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Based on interview and record review, the hospital failed to ensure four of 30 sampled patients (Patients 27, 28, 29, and 30) received care in a safe setting when patients fell while in the Emergency Department (ED) and post fall assessments were not completed in accordance with the hospital's policy and procedure titled, "Falls Prevention and Management Policy".

This resulted in patient falls with injury and there was no post fall assessment documented in the medical records.

Findings:

During an interview on 1/13/21, at 5:42 p.m., with the Director of Emergency Department (DRED), the DRED stated, when a patient falls, the expectation was for the nurse to notify the provider caring for the patient, for the nurse to perform a head-to-toe assessment, stabilize and initiate appropriate interventions to prevent falls and to document the assessment in the medical chart, notify family, and follow through with orders if there were injuries.

During a concurrent interview and record review, on 1/13/21, at 11:30 a.m., with the Quality Consultant (QC), Pt 27's Medical Chart (MC) dated 7/9/20 was reviewed. The MC indicated on 7/9/20, at 9 p.m., Pt 27 had a fall in the waiting room and endured a scratch to her right leg with a bruise. There was no evidence an initial fall risk assessment was completed. The QC stated a fall risk assessment should have been completed and documented, and it was not. There was no documentation of a post fall nurse assessment. The QC stated, "There was no documentation of a post fall assessment by a nurse and it is expected to be documented any time a patient falls."

During a concurrent interview and record review, on 1/13/21, at 11:42 a.m., with the QC, Pt 28's MC dated 8/14/20 was reviewed. Pt 28's Physician Note dated 8/14/20, at 5:25 a.m., indicated, "Notified patient fell and has hematoma." The MC did not have corresponding nurse entries which documented fall and injury had occurred. The QC stated the assigned nurse should have documented the fall and circumstances about the injury. There was no documentation of a post fall nurse assessment. The QC stated, "There was no documentation of a post fall assessment by a nurse and it is expected to be documented any time a patient falls."

During a concurrent interview and record review, on 1/13/21, at 12 p.m., with the QC, Pt 29's MC, dated 10/5/20 was reviewed. The MC indicated that on 10/5/20, at 3 p.m., Pt 29 fell in the hallway with scratch to his scalp and swelling to his left shoulder. There was no documentation of post fall nurse assessment. The QC stated, "There was no documentation of a post fall assessment by a nurse and it is expected to be documented any time a patient falls."

During a concurrent interview and record review, on 1/13/21, at 12:13 p.m., with the QC, Pt 30's MC dated 12/27/20 was reviewed. The MC indicated that on 12/27/20, at 11:15 p.m., "[Pt 30] stood up and fell, now has contusion (bruising) and swelling to left side of face..." There was no documentation of a post fall nursing assessment. The QC stated, "There was no documentation of a post fall nurse assessment and it is expected to be documented any time a patient falls."

During a review of the hospital's policy and procedure (P&P) titled, "Falls Prevention and Management Policy," dated 3/22/2017, the P&P indicated, " ...A. 1. The RN (Registered Nurse) will assess each patient's fall risk at the time of...after a patient fall...G. Post Fall Management 1. Assess a. Immediately perform and document complete head-to-toe assessment including neuro [neurological] check, vital signs, and assessment for possible injuries. Identify changes from pre-fall status. Follow facility process to stabilize neck and spine if indicated based on assessment. 3. Document a. Assessment of patient's condition, patient's explanation of what happened, name and time the physician and family was notified, and any interventions initiated by the physician or nurse..."

Based on observation, interview, and record review, the hospital failed to to ensure less restrictive measures were implemented prior to initiation of restraints for one of 30 sampled patients (Patient [Pt] 23) when soft restraints were applied to Pt 23's wrist and there was no documentation less restrictive measures were implemented.

This failure had the potential for patient movements to be restricted or restraint unnecessarily when other means may be effective to resolve behavioral issues or safety issues.

Findings:

During a concurrent interview and record review, on 1/11/21, at 12:50 p.m., with the Registered Nurse Educator (RNE), Pt 23's restraint record was reviewed. Pt 23 had bilateral (both right and left) soft limb (term used to describe arm or leg) restraints applied to both wrists, on 12/29/20, at 6:40 a.m. to prevent Pt 23 from pulling the intravenous (IV-into the vein) lines, dressings, and Bi-level Positive Air Pressure (BiPap-a device that helps push air into one's lungs when suffering from difficulty breathing) mask. The RNE was unable to find documentation of less restrictive interventions were attempted prior to the restraint application. The RNE stated the expectation was for less restrictive interventions to be tried first before restraints were applied.

During a review of the hospital's policy and procedure (P&P) titled, "Restraint Seclusion," dated 1/19, the P&P indicated, "...IV. General Information regarding Restraints: B. Less Restrictive Means 1. Restraints will not be used when less restrictive interventions would be effective. 2. When restraint is indicated, the least restrictive method of restraint is to be chosen..."

Based on interview and record review, the hospital failed to ensure the Emergency Department (ED) staffing assignment reflected all nursing personnel, including Certified Nursing Assistants (CNAs) on the staffing schedule.

This failure had the potential for qualified and competent nursing personnel to not be identified and accounted for maximum utilization of human resources to meet a safe level of care.

Findings:

During a concurrent interview and record review, on 1/11/21, at 1:59 p.m., with the Director of Emergency Department (DRED), the ED staffing assignment sheet dated 1/11/21 was reviewed. The ED staffing assignment sheet did not reflect four CNAs(CNA 1, CNA 3, CNA 4, and CNA 5) assigned as sitters (caregivers assigned to one patient to provide direct observation and monitoring under the supervision of a registered nurse) in the mental health area of the department. The DRED acknowledged the CNAs' names should have been included in the daily staffing assignment sheet.

During an interview on 1/11/21, at 2:05 p.m., with the Senior Director, Patient Care Services (SDPCS), the SDPCS acknowledged the names of the CNAs should have been included in the daily staffing assignment sheet that was posted.

During a review of the hospital's policy and procedure (P&P) titled, "Staffing Plan for Nursing Services," dated 3/17, the P&P indicated, "... I. Documenting Staffing: 1. Staffing requirements will be documented on a daily basis for each nursing area and each shift. Documentation will include at least the following: The actual number and skill mix of staff..."

Based on interview and record review, the hospital failed to ensure Registered Nurses (RNs) provided care in accordance with patients' needs when four of four Registered Nurses (RN 8, 9, 10 and 11) did not have the specialized qualifications and competencies required for their specific department (Emergency Department and Intensive Care Unit [ICU-clinical area for critically ill patients requiring extensive monitoring and care).

This failure had the potential to affect the level of care and could be detrimental (harmful) to patients when RNs did not have the competency to care for their patients.

