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Based on observation, interviews and document review, hospital staff failed to ensure patients ordered blood glucose testing received care in a safe setting by ensuring control tests were completed and/or test strips were in date for 2 of 5 units selected to sample.

The findings include:

The surveyor inspected fingerstick blood sugar devices, test strips and control solutions on the following units: 5 East, 5 West, 3 Center, 3 West and 3 East.

On 5 West, Level One test controls were out of date on 2/21/17, in one test supply container. Level One and Level Two were out of date on 4/11/17 in a second test supply container. The manager of the unit disposed of the out of date supplies immediately.

On 3 East, the testing strips (Stat strips) were not dated with open or discard dates, which makes it impossible to determine if the test strips can be used.

The DFU's (directions for use) were obtained from the manufacturer's web site and were provided to the surveyor by Staff Member #10, the Accreditation Coordinator/Quality Mgmt. Staff Member #10 stated the information provided could be used to determine compliance.

The DFU's read in part "STAT STRIP (50 strips/vial) * 24 month stability from date of manufacture. Expire in 180 days or 6 months when opened. Date vials with date opened and 6 month expiration date. Initial vial. " For QC (quality control vials) "% QC vial has 24 month stability from date of manufacture. Date QC vial when opened: 90 day or 3 month expiration after opened."

Hospital policy "POC: Nova Statstrip Glucose Meter Bedside Glucose Testing PolicyStat ID: 3137432". Last revised 1/2017, Expiration 1/2019, reads in part as follows: Under "Equipment and Materials *StatStrip Glucose Test Strips - expire 180 days after opening; date each vial *StatStrip Glucose Control Solutions - expire 90 days after opening; date each bottle"

The above information was shared with the management team prior to exit on 5/9/18, DFU were provided to the survey team at that time. No other information was provided.

Based on interviews, clinical record review and review of hospital policies, it was determined staff failed to release a patient from restraints at the earliest possible time for 2 of 2 patients who were restrained when the survey team entered the hospital. (Patient #19 and Patient # 20)

The findings include:

The clinical record of Patient #19 was reviewed on 5/1/18. Patient #19 was admitted on 4/29/18 with a diagnosis of hypoxemic respiratory failure and myoclonus (spasmodic jerky contraction of groups of muscles). Patient #19 was electively intubated and placed on Propofol (a sedative often used with intubated patients) and admitted to ICU. On 5/1/18 at approximately 8:01 a.m. an order was obtained to place soft upper bilateral restraints on the patient, the reason for restraint was listed as non-violent, attempting to remove medical interventions. Per hospital policy patients will be monitored every 15 minutes and assessed for continued need for restraints every 2 hours while they remain restrained. Hospital staff use the "Patient Monitoring Form to document the 15 minute checks. Noted on the form are instructions to "Document the type of precaution and document minimally every 15 minutes (20 for restraints)". Documentation on the patient monitoring form was completed by registered nurses from 8:00 a.m. until 7:00 when the restraints were removed.

At approximately 3:00 p.m. on 5/1/18 the surveyor visited the patient; checked for the proper application of restraint, noted the patient was sleeping and intubated, and spoke with family who were present in the room. Both a parent and the patient's fiancee` confirmed they had been informed of the need for restraints just prior to the surveyor's arrival to the unit. Both family members stated the patient had woken up and didn't understand the intubation tube and was trying to remove it. Both family members stated they did not want the patient restrained any longer than needed, and that he had been sleeping for a long time.

