HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 2 (Pt. #10) clinical records reviewed for restraints, the Hospital failed to ensure that each order for restraints was renewed every 2 hours for children and adolescents 9 to 17 years of age.

Findings include:

1. On 6/14/2022, the Hospital's policy titled, "Restraint and Seclusion" revised by the Hospital October 2021, was reviewed. The policy required, "...Restraint and Seclusion for Violent, self-destructive patients who are a threat to themselves or others...II. Orders for Restraint or Seclusion...2. Each order for Restraint or Seclusion may only last for the following amount of time...(B) 2 hours for children and adolescents 9 to 17 years of age..."

2. On 6/13/2022, Pt. #10's clinical record was reviewed. Pt. #10 was a 13 year old, who was admitted on 5/12/2022, with injuries related to a motor vehicle accident. The Physician order, dated 6/11/2022 at 6:19 AM, included, "...Restraints Violent/Self-destructive...duration 2 hours...". The Restraint flowsheet, dated 6/11/2022, showed that Pt. #10 had soft restraints from 6:55 AM - 4:00 PM (9 hours and 5 minutes). The clinical record lacked documentation of violent restraint renewal orders, every 2 hours, as required.

3. On 6/13/2022 at approximately 10:15 AM, an interview was conducted with a Patient Care Manager (E #2). E #2 stated that Pt. #10 had violent restraints on 6/11/2022, and the restraint order had not been renewed after the initial order at 6:19 AM. E #2 stated that violent restraint orders should be reviewed and renewed every 2 hours for patients between the ages 9 to 17, if the patient remains in restraints.

Based on document review, observation, and interview, it was determined that the Hospital failed to manage dietary services by not ensuring that equipment was cleaned properly; staff adhered to the dress code policy; and dry storage products were stored, as required. This has the potential to affect the average 400-450 patient food trays per day.

Findings include:

1. The Hospital's policy titled, "Food and Supply Storage" (dated 1/22), was reviewed on 6/15/2022, and required, "All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption...Foods that must be opened must be stored in NSF [National Sanitation Foundation] approved containers that have tight fitting lids...Hang scoop. Scoops may be stored in bins on a scoop holder..."

2. The Hospital's policy titled, "Uniform Dress Code" (dated 1/22), was reviewed on 6/15/2022, and required, "Associates Working with Food...Wear the approved hair restraint when on duty regardless of length or presence of hair..."

3. The Hospital's policy titled, "Cleaning of Food and Nonfood Contact Surfaces" (dated 1/16), was reviewed on 6/15/2022, and required, "Food Contact Surfaces: To prevent cross-contamination, kitchenware and food-contact surfaces of equipment shall be washed, rinsed, and sanitized after each use and following any interruption of operations during which time contamination may have occurred. Where equipment and utensils are used for the preparation of potentially hazardous foods on a continuous or production-line basis, utensils and food-contact surfaces of equipment shall be washed, rinsed, and sanitized before and after each use with raw animal products...Nonfood Contact Surfaces: Nonfood contact surfaces of equipment...shall be cleaned as often as necessary to keep the equipment free of accumulation of dust, dirt, food particles, and other debris..."

4. On 6/13/2022 at 11:50 AM, a tour of Dietary Services (Billings/Mitchell Kitchen) was conducted. The following observations were made:

- 4 separate bins (containing cornmeal, flour, rice, and white sugar), were noted with the scoops stored inside of the bins (not stored in the scoop holder).
- A powered-on circulating fan, near the food preparation area, contained a visable amount of dust build-up.
- The meat slicer, which was not in use at the time of the observation, contained dried pieces of meat that was from previous use.
- A Dietary Aide (E #10) , assigned to tray delivery to the units, wore a hair restraint. However, greater than 2 inches of hair was exposed.

- On 6/14/2022 at 11:20 AM, an additional tour of Dietary Services (Billings/Mitchell Kitchen) was conducted. A Dietary Aide (E #11), wore a hair restraint. However, greater than 3 inches of hair was exposed.

5. On 6/13/2022 at 12:15 PM, an interview was conducted with the Director of Food Services (E #12). E #12 stated that staff are required to wear the hair nets properly by covering all of the hair, and no hair should be exposed.