Findings:

During a concurrent interview and Personnel Education Record (PER) review, on 1/12/21, at 3 p.m., with the Education Manager (EM), the PER of three RNs assigned in the ICU (RN 8, RN 9, and RN 11) were reviewed. The EM stated, the following RN competencies were required in the ICU for RNs to work and safely function in the ICU: Ventilator (a device that facilitates breathing in cases of respiratory failure) Training, Care of Patients with IntraAortic Balloon Pump (a type of therapeutic device which helps the heart to pump more blood), Use of Rapid Infuser (used to administer blood products and fluids at rapid rates to critically ill patients), Care of patients with Pulmonary Artery Catheter (a small catheter inserted through the neck, arm, chest, or thigh vein and maneuvered into the right side of the heart to measure pressures at different spots in the heart), Percutaneous Coronary Intervention (PCI-a non-surgical procedure to improve blood flow to the heart), and Conscious Sedation (a drug-induced depression of consciousness during which patients respond to verbal commands). The EM was not able to find RN 8 and RN 9's required ICU competencies. The EM was unable to find RN 11's competency on Conscious Sedation.

During a concurrent interview and PER review, on 1/11/21, at 3:30 p.m., with the EM, the PER for one newly hired Emergency Department RN (RN 10) was reviewed. The EM was unable to find evidence of the Conscious Sedation competency for RN 10. The EM verified the findings.

There were no policies and procedures provided on Staff Competencies.

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

1. Ensure pain assessments were completed for two of 10 sampled patients (Pt 21 and Pt 25) in accordance with facility policy and procedure.

2. Ensure less restrictive measures were considered and tried prior to initiation of restraints for one of 10 sampled patients (Pt 23) in accordance with facility policy and procedure.

3. Ensure nurse fall assessments were completed and appropriate interventions implemented for four of 10 sampled patients (Pt 27, Pt 28, Pt 29, and Pt 30) who had fallen with injuries in the Emergency Department (ED) in accordance with facility policy and procedure.

These failures had the potential for patients' care needs to go unmet and possibly lead to injury and/or harm.

Findings:

1. During a concurrent interview and record review, on 1/13/21, at 10 AM, with the Registered Nurse Educator (RNE), Pt 21's pain assessments on the COVID-19 Unit (the area designated to care for patients with laboratory confirmed COVID-19 [a highly infectious respiratory illness caused by the Coronavirus]), dated 1/11/21 and 1/12/21, were reviewed. RNE was unable to find documentation of pain assessment upon admission on the unit, on 1/11/21 at 4:17 PM and thereafter. RNE was unable to find documentation of pain assessments on 1/12/21 at 9 AM, 12 PM, 8 PM, 11 PM, and 3 AM. RNE stated, "Pain assessments on the floor are done every four hours. If an oral pain medication is administered to a patient, pain is reassessed after an hour of administration; if an intravenous (IV) pain medication is administered, pain reassessment is done 30 minutes from the time of administration."

During a concurrent interview and record review, on 1/13/21, at 2 PM, with RNE, Pt 25's pain assessments in the Intensive Care Unit (area for critically-ill patients), dated 12/7/20 and 12/8/20, were reviewed. On 12/7/20, Pt 25's pain assessment was done at 9 AM, with zero pain, and the next pain assessment was done 11 hours later at 8 PM, with zero pain. On 12/8/20, pain assessments were done every four hours from midnight until 12 PM and eight hours later at 8 PM with zero pain.

During a review of the facility's policy and procedure (P&P) titled, "Pain Assessment and Management," dated 12/20, the P&P indicated, "A. When a patient presents for care he/she will be assessed regarding the presence of pain. The information will be documented as part of the initial nursing assessment."

During a review of the facility's policy and procedure (P&P) titled, "Vital Signs Assessment and Reassessment," dated 1/23/20, the P&P indicated, "A. Vital signs for patients in the Intensive Care Unit will be: 3. Assess and document pain level in all critically-ill adult patients who can self-report pain using pain assessment tools. . .a. Perform and document pain assessment every four hours, including a baseline evaluation at the beginning of nursing shifts."

2. During a concurrent interview and record review, on 1/11/21, at 12:50 PM, with RNE, Pt 23's restraint record was reviewed. Pt 23 had bilateral (both right and left) soft limb restraints (medical device applied to prevent patient from harming themselves) applied on both wrists, on 12/29/20, at 6:40 AM to prevent Pt 23 from pulling intravenous (IV) lines, dressings, and Bi-level Positive Air Pressure (BiPap-a device that helps push air into one's lungs when suffering from difficulty breathing) mask. RNE was unable to find documentation less restrictive interventions were considered and tried prior to restraint application. RNE stated the expectation was to implement the least restrictive measures prior to application of restraints.

During a review of the facility's policy and procedure (P&P) titled, "Restraint Seclusion," dated 1/19, the P&P indicated, "IV. General Information regarding Restraints: B. Less Restrictive Means 1. Restraints will not be used when less restrictive interventions would be effective. 2. When restraint is indicated, the least restrictive method of restraint is to be chosen."

3. During an interview on 1/13/21, at 5:42 PM, with the Director of Emergency Department (DRED), DRED stated, when a patient fell, the expectation was for the nurse to notify the provider caring for the patient, for the nurse to perform a head-to-toe assessment and stabilize and initiate appropriate interventions to prevent falls, to document the assessment in the medical chart, notify family, and follow through with orders if there are injuries.

During a concurrent interview and record review, on 1/13/21, at 11:30 AM, with Quality Consultant (QC), Pt 27's Medical Chart (MC), dated 7/9/20 was reviewed. The MC indicated that on 7/9/20, at 9 PM, Pt 27 had a fall in the waiting room and received a scratch to her right leg with a bruise. There was no evidence an initial fall risk assessment was done and QC stated a fall risk assessment should have been done and documented and was not. There was no documentation of a post fall nurse assessment. QC stated, "There was no documentation of a post fall assessment by a nurse and it is expected to be documented any time a patient falls."

During a concurrent interview and record review, on 1/13/21, at 11:42 AM, with QC, Pt 28's MC, dated 8/14/20 was reviewed. The MC indicated that on 8/14/20, at 5:25 AM, a physician note stated, "Notified patient fell and has hematoma." The MC did not have corresponding nurse entries documenting the fall and injury. QC stated the assigned nurse should have documented the fall and circumstances about the injury. There was no documentation of post fall nurse assessment." QC stated, "There was no documentation of a post fall assessment by a nurse and it is expected to be documented any time a patient falls."

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

1. Ensure one Emergency Department (ED) Registered Nurse (RN 7) followed the facility's policy and procedure on Medication Administration and the physician's order in administering Ativan (narcotic medication used to treat anxiety) 2 mg/ml (milligram per milliliter -a unit of measurement) IVP (intravenous-into the vein) for one of one sampled patient (Pt 21).