During the review of the clinical record, which was completed while on the unit, the surveyor noted the 15 minute documentation on the "Patient Monitoring Form" documented the patient as combative and insomnia at 8:00 a.m. but after that time the documentation stated the patient was sleeping with family and/or staff in the room through the 3:00 p.m. timeframe (which was when the surveyor arrived to the floor). The surveyor asked Staff Member (SM) #48 if family members had approached him/her about removing the restraints, SM #48 replied that he/she had not been told of the family's concern. SM #48 was asked what the criteria could be for the removal of the restraints and he/she stated it would be when the patient was no longer tying to remove medical devices and/or being combative. The surveyor pointed out to SM #48 that the patient had been documented as sleeping since 8:15 that morning and with either staff or family in the room. SM #24 asked how often the patient would be assessed for the removal of the restraints he/she replied it would be at least every 2 hours. The 2 hour assessments documented the patient behavior as non-violent "Attempts to remove".It should be noted that SM #48 documented both the 15 minute checks and the 2 hour assessments. It was brought to the attention of SM #48 that the documentation was conflicting and it would be reasonable to believe the 15 minute checks would give more information about the patient's behavior. SM #48 stated his/her agreement with this statement. And stated the removal of the restraints would be discussed with the treatment team. The surveyor witnessed the family members being informed of the intent of the staff.
On 5/7/18, the surveyor was provided with documentation of the removal of the restraint at 7:00 p.m. on 5/1/18.

2. The clinical record of Patient #20 was reviewed on 5/1/18. Patient #20 was admitted at 9:15 p.m. on 4/25/18 after being transferred for cardiology coverage available at this hospital. Patient #20 was admitted with a diagnosis of severe sepsis related to CAP (community acquired pneumonia), respiratory alkalosis secondary to CAP, AKI (acute kidney injury), A-Fib with RVR (rapid irregular heart rate), elevated troponin (cardiac injury marker), elevated pBNP (heart failure marker), diabetes mellitus type 2, and obstructive sleep apnea. On 5/1/18 at approximately 8:01 a.m. and order was obtained to place soft upper bilateral restraints on the patient, the reason for restraint was listed as non-violent, attempting to remove medical interventions. Per hospital policy patients will be monitored every 15 minutes and assessed for continued need for restraints every 2 hours while they remain restrained. Hospital staff use the "Patient Monitoring Form) to document the 15 minute checks. Noted on the form are instructions to "Document the type of precaution and document minimally every 15 minutes (20 for restraints). Documentation on the patient monitoring form was completed by registered nurses from 8:00 a.m. until 7:00 when the restraints were removed.

At approximately 3:45 p.m. on 5/1/18 the surveyor visited the unit and found restraints had been discontinued at 2:07 p.m. that day. Surveyor review of "Patient Monitoring Record" completed by the assigned nurse, found that Patient #20 had been placed in soft bilateral upper extremity restraints on 4/29/18 at 7:00 p.m. for attempts to remove medical devices. Every 15 minute documentation reveals the patient was "in room and sleeping" from 7:00 p.m. on 4/29/18 until 10:45 a.m. on 4/20/18. Documentation reveals the patient as agitated for a 1 hour period from 11 a.m. to 12 noon when documentation shows the patient again "in room asleep" from 12:15 p.m. on 4/30/18 until 2:00 p.m. on 5/1/18. Visitors were documented as being with the patient from 7:30 am until 2:00 p.m. on 5/1/18. Based on this documentation Patient #20 was in restraints for a total of 43 hours with only 1 hour of documentation supporting the need for restraints, and documentation showing the patient "in room and asleep" for 25 hours and 45 minutes after the brief period of agitation occurred. The 2 hour assessments documented by the registered nurse have the patient behavior as non-violent "Attempts to remove".

The aforementioned conflicting documentation was discussed with SM #43, the director of the unit. It was brought to the attention of SM #48 that the documentation was conflicting and it would be reasonable to believe the 15 minute checks would give more information about the patient's behavior. With nursing documenting both the 15 minute checks and the 2 hour assessments, the lack of consistency in documenting the patient's behavior resulted in the failure to support the continued need for restraints was discussed with SM #43. SM #43 agreed the documentation was conflicting.