6. On 6/13/2022 at 12:30 PM, an interview was conducted with the Regional Director of Food Services (E #13). E # 13 stated that scoops should not be stored inside of the bins of the dry storage foods and should be stored on the side of the bin in the holder. E #13 stated that the meat slicer should be cleaned after each use. E #13 acknowledged the excessive build up of dust on the fan near the food prep area and stated that it should be cleaned.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of a Full Survey Due to a Complaint conducted on June 14 - 16, 2022, the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of the Full Survey Due to a Complaint conducted on June 14 - 16, 2022, the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

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

Based on observation, document review, and interview, it was determined that the Hospital failed to ensure expired patient care supplies were not available for patient use.

Findings include:

1. A tour of the Pediatric Emergency Department (ED) was conducted on 06/15/2022 between 8:50 AM and 9:10 AM. In the storage room, the following sterile expired items were observed:
-Four (4) Multi-Lumen Central Venous Catherization Kits ( expired December 2021).
-Two (2) Chest Trocar Kits (used to drain fluid from chest cavity) (expired November 30, 2021).
-One (1) Thora-Para Catheter Drain Kit (used to drain fluid from chest or abdomen) (expired February 28, 2021).
-One (1) 50 ml (milliliter) bottle of normal saline (expired October 2021).

2. The Hospital's policy titled, "Supplies: Selection, Storage, and Use" ( reviewed by Hospital 7/2021) was reviewed and required, "...2. Sterile Items a) If the manufacturer provides an expiration date on its sterile item, that item will be considered sterile until the expiration date has been reached... j. Storage shelves should be free of expired sterile items..."

3. The findings were discussed with the Patient Care Manger of Pediatric ED (E#15) on 6/15/2022 at approximately 9:15 AM. E#15 stated that all expired patient care supplies should be removed. E#15 stated that he is not sure why these items were not removed and will have staff remove them immediately.

Based on document review, observation, and interview, it was determined that for 2 of 2 General Medicine Units, the Hospital failed to ensure that proper PPE (personal protective equipment) was utilized in order to prevent and control the transmission of COVID-19. This has the potential to affect all 56 patients (total) on both of the units.

Findings include:

1. The Hospital's policy titled, "Isolation" (dated 7/2021), was reviewed on 6/15/2022, and required, "...Special Respiratory Precautions. This isolation category is designed to prevent the transmission of infectious diseases such as Coronavirus-2019 (COVID-19)...Patients with confirmed COVID-19 or patients under investigation (PUI) for COVID-19 will be placed on Special Respiratory precautions until they meet the criteria where isolation is no longer required or have been ruled out as having COVID-19...N95/half-face respirator/PAPR [powered air purifying respirator] required..."

2. The Hospital's "COVID-19 Adult Inpatient Pathway" (dated 12/22/2021), was reviewed on 6/15/2022, and required, "Patient meets the following criteria: Patient has new onset symptoms concerning for COVID-19 (symptoms), Symptoms outside transfer hospital, Physician identifies patient as Person Under Investigation (PUI): Isolation Precautions: Special Respiratory..."

3. The Hospital's "Special Respiratory Precautions" signage included, "N95 or PAPR required...All Healthcare workers MUST WEAR A TYPE N95 PARTICULATE RESPIRATOR or a POWERED AIR PURIFYING RESPIRATOR (PAPR)..."

4. The Centers for Disease Control and Prevention (CDC)'s Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic,
(updated Feb. 2, 2022), required, "2. Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed SARS-CoV-2 [COVID-19] infection: Personal Protective Equipment: HCP [healthcare professional] who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator..."

5. On 6/13/2022 at 9:35 AM, a tour of the General Medicine Unit (9 West) was conducted. The unit had 6 patients on "Special Respiratory Precautions" (patients with COVID-19 symptoms or COVID-19 PUI). During the tour, there was observation of direct care staff with surgical masks on (not the required N95 masks), entering the isolation rooms. The Unit's Director (E # 9) was present and stated that the staff are not required to wear N95 masks anymore since the staff have been fully vaccinated and received boosters for COVID-19.