2. Ensure the Insulin Lispro (medication used to lower blood sugar) was available and administered to one of one sampled patient (Pt 13) as ordered.

These failures resulted in medication errors or adverse drug reactions and the potential for patient injury and harm.

Findings:

1. During an observation on 1/11/21, at 11:30 AM, in the ED Room 22, RN 7 prepared Ativan 2 mg/ml [1 ml vial of a 2mg/ml] for Pt 21. While in room 22, RN 7 put on gloves without washing her hands. RN 7 removed the top of the medication vial without wiping it with an alcohol wipe, and then inserted the needle into the vial, and withdrew the medication. RN 7 asked for someone to witness her waste three ml of the medication. The Director of the Emergency Department (DRED) witnessed the waste. RN 7 was not observed to check the medication order prior to pulling the medication from the automated drug dispensing cabinet.

During an interview on 1/11/21, at 12:07 PM, with RN 7, RN 7 stated, "I needed to give [Pt 21] Ativan to make sure he stays calm prior to transfer to the floor. I went back to [Pt 21]'s chart in the computer, and I saw I could give him 2 mg of Ativan IV (intravenous, through the vein)) but I got confused. I saw three orders: one to be given via intramuscular (via the muscles) route, one to be given IV, and one was discontinued. I was not reading the order correctly. I withdrew one ml and diluted it with five ml of normal saline, and wasted 3 ml of the mixed solution. I should have pulled the medication, wasted what was not needed, pushed the right amount of medication, and then flushed it". At 12:20 PM, RN 7 stated, "I totally blew it. I did not follow the right medication administration process." RN 7 acknowledged she may not have given Pt 21 the right medication dosage after the admixture.

During a review of Pt 21's "Order Sheet," dated 1/11/21 at 10:59 AM, the order indicated, "Ativan 0.5 ml [1 mg of a 2 mg/ml] PRN (as needed) IV Push Route 1-2 mg/min. Order comments: For IV administration, dilute with an equal amount of compatible solution prior to administration. This order was discontinued but reordered at 1:18 PM. The order indicated, "Ativan 0.5 ml PRN IV Push rate: 1-2 mg/min. For IV administration, dilute with an equal amount of compatible solution prior to administration."

During a review of the facility's policy and procedure (P&P) titled, "Medication Administration," dated 2/19, the P&P indicated, "Medications are safely and accurately administered following the six rights (patient, drug, dose, route, time, reason). Guidelines A. Medications and IV fluids will be administered upon a written or transcribed telephone order from a Licensed Independent Practitioner (LIP). . ."

During a review of the facility's policy and procedure titled, "Multi-Dose Vials," dated 8/20, the P&P indicated, "Use aseptic technique when handling multi-dose vials: 4. Cleanse the rubber diaphragm of the vial wih alcohol before inserting a sterile device into the vial."


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2. During a review of Pt 13's "Prescription Details", dated 1/10/21, indicated insulin lispro was ordered on 1/10/21 with meals and HS (night time) per sliding scale (refers to the progressive increase in the pre-meal or nighttime insulin dose, based on pre-defined blood sugar ranges).

During a review of Pt 13's "Medication Administration [Record]" (MAR), dated 1/10/21, the MAR indicated insulin lispro was not given at 8:54 a.m. The MAR indicated the insulin lispro was not given due to "missing med [medication]".

During a review of Pt 13's "Diabetic - Data Blood Glucose" dated 1/10/21, indicated Pt 13's blood glucose was 243 mg/dL (referring to the level of sugar or glucose in blood represented by milligrams [mg or weight) in deciliters [dL or volume]) at 8:36 a.m. Pt 13's blood glucose was 304 mg/dL at 12:12 p.m. (61 mg/dl increase).

During a concurrent interview and record review on 1/13/21, at 6:42 p.m., with Clinical Manager (CM) 1, CM 1 stated the insulin lispro was not administered as ordered by the physician. CM 1 stated Pt 13 should have been given 4 units of insulin lispro on 1/10/21 at 8:36 a.m. for a blood sugar of 243 mg/dL per the sliding scale. CM 1 stated the registered nurse should have requested the insulin from the pharmacy and notified the physician of a missing medication. CM 1 stated Pt 13's blood sugar increased to 304 at 12:12 p.m. by the time Pt 13 had the first dose of insulin lispro. CM 1 stated leaving Pt 13's blood sugar to go uncontrolled could have led to medical complications such as kidney failure and diabetic ketoacidosis (diabetic complication where the body produces blood acids that lead to weakness, confusion, nausea, abdominal pain ). Pt 13's "Prescription Details", dated 1/10/21, indicated, the amount of insulin needed with meals was, " ...70-150 = none ...151-200 = 2 units ...201-250 = 4 units ...251-300 = 6 units ...301-350 = 8 units ...351-400 = 10 units ...>400 = 12 units ..." and Pt 13 needed to be given 4 units of insulin lispro.

During a review of the facility policy and procedure titled, "Medication Administration", dated 2/25/19, indicated, " ...Q. Meds administered outside of the prescribed timeframe (early and/or late) ...2. Medications that remain "not given" (Red Medication): a. At bedside shift report all medications administration times in "RED" indicating NOT GIVEN on the e-MAR or Status Board must be addressed. I. Reason for not administering the medication is to be noted in Nurses Notes in the electronic record. II. Caution needs to be taken so that RED MEDS are not missed. 3. If meds need to undergo re-scheduling, a. Message is sent to Pharmacy requesting rescheduling. b. Medication is to be acknowledged and administered per new schedule ...S. An Event Report must be generated for all medication errors. Examples are: 1. Late medication ...2. Missed medications ..."

Based on interview and record review, the facility failed to ensure the Informed Consent (a process that explains the risks, benefits, and other alternatives of a medical treatment or surgical procedure to a patient before the patient agrees to it) was properly executed for one of one patient (Pt 24) and the form completed.

This failure had the potential for patients to not be fully informed and make an educated choice.

Findings:

During a concurrent interview and record review, on 1/13/21, at 2 PM, with the Registered Nurse Educator (RNE), Pt 24's Informed Consent for Repeat Caesarean Section, dated 1/8/21, was reviewed. The informed consent indicated Pt 24 signed it on 1/8/21 at 5:30 AM. The Informed Consent had the following sections on the form missing:
The informed consent did not have the name of the patient written on the form.
The full name of the surgeon performing the procedure was not spelled out completely.
The names of the two surgical assistants/surgeons were not filled in.
The type of anesthesia to be used was left blank.
The name of the anesthesiologist was not identified on the form.
The informed consent was not dated, timed, and signed by the physician who explained the risks, the benefits, and alternatives of the surgery and blood transfusion.
RNE verified the findings.