Review of hospital policy "Patient Restraint/Seclusion, PC.13.329.00.0", last revised 06/2017 and expiring 06/2020 contained the following information in part:
"11. Discontinuation of Restraint/Seclusion: The patient in restraint or seclusion in evaluated frequently and the intervention is ended at the earliest possible time. The time-limited order does not require that the application be continued for the entire period."

SM #10, the Accreditation Coordinator/Quality Management, provided the surveyor with education materials related to restraint that had been a part of an action plan for restraint documentation. Data was provided or November 2017 to April 2018. However, the plan focused only on documentation and the surveyor was unable to find any education related to discontinuing the restraint at the earliest possible time.

The above information was shared with the management team on 5/1/18 at the end of day meeting and again prior to exit on 5/9/18. No further information was provided to the survey team.

Based on a review of hospital documents and interviews, it was determined the hospital staff failed to use data collected regarding assessments and monitoring of patients who received blood transfusions to identify opportunities for improvement and to implement changes to achieve sustained improvements.

The findings were:

The surveyor met with the Vice President (VP) of Quality & Risk and the Director of Patient Safety on 05/08/18 at 1:50 p.m., for a discussion/review of the hospital's quality program. At the end of the meeting, the surveyor discussed the findings from the review of three (3) clinical records of patients having received blood transfusions. The VP of Quality & Risk acknowledged having an awareness of those findings. The surveyor requested to review any current performance improvement projects related to assessments/monitoring/vital signs for patients receiving blood transfusions. The VP of Quality & Risk stated there was a performance improvement project for that and he/she would make the data available for surveyor review.

During a meeting with the hospital's leadership team at the end of the day on 05/08/18 at 4:45 p.m., the VP of Quality & Risk provided the surveyor with data for a performance improvement project related to patient monitoring and safety during blood transfusions.

The surveyor reviewed the data for the performance improvement project related to patient monitoring and safety during blood transfusions, on 05/09/18 at 9:20 a.m. The "Monthly Quality Outcomes Report" data for January, February, March and April, 2018 included tracking of data for "Blood Administration Compliance/Transfusion Record Complete (BCTA) [the EHR electronic health record]." The stated benchmark or goal was listed as "100% and the hospital's data was listed as (January 2018) 72%, (February 2018) 76%, (March 2018) 68%, and (April 2018) <50%. The aforementioned results (values) for January, March, and April were colored red, and February was colored yellow. The document included the following information under "Color Code"... "Blue = Increasing Toward Goal," "Yellow = Declining Below Goal," and "Red = Below Goal > 2 Monitoring Cycles." The document included, "MONTHLY ACTION PLAN - required for ALL Red Status; and/or Yellow Status Trends Over 2 Months." The document included an area for monthly entries under a section titled, "STRATEGY FOR IMPROVEMENT." That section included no entries for January 2018, "starting a QI project to help track transfusion vitals" for February 2018, assessments/vital signs not addressed for March 2018, and "Requested to have vital sign documentation added to the agenda at the next Nurse Director Meeting." Provided along with this data were emails dated January 18, 2018 and February 19, 2018, from The Blood Bank Supervisor to the Director of Patient Safety. Those emails relayed the concerns of the Blood Bank Supervisor related to the findings of the hospital's internal audits for compliance with vital signs and monitoring during blood transfusions. The email dated January 2018 read, in part, as follows: "One of the items I have to report on the quality report card is transfusion vital documentation.... Due to the new documentation I am no longer able to see the same things as before so I am unable to track the vital signs. I would like to go ahead and start monthly audits for each floor regarding transfusion vitals. Does this sound like an acceptable thing to do? Also, in the transfusion policy for nursing it states when they should do the vitals and that the information will be documented in BCTA [the EHR]. This rarely happened before and is not happening now...."

