opened from the box.

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 on January 9 & 10, 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 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 on January 9 & 10, 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.

A. Based on document review, observation, and interview, it was determined that for 1 of 1 Environmental Services staff (E#14) observed cleaning a room, the Hospital failed to maintain infection control practices by ensuring that the equipment was properly disinfected between surgical cases. This potentially affected the remaining patients having surgery in the Operating Room (R #3) on 01/10/2023.

Findings include:

1. The Hospital's policy titled, "Surgery Cleaning" (revised 2/1/22) was reviewed and required, "Between Case Cleaning... 2. Clean and disinfect surgical lights and high equipment/surfaces. 3. Disassemble OR table, damp wipe/disinfect surfaces... 4. Damp wipe and disinfect all horizontal an vertical surfaces including walls, OR tables, equipment ... etc."

2. During an observational tour of the Operating Room on 01/10/2023 between 9:05 AM - 9:20 AM, OR #3 was being cleaned after a procedure. At approximately 9:15 AM, an environmental service staff (E#14) was observed disinfecting a Bovie OR tower (tower with shelves that holds electrosurgical equipment) from top to bottom, including electrical cords that were on the floor. The staff then proceeded to clean an overhead, surgical light with the same cloth used to disinfect the Bovie tower and cords that were on the floor.

3. On 01/10/2023 at approximately 9:30 AM, an interview was conducted with the OR Manager (E #13). E #13 stated that equipment the OR should be cleaned/disinfected from top to bottom. E #13 stated that it is not appropriate to clean the surgical lights with the same cloth after cleaning equipment that was touching the floor or the base of equipment.

B. Based on record review and interview, it was determined that for 2 of 3 clinical records reviewed for isolation orders (Pt #8 and Pt #9), the Hospital failed to ensure that isolation orders were documented, as required to prevent and control the transmission of infections within the hospital.

Findings include:

1. On 1/9/2023, the Hospital's policy titled, "Isolation Precautions" (dated 11/20/2022) was reviewed and indicated, "... IV. Procedure - Identify the need for isolation - by symptoms, diagnosis or laboratory results, or patient/family report of prior MDRO history/recent communicable disease - by physician order..."

2. On 1/9/2023, Pt #8's clinical record dated 1/8/2023 thru 1/9/2023 was reviewed and indicated:
-Pt #8 was admitted on 1/8/2023 with the diagnosis of CVA (stroke). Pt #8 was in isolation for MRSA (methicillin-resistant staphylococcus aureus) and VRE (vancomycin resistant enterococcus).
-Pt #8's physician orders, dated 1/8/2023 thru 1/9/2023, lacked documentation of a physician order for isolation.

3. On 1/9/2023, Pt #9's clinical record, dated 1/6/2023 thru 1/9/2023, was reviewed and indicated:
-Pt #9 was admitted on 1/6/2023 with the diagnosis of sepsis and pneumonia. Pt #9 was in droplet isolation for COVID.
-Pt #9's physician orders, dated 1/6/203 thru 1/9/2023, lacked documentation of a physician order for isolation.

4. On 1/9/2023, an interview at 10:40 AM was conducted with the Charge Nurse of the Telemetry Unit (E #1). E #1 stated that there should be a physician order for isolation.

Based on document review, observation, and interview, it was determined that for 1 of 1 (E#3) blood glucose testing observed, the Hospital failed to ensure the staff adherence to prevention of spread of nosocomial infection as required.

Findings include:

1. On 01/09/2023 the Hospital's policy titled, "Cleaning/Disinfecting of Non-critical Patient Care Equipment" dated 12/10/2022 was reviewed and included, "...4. Cleaning and Disinfection: ...c. ...Wipe all areas thoroughly and allow the contact/dwell time as indicated on the disinfectant wipes manufacturer's product labeling ..."

2. On 01/09/2023 the Hospital's disinfectant wipes named, "Sani-Cloth Germicidal Disposable Wipe" manufacturer guidelines were reviewed and indicated, "Directions for use: To Disinfect: ...Unfold a clean wipe and thoroughly wet surface. Allow treated surface to remain wet for two (2) minutes ... bactricidal, tuberculocidal, and virucidal in 2 minutes ..."

3. On 01/09/2023 between 11:28 AM to 11:45 AM, during the observation of the bedside blood glucose testing in the Intensive Care Unit by the Registered Nurse (E #3), the following was observed:

- At 11:35 AM, the Registered Nurse (E #3) completed the blood glucose testing for Pt. #13, and with the same gloved hands she (E #3) opened the Sani-Cloth- germicidal disposable wipe container and inserted the gloved hands inside the container to pull out a disposable wipe to clean the used glucometer. The Registered Nurse (E #3) wiped the glucometer using the Sani-cloth-germicidal disposable wipe once for less than 3- 4 seconds and placed the glucometer back into the docking station outside the room, available for use.

4. On 01/09/2023 at 11:50 AM, the Registered Nurse (E #3) was interviewed. E #3 stated that she (E #3) was not thinking and should not have inserted the dirty gloved hands inside the container to get the disinfectant wipe. E #3 stated that now the whole container is dirty and could cause cross-contamination.

5. On 01/09/2023 at 11:55 AM, the ICU Nurse Educator (E #4) who was also observing the bedside glucose testing was interviewed. E #4 stated that it was unacceptable for the nurse to have inserted her dirty gloved hand inside the container to get the disinfectant wipes. E #4 stated that the nurse (E #3) should have waited for 2 minutes dwell time before docking the glucometer.