During an interview on 1/13/21, at 2:15 PM, with the Quality and Patient Safety Coordinator (QPSC), QPSC stated the Informed Consent should be completed and should have all the elements needed before the patient signs the form. The patient's name must be written, not just a sticker applied on the form, the names of the doctors who assisted the primary surgeon must be listed, the type of anesthesia, the anesthesiologist, and the signature of the physician who gave the informed consent. QPSC provided the names of the two surgeon assistants and verified the findings.

During a review of the facility's policy and procedure (P&P) titled, Consent for Treatment/Informed Consent," dated 12/19, the P&P indicated, "B. Consent to Surgery: 1. The concept of "Informed Consent" holds that the patient or person authorized to consent has the right to be informed of the following: a. The proposed care, treatment, service, medication, intervention, or procedure. . . The duty to provide this information and obtain informed consent is exclusively that of the treating Licensed Independent Practitioner (LIP)."

Based on observation, interview, and record review, the facility failed to ensure drug storage areas were adequately monitored, stored, and labeled as evidenced by:

1) A Sterile Water bottle was opened and not dated.

2) An open bottle of Humulin R insulin (medication used to lower blood sugar) was opened and not dated.

3) A bottle of Proparacaine (eye drops used to numb the eye) was out of the refrigerator, not protected by light, and found inside the eye tray in the clean utility room.

4) Different medications were stored in bins with wrong labels.

These failures had the potential to result in medication error or adverse reaction to patients.

Findings:

1. During a concurrent observation and interview on 1/11/21, at 11:07 AM, with Clinical Manager (CM 2), in the Emergency Department (ED) south station medication room, there was an open bottle of Sterile Water that was half way full with the seal broken. There was no label or date on the bottle. CM 2 stated, the opened bottle of Sterile Water should be dated when opened.

During a review of the facility's policy and procedure (P&P) titled, "Multi-Dose Vials," dated 6/8/20, the P&P indicated, "H. Discard multi-dose vials 28 days after initial entry into the vial. 1. A sticker or hand written date that identifies when the vial expires will be applied to the vial."

2. During a concurrent observation and interview on 1/11/21, at 1:04 PM, with CM 2, in the ED north station medication room, there was a bottle of Humulin R insulin with a broken seal in the medication refrigerator. There was no opened date on the bottle. CM 2 stated, insulin bottles should be dated when opened.

During a review of the facility's policy and procedure (P&P) titled, "Multi-Dose Vials," dated 6/8/20, the P&P indicated, "H. Discard multi-dose vials 28 days after initial entry into the vial. 1. A sticker or hand written date that identifies when the vial expires will be applied to the vial."

3. During a concurrent observation and interview on 1/11/21, at 1:15 PM, with the Director of the Emergency Department (DRED), in the clean utility room, there was a bottle of Proparacaine, in the eye tray. DRED stated, this should be refrigerated and not left out in a utility room.

During a review of the clinical drug resource Lexicomp.com, (undated), Lexicomp indicated "Proparacaine Storage/Stability: Store under refrigeration at 2 degrees to 8 degrees Celsius (a unit of temperature). Protect from light."

During a review of the facility's policy and procedure (P&P) titled, "Medication Storage and Security," dated 7/26/19, the P&P indicated, "A. Storage 1. Medications dispensed from the pharmacy and stored in the locations outside of the pharmacy will be maintained in a manner that protects the integrity of the individual medication(s). This is inclusive of temperature, light, and humidity, as appropriate. "

4. During a concurrent observation and interview on 1/11/21, at 11:19 AM, with CM 2, in the ED south station medication room, there were two boxes of Premarin (used for abnormal uterine bleeding) injection boxes stored in the bin labeled "Tetanus Toxoid (Vaccine for lockjaw)", five Diltiazem (medication used for abnormal heart rhythm) vials stored in bin labeled "Filgrastim (medication used to stimulate white blood cells)", and five vials of Octreotide (Medicaiton used to help gastric bleeding) stored in bin labeled "PPD skin test (vaccine used to detect tuberculosis [a highly infectious lung disease])."

During a concurrent observation and interview on 1/11/21, at 1:04 PM, with CM 2, in the ED north station medication room, there were three vials of Vasopressin (medication used to raise blood pressure) stored in a bin labeled "Promethazine (medication used for nausea and vomiting) suppositories."

During a review of the facility's policy and procedure (P&P) titled, "Medication Storage and Security," dated 7/26/19, the P&P indicated, "Facility staff follows practices that insure safe and appropriate storage and handling of medications. Those practices maintain product integrity, minimize the risk of diversion, and reduce the potential for dispensing errors."

Based on observation, interview, and record review, the facility failed to discard three expired bottles of Betadine (a topical solution used to protect the skin against germs) found in a procedure cart.

This failure had the potential to result in a patient receiving a solution that was expired and could cause adverse reactions.

Findings:

During a concurrent observation and interview on 1/11/21, at 5:53 PM, with Charge Nurse (CN) 4, at the nursing station in the intensive care unit (ICU-unit for critically ill patients), three bottles of Betadine were found in the bottom drawer of a procedure cart. The date on the bottles stated "Exp: 08/19." CN 4 stated, there should not have been expired bottles of Betadine inside the cart available for patient use.

During a review of the facility's policy and procedure (P&P) titled, "Medication Storage and Security," dated 12/06, the P&P indicated, "Disposal/Return 1. Medications not immmediately administered or found to be not [sic] needed are to be returned/disposed of per hospital policy."

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

1. The Medical Gas Outlet/Inlet Machines, called BOOM, in the Emergency Department (ED) Trauma Rooms 1 and 2 and Exam Room 3 were not maintained in an acceptable level of safety and quality.

2. The crash cart did not have the portable suction machine (a medical equipment used for removing obstructions from a patients airway) required for medical emergencies.

These failures had the potential to place patients at risk for harm.

Findings:

During a concurrent observation and interview on 1/11/21, at 12:35 PM, with the Director of the Emergency Department (DRED), in the Trauma Room, the two BOOM machines had no Preventative Maintenance sticker to indicate the machines had been checked and maintained. These machines had the circuits for Code Blue (used for medical emergencies), vacuum for suctioning, heart monitors, and other gas and electrical circuitry. DRED called the Facilities Director (FD) and was informed the machines do not get preventative maintenance but they are checked for safety.

During a concurrent interview and review of the Medical Gas Outlet/Inlet Safety Record, on 1/11/21, at 1:07 PM, with FD, the safety record, dated 5/1/20, was reviewed. The safety record indicated, "BOOM 1, Room 1015 Vacuum Leaks without adapter. BOOM 2, Room 1014 Vacuum Reduced Flow 85/50." FD stated, "85/50 meant only 58% is the flow rate, which falls below the standards set forth by NFPA 99 Healthcare Code (establishes criteria for levels of health care services or systems to minimize the hazards of fire, explosion, and electricity)." FD stated, the machines are checked every six months. FD was unable to find a maintenance repair request from the ED.