The surveyor met with the Blood Bank Supervisor and the Director of Laboratory Services on 05/09/18 at 1:30 p.m. The Blood Bank Supervisor stated he/she was/is the staff member responsible for completing and submitting the aforementioned "Monthly Quality Outcomes Report." The Blood Bank Supervisor described that he/she completes the data in the "dashboard" and submits it electronically on a monthly basis to the quality department. The Blood Bank Supervisor provided data for the surveyor to review for the last quarter of 2017, which identified the following: the "Blood Administration Compliance/Transfusion Record Complete (BCTA)" results were listed as (November 2017) 74.4% and colored yellow, and (December 2017) 43.7% and colored red. The report revealed that for September and October of 2017 the values were colored blue and were >80%. The Blood Bank Supervisor stated this indicator had been an issue more than a year ago, but had achieved sustained improvements until a steady decline which was identified as beginning in November of 2017. The Blood Bank Supervisor and the Director of Laboratory Services both described not having access to key data elements within the electronic health records, which hinders the ability to gather the required data for the Monthly Quality Outcomes Report.

The surveyor met with the VP of Quality & Risk on 05/09/18 at 10:05 a.m. He/she stated during the discussion there had been "enormous turnover in leadership over the last 3 to 4 years" and "some positions multiple times." The VP of Quality & Risk stated that had led to new leaders/managers having "multiple areas of concern and had to prioritize." The VP of Quality & Risk stated, having been in his/her current position since April of 2017, the Director of Quality in place when he/she started this position left 3 months later, and since then he/she had been doing both jobs. The VP of Quality & Risk acknowledged he/she was first aware that blood transfusion assessments/vital signs were an issue of concern when the surveyor identified it as such. The VP of Quality & Risk did not recall this issue or the aforementioned collected data making it to the quality program in regards to being a topic of discussion and/or deciding upon actions to be taken to bring about improvements. He/she acknowledged the quality program failed to use the data collected, regarding assessments and monitoring of patients who received blood transfusions, to identify opportunities for improvement and to implement changes in a timely manner to achieve sustained improvements. The VP of Quality & Risk stated, "we deserve to take a hit on that."

The surveyor met with the hospital's Chief Nursing Officer/CNO on 05/09/18 at 11:00 a.m. The CNO acknowledged he/she was also first aware that blood transfusion assessments/vital signs were an issue of concern when the surveyor identified it as such. The CNO stated, "we do need to fix it."

Based on a review of clinical records, facility policies, and interviews, it was determined the hospital's nursing staff failed to perform required nursing assessments and monitoring for the identification of possible reactions or adverse outcomes during blood transfusions, as required by the hospital's policy, for three (3) of three (3) patients sampled for blood transfusions (Patient #6, #7, and #8).

The findings were:

The surveyor reviewed the hospital's policy titled, "Transfusion: Blood and Blood Products" (Policy ID # 2926779) on 05/02/18. The policy included, in part, the following:

"Purpose:
Prevent and/or alleviate complications secondary to blood and blood product replacement procedures.
Provide guidelines for administering blood and blood components with the maximum degree of safety....

Patient Monitoring and Vital Signs:
Vital Signs for blood administration must be obtained no more than 15 minutes before beginning the transfusion.... Vital signs will be repeated at 15 minutes [after the transfusion is started] and every hour as long as the patient remains stable. The nurse will document vital signs in BCTA in [the electronic health record]. The nurse will assess the transfusion and the patient's response at least every hour and PRN [as needed]."

The clinical records of Patients #6, #7 and #8 were reviewed, with SM #17 and #18 serving as navigators of the EHR (electronic health record). The findings of the record reviews were as follows:

Patient #6's clinical record contained evidence the patient received a unit of PRBCs (Packed Red Blood Cells) on 05/02/18 which started at 2:39 a.m. and ended at 4:54 a.m. The record contained evidence the patient's vital signs were last monitored and assessed for changes at 3:56 a.m. The record failed to contain evidence the patient's vital signs were monitored between 3:56 a.m. and one hour later when the transfusion ended at 4:54 a.m. The record contained evidence the patient's vital signs were not monitored again until 8:02 a.m.