During a review of the document titled, "Certified Medical Testing," dated 10/22/20, the document indicated, "Minimum Flow Rates: Vacuum Flow Rate > or =85 LPM (liters per minute). The 'Substandard Flow Rate' indicates that the flow characteristics demonstrated by specific component falls below the minimum standards set forth by the NFPA guidelines as established by the Certified Medical Testing interpretation."

During a review of "The Medical Gas "PM" Inspection 2020 Repairs Completed Record," dated 6/1/20, the repair record indicated "BOOM 1 Room 1015 Leak eliminated. BOOM 2 Room 1014 Flow restored to 85." FD verified the repair was completed one month later and stated, "We waited for the routine scheduled safety check for these machines. I did not feel it was urgent enough to get the service here. There was still some air pressure to be able to suction."

During a concurrent interview and review of the Medical Gas Outlet/Inlet Safety Record, on 1/11/21, at 2:10 PM, with FD, the safety record, dated 10/22/20, was reviewed. The safety record indicated, Exam 3 Room 1066 Vacuum No Flow." FD stated, "No vacuum is urgent and needs to be repaired within 24 hours."

During a review of "The Medical Gas "PM" Inspection 2020 Repairs Completed Record," dated 11/2/20, the repair record indicated, "Repair date 11/2/20" FD verified the findings and acknowledged the repair was done 11 days later for a machine identified as urgent and requiring a 24-hour repair.

During a review of the "Emergency Department Patient Log," dated 5/1/20 through 5/31/20, the ED Patient Log indicated, "There were 81 patients seen in the Trauma Room, 21 patients were Emergent, seven were Critical, and seven were hospitalized. Out of the seven Critical patients, two patients were transferred to another facility and five patients died.

During a review of the facility's policy and procedure (P&P) titled, Defective And/or Unsafe Equipment," dated 2/20, the P&P indicated, "A. Equipment that is not operating without proper parameters will be immediately taken out of use and reported to the Engineering/Biomedical Services and/or appropriate vendors or contracted service."


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2. During a concurrent observation and interview, on 1/11/21, at 10:32 a.m., with Charge Nurse (CN) 3, in the 7th floor Covid-19 Unit, the Crash Cart (a cart stocked with emergency medical equipment, supplies, and drugs use by medical personnel during efforts to resuscitate patients) did not have a portable suction machine. CN 3 stated the portable suction was not on the Crash Cart.

During a concurrent observation and interview, on 1/12/21, at 10:53 a.m., with Clinical Manager (CM) 1, in the 7th floor, the Crash Cart did not have a portable suction machine. CM 1 stated she will review the policy and procedure if the portable suction is a required equipment in the Crash Cart.

During a concurrent observation and interview, on 1/13/21, at 5:10 p.m., with Charge Nurse (CN) 2, in the 7th floor, the Crash Cart did not have a portable suction machine. CN 2 stated the Charge Nurse is responsible to make sure the equipment in the Crash Cart is available and working properly. CN 2 stated the Crash Cart is important during Code Blue and Rapid Response (medical emergency such as cardiac or respiratory arrest). CN 2 stated the portable suction machine was not available in the Crash Cart.

During a concurrent interview and record review, on 1/13/21, at 6 p.m., with CM 1, the facility's policy and procedure titled, "Crash Cart Management," 1/2019 was reviewed. The facility's policy and procedure "Crash Cart Management," indicated, All Crash Cart will be maintained with age appropriate emergency equipment, supplies, and medications for the patient population being served...The Crash Cart "Content List" which is laminated and available on the cart, describes the exact location... contained in the Crash Cart. This is standardized in all nursing units, describing the required... portable suction... Crash Cart Check Process:... Suction must be available... Portable unit on the Crash Cart. Portable suction is checked by turning it in and occluding the connecting tube and checking the gauge..." CM 1 stated the portable suction machine should be on the Crash Cart.

Based on observation, interview, and record review, the hospital failed to implement methods to prevent and control the transmission of infections within the hospital when:

1. Two of two direct care staff (Registered Nurse [RN] 7 and Certified Nursing Assistant [CNA] 2 were unable to demonstrate the proper sequence of donning (putting on) and doffing (taking off) of Personal Protective Equipment (PPE- refers to gowns, gloves, masks, goggles, or face shields worn to protect the wearer from injuries or infections), including a user seal check (a procedure performed by the mask wearer to verify if the N95 respirator [a filtering face piece respirator that filters at least 95% of airborne particles] is being properly worn and that there is no air leak between the face and the mask) when wearing an N95 respirator;

2a. CNA 1 assigned as a "sitter" (member of hospital personnel that will essentially monitor the behavior and habits of a particular patient) for one of 30 sampled patients (Patient [Pt] 21) who was diagnosed with COVID-19 (-a serious respiratory illness caused by a virus which is the cause of a current worldwide pandemic [prevalent over a whole country or the world]) did not wear isolation gowns and gloves while providing direct observation in the Emergency Department (ED) and during transport to the designated COVID-19 Unit;

2b. Two CNAs (CNA 6 and CNA 7) assigned as "sitters" for two of 30 sampled (Pt 7 and Pt 21) who were diagnosed with COVID-19 did not wear isolation gowns and gloves while providing direct observation for Pt 7 and Pt 21 while on the 7th floor (COVID-19 unit-designated area in the hospital for COVID-19 positive patients);

3. One of one RN (RN 7), stepped out of a positive COVID-19 patient's room, did not remove her PPE, entered the Medication Room while wearing the PPE, and disposed the PPE inside the Medication Room;

4. One of one positive COVID-19 patient's rooms (Pt 21) did not have a trash receptacle (bin) by the exit door for staff to discard their used PPE;

5. One of one RN (RN 5) did not perform hand hygiene (term used to cover both hand washing using soap and water, and cleaning hands with waterless or alcohol-based hand sanitizers) prior to putting on gloves and before medication administration;

6. One of one medication rooms had a stack of clean medication cups and intravenous connectors stored under a soap dispenser near a sink.

7. Two of two machines used to test urine samples were stored on top of a counter near the hopper (trash chutes to empty urine, feces, or other liquid wastes) and was actively used by staff to empty urine, feces, or other liquid wastes;

8. Single-item medication cutters had not been disposed and non-disposable (not designed to be thrown away after use) medication cutters were covered with gray colored particles and had not been cleaned;

9. One of one RN (RN 12) did not perform hand hygiene after exiting one of 30 sampled patient's (Pt 16) room; and

10. One of one Environmental services staff (EVS 1) did not follow manufacturer's directions for use for [brand name] disinfectant (a chemical liquid that destroys bacteria) and did not use the correct disinfectant on the 4th floor.

These failures had the potential for cross contamination (inadvertent transfer of germs from one surface or person to another) and transmission of disease, including but not limited to COVID-19 to 132 patients, staff, and visitors in the hospital.