Patient #7's clinical record contained evidence the patient received two (2) units of PRBCs (Packed Red Blood Cells) on 05/02/18. The first unit of PRBCs started at 4:27 a.m. and ended at 7:11 a.m. The EHR failed to contain evidence the patient's vital signs were monitored at no more than 15 minutes before, or at any point during the transfusion of the first unit. SM #17 and SM #18 facilitated a review of the "Blood Bank Transfusion Record" which provided evidence the registered nurse documented "pre" transfusion vital signs at 4:18 a.m. and "15 minute" vital signs at 4:45 a.m. on that paper document. After the 4:45 a.m. vital signs, there was no evidence the vital signs were monitored for the remaining 2 hours and 26 minutes of the transfusion which ended at 7:11 a.m. The vital signs were next documented at 7:25 a.m. The second unit of PRBCs started at 10:52 a.m. and ended at 2:03 p.m. The record failed to contain evidence the patient's vital signs were monitored between 1:08 p.m. and one hour later when the transfusion ended at 2:03 p.m. The record contained evidence the patient's vital signs were not monitored again until 3:46 p.m.

Patient #8's clinical record contained evidence the patient received five (5) units of PRBCs (Packed Red Blood Cells) from 04/30/18 to 05/02/18. There was missing documentation/omitted monitoring identified with four (4) of the five (5) units. The first unit of PRBCs were transfused on 04/30/18 starting at 5:45 p.m. and ending at 9:26 p.m. The record contained evidence the "15 minute" vital signs were monitored 6:00 p.m. and the next set of vital signs were monitored at 7:23 p.m., 23 minutes late. The second unit of PRBCs were transfused on 04/30/18 starting at 8:07 p.m. and ending at 10:54 p.m. The record contained evidence the patient's "pre" vital signs were monitored at 7:23 p.m., 44 minutes before beginning the transfusion and exceeding the "no more than 15 minutes before beginning the transfusion" required per the above described policy. The fourth unit of PRBCs were transfused on 05/01/18 starting at 4:29 p.m. and ending at 6:57 p.m. The was no evidence the patient's "pre" vital signs (monitored no more than 15 minutes prior to beginning the transfusion) were obtained. The "15 minute" vital signs were monitored at 4:44 p.m. and the next vital signs were monitored at 5:54 p.m. (10 minutes late). The fifth unit was transfused on 05/02/18 starting at 10:20 a.m. and ending at 12:30 p.m. There was evidence the "pre" transfusion vital signs were monitored at 10:15 a.m. and the "15 minute" vital signs at 10:30 a.m. After the 10:30 a.m. vital signs, there was no evidence the vital signs were monitored for the remaining 2 hours of the transfusion which ended at 12:30 p.m. The vital signs were next documented at 1:08 p.m.

The surveyor met with the hospital's Accreditation Coordinator on 05/04/18 at 11:15 a.m. and discussed the clinical record review findings. The Accreditation Coordinator was informed the monitoring and assessments of patient's receiving blood transfusions was not identified to be in accordance with the hospital's policy. The Accreditation Coordinator acknowledged the described findings were not in accordance with the hospital's policy and expectations.

The surveyor met with the hospital's Accreditation Coordinator again on 05/07/18 at 3:40 p.m. and discussed the monitoring and assessments of patient's receiving blood transfusions. The Accreditation Coordinator acknowledged there was no additional evidence to provide.

Based on interviews and the review of documents, it was determined the facility staff failed to document food safety training for dietary contract employees (who prepares/handles food) for three (3) of three (3) sampled dietary staff personnel files.

The findings include:

On the afternoon of 5/8/18, the facility's dietary services were reviewed. Three (3) names of individuals with food preparation responsibilities were selected from the dietary schedule for education/training review. On 5/8/18 at 3:38, the Director of Food/Nutrition stated the employees were provided on the job training but no documentation of the training was available. During this interview it was discovered that two (2) employees were currently in training for food preparation; the Director of Food/Nutrition reported no orientation check-off list was being used by the two (2) employees currently being trained for food preparation. The Director of Food/Nutrition reported that all dietary staff receive monthly training on different topics.

The following information was found in a facility policy with the 'function' identified as "Surveillance, Prevention and Control of Infection" (with an effective date of December 1996 and a revised/reviewed date of November 2012): "On the Job Training [sic] and in-services shall include but are not limited to: A. Personal hygiene and proper hand-washing. B. Causes of Food Borne illness. C. Proper cleaning and maintenance of equipment and utensils. D. Sources and transmission of infection. E. Use of HACCP controls. F. Gloves, [sic] and hand-washing importance and techniques." (HACCP (Hazard Analysis and Critical Control Point) is a system to address food safety.)

The agreement/contract between the facility and the food service included the following statement: "Training Programs: Vendor shall provide a formal in-service training program to enhance the development of service employees. Vendor shall maintain accurate records of training sessions."

On the morning of 5/9/18, the Director of Food/Nutrition (with the Accreditation Coordinator present) reported that due to changes in management in the dietary department not all of the employee training documentation could be found. The Director of Food/Nutrition stated some, but not all, of the employee files kept by previous Directors of Food/Nutrition had been found.

The aforementioned absence of dietary staff training was discussed, on 5/9/18 at 4:05 p.m., during a survey team meeting with the facility's Accreditation Coordinator and Vice-President of Quality/Risk. The Accreditation Coordinator confirmed that as stated earlier by the Director of Food/Nutrition some food safety training had been found but not all training for all employees who prepare food was available.

Based on observation, interviews, and facility document reviews, facility did not meet the Condition of Participation related to Physical Environment.

The findings include:

1. Multiple standard level citations were noted on the Life Safety Code survey.

2. On the health survey, it was noted the facility failed to have documentation of fire drills done by facility staff since June 2017.

3. On the health survey, review of the dietary department revealed the facility staff failed to ensure food items were stored appropriately in the dietary department's refrigerators.

Based on interviews and the review of documents, it was determined the facility staff failed to ensure monthly fire drills were documented.

The findings include:

Review of the facility's fire drill documentation, on 5/9/18, failed to provide evidence of a fire drill occurring since June of 2017.

The following information was found in a facility policy and procedure titled "Life Fire Safety Management Plan" (with an effective date of 06/1995 and a last revised date of 06/2017): "The Safety Officer is responsible for conducting required fire drills. Drills are conducted once per shift per quarter in each building defined as a health care occupancy by the Life Safety Code ... All drills are documented, with the subsequent positive and negative findings shared with departmental and facility leadership so as to appropriately be addressed."

The facility's Director of Facilities Management (DFM) was interviewed on 5/9/18 at 1:45 p.m. The DFM acknowledged that no fire drills had been documented since June of 2017. The DFM reported the fire drill had been the responsibility of the facility's security department. The DFM reported that fire drills had occurred at the facility but due to changes in the facility's security department that the documentation could not be found. The DFM reported he/she was unsure if upcoming fire drills had been scheduled but that two (2) fire drills were being planned.

The missing fire drill documentation was discussed, on 5/9/18 at 4:05 p.m., during a survey team meeting with the facility's Accreditation Coordinator and Vice-President of Quality/Risk.

Based on observations, interviews, and the review of documents, it was determined the facility staff failed to ensure food items were stored appropriately in the dietary department's refrigerators.

The findings include:

Observations, on the afternoon of 5/8/18, of the facility's refrigerators in the dietary department revealed the following items were not labeled and dated to indicate when they were no longer to be used: an opened package of sliced roast beef, an opened package of cubed ham, an opened package of diced tomatoes, a tray of unbaked muffins, and ten (10) salads (on two (2) trays). The facility's Director of Food/Nutrition was present for the observations. The Director stated the opened items should have been dated; he/she stated the trays of the salads and unbaked muffins should have been dated.