Findings:

1. During a concurrent observation and interview, on 1/12/21, at 11:30 a.m., with RN 7, in the Conference Room, RN 7 demonstrated donning and doffing of PPE. During donning of the N95 respirator, RN 7 did not perform a user seal check. RN 7 stated, "I don't know what a user seal check is." During doffing, RN 7 removed her gloves, removed her face shield, laid her contaminated face shield on the table, and then removed her gown. RN 7 acknowledged she did not perform hand hygiene, did not clean and disinfect her face shield, and did not follow the proper sequence of doffing PPE.

During a concurrent observation and interview, on 1/12/21, at 11:55 a.m., with CNA 2, in the conference room, CNA 2 demonstrated donning and doffing of PPE. During donning, CNA 2 put on her N95 respirator, goggles, face shield, gown, and gloves. During doffing, CNA 2 removed her gloves, face shield, goggles, mask, and gown. CNA 2 was observed not performing hand hygiene between removals of the contaminated PPE. CNA 2 wiped down the goggles and face shield from the dirty surface to the clean surface of the face shield. CNA 2 stated she had not done a user seal check when putting on an N95 respirator, did not perform hand hygiene, and did not follow the sequence of donning and doffing of PPE.

During an interview on 1/12/21, at 12 p.m., with the Infection Control Preventionist (ICP), the ICP stated, "We remove the gloves, face shield, and then the gown."

During a review of the hospital's policy and procedure (P&P) titled, "Isolation Precautions" dated 12/19, the P&P indicated " ...A. Standard Precautions 3. Appropriate Personal Protective Equipment (PPE) include: a) Gloves, b) Gowns, c) Mask, eye protection or face shield. . . Attached to the P&P is the Centers for Disease Control (CDC) Guidelines on the Sequence for Putting on Personal Protective Equipment: 1. Gown 2. Mask or Respirator 3 Goggles or Face Shield 4. Gloves and the Sequence for Removing Personal Protective Equipment 1. Gloves 2. Goggles or Face Shield 3. Gown 4. Mask or Respirator. Perform hand hygiene between steps if hands become contaminated and immediately after removing all PPE. PPE must be removed slowly and deliberately in a sequence that prevents self-contamination..."

During a review of the CDC Guidelines titled, "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic," updated 12/14/20, the CDC Guidelines indicated, " ...Hand Hygiene: HCP (health care personnel) should perform hand hygiene before and after all patient contact, contact with potentially infectious material, and before putting on and after removing PPE, including gloves. Hand hygiene after removing PPE is particularly important to remove any pathogens (an agent that causes infection or disease) that might have been transferred to bare hands during the removal process. . . Filtering Face piece Respirators (FFR) Including N95 Respirators: FFR users should also perform a user seal check to ensure proper fit each time an FFR is used ..."

2. a. During a concurrent observation and interview, on 1/11/21 at 10:55 a.m., with CNA 1, outside Room 21 in the ED, CNA 1 was seated outside Room 21. CNA 1 stated he was a sitter and watched Pt 21 who was confirmed COVID-19 positive with some psychiatric behaviors. CNA 1 wore an N95 respirator and a face shield. CNA 1 stated he wore a mask [respirator] and a face shield but needed to put on an isolation gown when entering the room.

During an interview on 1/11/21, at 11 a.m., with the Clinical Manager of the ED (CM 2), CM 2 stated the sitter [CNA 1] was supposed to wear full PPE (gown, gloves, N95 respirator, and face shield) when assigned to provide direct observation in anticipation of an emergent need to assist the patient.

During an observation on 1/11/21, at 11:41 a.m., Pt 21 was transported from the ED to the COVID-19 Unit (7th floor). CNA 1 was at the head part of the gurney and pushed the gurney without wearing an isolation gown. RN 7 and a security guard assisted with the transport of Pt 21 to the COVID-19 Unit. RN 7 did not wear an isolation gown, did not wear eye protection, besides for her glasses, and did not have gloves on.

During an interview on 1/11/21, at 11:50 a.m., with CM 2, CM 2 stated, "The transporter should be in full PPE: goggles or face shield, mask, gown, and gloves... The other person is supposed to escort the patient, open the doors, open the elevators, etc. The second person is deemed to be clean. The second person is not expected to wear an isolation gown but must wear mask, goggles or face shield, and gloves..."

During an interview on 1/13/21, at 9:30 p.m., with the Chief Nursing Officer (CNO), the CNO stated, "The sitters are expected to be in full PPE: gowns, gloves, N95 masks [respirators], and goggles or face shields."

During a review of the hospital's P&P titled, "Isolation Precautions" dated 12/19, the P&P indicated, " ...D. Patient Transport: 2. Appropriate barriers (e.g. impervious dressing, clean gowns, and proper mask) are to be worn or used when patient movement outside of room is necessary..."

During a review of the CDC Guidelines titled, "Interim Infection Prevention and Control Recommendations for Healthcare Personnel during the Coronavirus Disease 2019 (COVID-19) Pandemic," updated 12/14/20, the Guidelines indicated, " ...Patient Placement: Personnel entering the room should use PPE. The recommended PPE when caring for a patient suspected or confirmed COVID-19 includes the following: Respirator or Face Mask, Eye Protection, Gloves, and Gowns..."

2. b. During an observation on 1/13/21, at 11:30 p.m., on the COVID-19 unit (7th floor), CNA 6 provided close observation to Pt 21 while in an ante room (a small room between areas of contamination) and did not wear an isolation gown (a protective apparel used to protect healthcare workers and patients from transfer of microorganisms and body fluids in isolation patients). CNA 7 provided close observation to Pt 7 in the ante room and did not wear an isolation gown.

During an interview on 1/13/21, at 1:50 p.m., with the CNO, the CNO stated CNA 6 and CNA 7 should have worn complete Personal Protective Equipment (PPE-gowns, gloves, N95 respirator, face shield) while providing close observation to patients on isolation precaution (a barrier between people and germs, helps prevent the spread of germs in the hospital) to respond immediately and enter patients' rooms during emergencies.

During a review of the hospital's P&P titled, "Isolation Precautions" dated 12/19, the P&P indicated, " ...D. Patient Transport: 2. Appropriate barriers (e.g. impervious dressing, clean gowns, and proper mask) are to be worn or used when patient movement outside of room is necessary..."

During a review of the CDC Guidelines titled, "Interim Infection Prevention and Control Recommendations for Healthcare Personnel during the Coronavirus Disease 2019 (COVID-19) Pandemic," updated 12/14/20, the Guidelines indicated, " ...Patient Placement: Personnel entering the room should use PPE. The recommended PPE when caring for a patient suspected or confirmed COVID-19 includes the following: Respirator or Face Mask, Eye Protection, Gloves, and Gowns..."

During an observation on 1/11/21, at 11:38 a.m., in the ED, RN 7 wore gloves and an isolation gown that was untied. RN 7 entered Pt 21's room to administer medication to Pt 21. RN 7 exited Pt 21's room without discarding her isolation gown and gloves. RN 7 proceeded to the medication room to dispose the sharps (needles) used. RN 7 discarded her used isolation gown and gloves inside the medication room.

During an interview on 1/11/21, at 11:45 a.m., with the Director of the Emergency Department (DRED), the DRED acknowledged [RN 7] should have discarded her used PPE upon exiting the COVID-19 positive room [Pt 21's room].

During an interview on 1/11/21, at 12:21 p.m., with RN 7, RN 7 stated, " ...Yes, I discarded the contaminated gown and gloves in the medication room. There was no trash can by the exit door inside the room."

During a review of the CDC Guidelines titled, "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic," updated 12/14/20, the Guidelines indicated, "Gloves: Remove and discard gloves before leaving the patient room or care area, and immediately perform hand hygiene. Gowns: Put on a clean isolation gown upon entry into the patient room or area . . . Tie all of the ties on the gown . . . Remove and discard the gown in a dedicated container for waste or linen before leaving the patient room or care area. Disposable gowns should be discarded after use. Reusable (washable or cloth) gowns should be laundered after each use..."

4. During an observation on 1/11/21, at 11:38 a.m., outside Pt 21's room, the trash receptacle was located outside the room. Pt 21 was on isolation for COVID-19. RN 7 exited Pt 21's room without discarding her gown and gloves, and later disposed them inside the medication room.

During an interview on 1/11/21, at 12:21 p.m., with RN 7, RN 7 stated, " ...Yes, I discarded my contaminated gown and gloves in the medication room. There was no trash can by the exit door inside the room."

During a review of the CDC Guidelines titled, "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic," updated 12/14/20, the Guidelines indicated, "Gloves: Remove and discard gloves before leaving the patient room or care area, and immediately perform hand hygiene ...Gowns: Remove and discard the gown in a dedicated container for waste or linen before leaving the patient room or care area. Disposable gowns should be discarded after use. Reusable (washable or cloth) gowns should be laundered after each use..."

5. During an observation on 1/11/21, at 11:30 a.m., in the ED, RN 7 was in the nurse's station and wore an isolation gown untied in the back, carried a vial of medication, a syringe, and a normal saline [salt water] solution in a syringe. RN 7 went to the Registration area, touched the door, touched the computer scanner and grabbed a pair of clean gloves from the isolation cart situated between Exam Room 21 and 22. RN 7 entered Exam Room 22, turned on the computer, and while looking at the computer, put on the pair of gloves without performing hand hygiene. RN 7 removed the metal cover of the medication vial and inserted the needle into the rubber top of the medication vial without cleaning and wiping the top of the medication vial. With the same pair of gloves, RN 7 entered Pt 21's room and administered the medication without performing hand hygiene during the entire observation.

During an interview on 1/11/21, at 12:21 p.m., with RN 7, RN 7 stated, " ...I totally blew it. I know I did not wash my hands and I did not change my gloves."

During a review of the hospital's P&P titled, "Multi-Drug Resistant Organisms (MDRO)," dated 12/19, the P&P indicated, " ...B. Hand Hygiene: 1. Strict compliance with hand hygiene policy is required of all personnel . . . E. Personal Protective Equipment (PPE) 2. Gloves will be changed between tasks on the same patient to prevent infection/colonization of another site on the same patient . . . 5. Gown and gloves are to be removed and hand hygiene performed prior to leaving room ..."

During a review of the hospital's P&P titled, "Hand Hygiene" dated 3/25/20, the P&P indicated, " ...3. Health care workers shall decontaminate hands using alcohol-based hand rub or washing with soap (plain antimicrobial) and water under the following circumstances: a. Before and after patient contact . . . f. Before preparing or handling medication in anticipation of patient care . . . h. After contact with inanimate objects that are used for direct patient care in the immediate vicinity of the patient. i. After removing gloves..."

6. During a concurrent observation and interview, on 1/11/21, at 11:21 a.m., with CM 2, a stack of clean medication cups and a box of IV connectors were stored under the soap dispenser and in close proximity to the sink. CM 2 validated the findings.

During a review of the hospital's P&P titled, "Cleaning of Patient Care Equipment," revised 6/20, the P&P indicated, " ...8. Equipment will not be stored on or immediately around the sink to avoid contamination ..."

7. During a concurrent observation and interview, on 1/11/21, at 1:25 p.m., with the DRED and CM 2, in the ED's Dirty Utility Room, there were two point-of-care (bedside or near-patient testing) urine test machines stored on the counter in close proximity to the hopper. The hopper had a clear plastic covering in the front but not on both sides in which splatter could occur and potentially contaminate the urine test machines. The DRED stated the hopper was actively used and acknowledged the potential for cross-contamination. The DRED and CM 2 were unclear about the cleaning and disinfection of the urine test machines.

During a review of the hospital's P&P titled, "Cleaning of Patient Care Equipment," revised 6/20, the P&P indicated, " ...8. Equipment will not be stored on or immediately around the sink to avoid contamination . . . 13. If it is unclear whether patient care equipment has been cleaned, it must be cleaned again before patient use. The urine test equipment is not on the general guideline list for cleaning and disinfection of patient care equipment..."


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8. During a concurrent observation and interview on 1/11/21, at 11:07 a.m., with CM 2, in the ED south station medication room, a plastic pill cutter was on a paper towel in a blue bin. The pill cuter was opened. There was white powder around the top and bottom of the pill cutter. CM 2 stated, "It [pill cutter] looks used and pill cutters should be single use only and there should not be a used one out in the medication room."

During a concurrent observation and interview on 1/11/21, at 5:45 p.m., with Charge Nurse (CN) 4, inside the medication room in the intensive care unit (ICU-clinical area for critically ill patients requiring extensive monitoring and care), two plastic pill cutters were in a blue bin on the counter. One of the pill cutters had grey particles on it. CN 4 stated, "They [pill cutters] are hard to find ... being used for more than one patient and should be cleaned in between use. Those are dust. I don't know when they [pill crushers] have been cleaned."

During an interview on 1/11/21, at 4:25 p.m., with the Director of Pharmacy (DP), the DP stated pill cutters should be single patient use and should not be used on multiple patients.

During a review of the hospital's P&P titled, "Infection Control," dated 12/19, the P&P indicated, " ...E. Patient Equipment: 1. Use disposable noncritical patient care or implement patient dedicated equipment use. 2. If common use of equipment is unavoidable, clean and disinfect with hospital approved disinfectant wipe before use. . ."