The following information was found in a facility policy and procedure with a 'policy description' of "Refrigerators and Nourishment Areas" (with an effective date of August 1900 and a last reviewed/revised date of December 2011): " ... B. Patient food must be labeled and dated. Prepared items should not be kept for more than 48 hours. C. Employee food must be kept in a separate refrigerator. Items must be dated and labeled. Commercially prepared and packaged items that have not been open [sic] may be stored in the refrigerator or freezer. Other items stored for greater than 3 days should be discarded. ..." During an interview on 5/8/18 at 3:10 p.m., the facility's Director of Food/Nutrition confirmed this policy would apply to the aforementioned observations of undated/unlabeled food items.

The failure of the facility staff to appropriately date stored food items was discussed for a final time, on 5/9/18 at 4:05 p.m., during a survey team meeting with the facility's Accreditation Coordinator and Vice-President of Quality/Risk.

Based on observations, interviews and hospital document review, it was determined hospital staff failed to follow the policy for surgical attire worn within the semi-restricted and restricted areas of the surgical environment, for two (2) of two (2) observations made.

The findings include:

On 5/8/18 the surveyor observed a surgical procedure performed in Operating Room (OR) 10 at approximately 2:30 p.m. Among those present in the room were the Certified Registered Nurse Anesthetist (CRNA), an X-ray technician (Staff Member (SM) )#47) the Manager of the OR (SM #45) and the surveyor. While making observations the surveyor noted the CRNA and the X-ray technician were wearing earrings which were not covered by their hair coverings, and further observed the X-ray technician not to be wearing shoe coverings.

SM #45 was asked what the expectation was regarding jewelry in the surgical area, he/she replied that it would need to be removed or covered. The surveyor asked SM #45 to look around the room in relation to exposed earrings, SM #45 confirmed the surveyor's observation. SM #45 was also asked about the lack of shoe coverings in the surgical area, he/she stated that shoes that were "dedicated" to wear on in the surgical area would not require shoe covers but all other shoes would.

SM #47 was asked if he/she went to other areas of the hospital or if he/she only served the surgical areas. SM #47 replied that he/she went to all areas of the hospital as needed, SM #47 was then asked if the shoes he/she was wearing were dedicated only to be worn in the OR. SM #47 replied that they were not. He/she was then asked if anyone had spoken to him/her about wearing shoe coverings. SM #47 stated that no one had mentioned it but that "it would probably be a good idea".

The above observation was shared at the end of day meeting on 5/8/18 with management staff. No further evidence or comments were provided.

On 5/9/18, the surveyor was observing the end of an ECRP (Endoscopic retrograde cholangio-pancreatography) diagnostic procedure in ENDO (endoscopy) Room #34 at approximately 1:05 p.m. in order to follow the process of cleaning the scope. During observations the surveyor noted the CRNA and the X-ray technician were wearing exposed earrings. Following the process for cleaning the scope did not provide the survey with the opportunity to speak with the staff.

The above observation was share with the management team prior to the exit on 5/9/18. The surveyor asked the management team to clarify if the ENDO rooms were considered to be a surgical area and if they would follow the same policy for attire. The "Surgical Attire, 661-235" last revised 5/2018 and expiring 5/2021. The policy states in part: "G. All personnel entering the semi restricted and restricted areas of the surgical suite should confine or remove all jewelry. 2. Other jewelry (e.g., watches, earrings, and piercings) should be removed or totally confined within the scrub attire. I.5. Fluid-resistant shoe covers are considered part of PPE and must be worn when it can be reasonably anticipated that splashed or spills may occur."
The management team was given time to clarify the policy. SM #27 stated that it was "not likely" there would be a separate policy for the endo rooms. SM #10 later informed the survey team that the policy would be the same for the endo rooms as for the surgical rooms.