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9. During an observation on 1/11/21, at 11:07 a.m., near Pt 16's room, RN 12 was inside Pt 16's room. RN 12 walked out of the room without performing hand hygiene. RN 12 walked to the nurse's station and then walked back into Pt 16's room.

During an interview on 1/11/21, at 11:24 a.m., with RN 12, RN 12 stated he did not perform hand hygiene after he exited Pt 16's room. RN 12 stated he needed to perform hand hygiene every time he came in contact with a patient but did not do so. RN 12 stated it was important to perform hand hygiene to prevent the spread of infection to other patients especially the COVID-19 virus.

During an interview on 1/11/21, at 11:28 a.m., with CN 5, CN 5 stated it was important for RNs to perform hand hygiene after exiting a patient's room to prevent the spread of infection. CN 5 stated RN 12 should have performed hand hygiene with the hand sanitizer. CN 5 stated during the recent COVID-19 pandemic, it was very important to prevent the spread of the virus due to patients and staff possibly experiencing asymptomatic infection (infection which presents with no symptoms and will not develop at a later time). CN 5 stated it was the expectation for all staff to perform hand hygiene for any patient contact.

During a professional reference review, retrieved on 1/25/21, from https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, titled, "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic," dated 12/14/20, indicated, " ...Hand Hygiene ...HCP should perform hand hygiene before and after all patient contact, contact with potentially infectious material, and before putting on and after removing PPE, including gloves. Hand hygiene after removing PPE is particularly important to remove any pathogens that might have been transferred to bare hands during the removal process ...HCP should perform hand hygiene by using ABHS with 60-95% alcohol or washing hands with soap and water for at least 20 seconds. If hands are visibly soiled, use soap and water before returning to ABHS ...Healthcare facilities should ensure that hand hygiene supplies are readily available to all personnel in every care location ..."

10. During an interview on 1/12/21, at 11:13 a.m., with EVS 1 on the 4th floor, EVS 1 stated he used "[brand name] Plus" disinfectant to disinfect high touch (surfaces that are handled frequently throughout the day by numerous people) surfaces in patients' rooms. EVS 1 stated he would soak a cloth wipe in the disinfectant and wipe surfaces in patients' rooms to disinfect the environment. EVS 1 stated he would let the disinfectant air dry. EVS 1 stated he did not know how long the [brand name] disinfectant needed to air dry. EVS 1 stated it was important to let the disinfectant air dry to kill viruses that may be on surfaces. EVS 1 stated he needed to allow time to disinfect objects in a patients' room before using them.

During an interview on 1/12/21, at 1:38 p.m., with Environmental Services Lead (EVSL) 1, EVSL 2, and the EVS Director (EVSD), EVSL 1 stated "[brand name] Plus" disinfectant that was used by EVS 1 on the 4th floor was not appropriate. EVSL 1 stated "[brand name] Plus" disinfectant should have only been used for the operation room (OR). The EVSL stated "[brand name] Regular" disinfectant was the disinfectant that should have been used on the 4th floor (medical surgical floor in the hospital). EVSL 1 stated the contact time (time allowed for disinfectant to be on surfaces to kill viruses) for the "[brand name] Regular" disinfectant was three minutes. EVSL 1 stated EVS 1 needed to use the correct [brand name] disinfectant on the 4th floor. EVSL 1 stated it was important for EVS 1 to know the correct contact time for all solutions in order to properly disinfect surfaces. The EVSD stated it was his responsibility to ensure EVS personnel knew what disinfectants to use in the correct environments and how to use the disinfectants correctly. The EVSD stated it was important to correctly disinfect all surfaces to prevent cross contamination and avoid patients acquiring secondary infections in the facility.

During a review of the facility policy and procedure titled, "EVS Cleaning/Sanitizing Solutions," dated 7/20, indicated, " ...Step 1: EVS director, in collaboration with facility, is responsible for identifying products used for cleaning/sanitizing. Director is responsible for ensuring chemicals are effective in providing a clean and sanitary facility when used properly ...Step 3. Wet times are based on manufacturer recommendation. It is important to follow manufacturer recommendations for proper dwell times. Dwell times need to be kept in order to ensure chemicals are working effectively ...Step 5: EVS director is responsible to provide in-service education to EVS staff regarding cleaning/sanitizing solutions. Staff must be trained on use of chemicals. Training must be documented to ensure all staff has received proper training ..."

During a review of the [brand name] Plus disinfectant manufacturer guidelines, dated 2019, indicated, " ...Dilutable Disinfectant Cleaner ...1:256 dilution - Bactericidal, Virucidal, and Fungicidal, in 3 minutes ...Some organisms require a 10 minute contact time and/or other dilutions. Please see product label or reference sheet for complete information..."

Based on interview and record review, the facility failed to conduct infection control surveillance (provides information on the occurrence of unusually high rates of infection and trends over time) activities related to COVID-19 (a highly contagious respiratory illness caused by the coronavirus). This failure had the potential for the facility to not identify infections, implement the actions necessary to prevent and control infections, and evaluate the impact of the interventions on the rate of infections.

Findings:

During a concurrent interview and record review, on 1/13/21, at 2:50 PM, with the Infection Control Preventionist (ICP), ICP stated, "The facility conducts surveillance activities on testing, deaths reported, hand hygiene, use of personal protective equipment (PPE- refers to gowns, gloves, masks, goggles, or face shields worn to protect the wearer from injuries or infections), appropriate isolation, and screening." ICP reviewed the hand washing surveillance activities dated 12/20. ICP was unable to provide evidence of surveillance records with the indicators used to monitor those who are being directly observed for hand washing. ICP presented a record with hash marks, indicating the number of staff observed. ICP was unable to show evidence of non-compliance and how non-compliance was corrected. There were no tracking and trending reports as well as outcome of the surveillance conducted. ICP stated, "The facility uses anonymous observers, mostly volunteers, to directly observe hand hygiene. I receive the report verbally from the anonymous observers but I don't have a record of what has been observed for compliance or non-compliance."

During a review of the facility's policy and procedure (P&P) titled, "Infection Prevention Program FY 2021," dated 11/20, the P&P indicated, "Hand Hygiene: Track and report compliance rates by location and job type. Provide immediate feedback to personnel at time of observed non-compliance. . ."

During a review of the Centers for Disease Guidelines titled, "Public Health Guidance for Community-Level Preparedness and Response to Severe Acute Respiratory Syndrome (SARS), dated 11/17/20, the guidelines indicated, "... Supplement B: SARS Surveillance Surveillance case definitions are used primarily for identifying and classifying cases. . . However, for conditions of public health importance such as SARS-CoV disease, disease-control activities should be initiated as soon as possible after a potential case is recognized. . .The U.S. COVID-19 Surveillance goals are to: Monitor spread and intensity of COVID-19 disease. . ., Understand disease severity and the spectrum of illness, Understand risk factors for severe disease and transmission. . ."