- On 6/13/2022 at 11:10 AM, a tour of the General Medicine Unit (9 East ) was conducted. The unit had 3 patients on "Special Respiratory Precautions". During the tour, direct care staff were noted with surgical masks on (not the required N95 masks), entering the isolation rooms.

- On 6/15/2022 at approximately 10:30 AM, an additional tour of 9 East and 9 West was conducted. During the tour, interviews were conducted with staff nurses (E #6 and E #7), caring for patients on "Special Respiratory Precautions". Both E #6 and E #7 (who had on surgical masks at the time of the tour), stated that they wear surgical masks when caring for patients on "Special Respiratory Precautions".

6. On 6/15/2022 at 10:15 AM, an interview was conducted with the Director of Infection Prevention and Control (E #8). E #8 stated that N95 masks are required any time a staff is taking care of a suspected COVID-19 patient or a patient with COVID-19.

Based on document review and interview, it was determined that for 1 of 2 (Pt. #27) patient death records reviewed, the Hospital failed to notify the organ procurement organization (OPO) of a patients death.

Findings include:

1. The Organ and Tissue Procurement Agreement between Gift of Hope (GOH-OPO) and the (Hospital) was reviewed on 6/15/2022 and required, "Hospital Obligations: ... Provide GOH ... with a timely notification ... of any individual who has died."

2. The Hospital's policy titled, "Organ Procurement & Tissue Donation (April 2019)" was reviewed on 6/15/2022 and required, "Notifications of Deaths to GOH ... The staff nurse responsible for the patient will notify Gift of Hope [GOH] regarding a patent ... who has died (for tissue or corneal donation) within two hours. Once the notification is made to the GOH, the patient's nurse will record the name of the GOH referral coordinator contacted, the referral reference number provided by the coordinator and the results of the initial telephone referral will be placed in a progress note in the electronic record."

3. The clinical record of Pt. #27 was reviewed on 6/15/2022. Pt. #27 was admitted on 5/8/2022 with a diagnosis of end stage liver disease. Pt. #27 died on 6/5/2022. The record lacked documentation of notification to GOH after the patients death.

4. During an interview on 6/15/2022 at approximately 11:00 AM, the Director of Regulatory Compliance (E#5) stated that there was no documentation of notification to the OPO. E#5 stated, "Based on our policy, we should have notified GOH."

A. Based on observation, document review, and interview, it was determined that for 2 of 2 staff (Certified Registered Nurse Anesthetist/E #4 and Resident Physician/MD #3) in OR (operating room) #5, and 1 of 3 (Surgeon/MD #1) staff in OR #22, and 1 of 2 (Medical Student - MD #4) in OR #25, the Hospital failed to ensure adherence to the dress code while in the operating room, as required.

Findingsinclude:

1. On 06/14/2022, between 9:15 AM and 11:45 AM, an observational tour of OR #22 was conducted. At approximately 11:20 AM, where a sterile field was opened, Surgeon/MD #1's sideburns, approximately 2.0 inches, were not covered by head cover/hood.

2. On 06/14/2022 between 9:35 AM and 10:15 AM, during observation of OR #25, it was noted that the Medical Student (MD #4) sideburns, approximately 3 inches, were not covered by the head cover/hood on the sides of his face and bottom of chin.

3. On 6/14/2022 between 9:10 AM through 10:00 AM, an observational tour of Pediatric OR (operating room) #5 was conducted. At approximately 9:30 AM, where a sterile field was opened two staff (CRNA/E#4, and MD #4) were observed in the OR. E#4 had approximately 3.5 inches of hair on the nape area that was not confined by the head cover/hood. MD#4 had approximately 3 inches of hair on both sides of face and neck not confined by the head cover/hood.

4. On 06/14/2022 at approximately 12:30 PM, the Hospital's policy titled, "Surgical/Procedural Attire Requirements" dated 09/2018 was reviewed and required, "...Dress code requires that ... all head cover or hood that confines all hair and completely covers the ears, scalp skin, sideburns, and nape of the neck should be worn in the restricted areas ..."

5. On 06/14/2022 at approximately 11:50 AM, the Surgeon/MD #1 was interviewed. MD #1 stated, "Do I have to wear the beard coverings?"

6. On 06/14/2022 at approximately 11:55 AM, findings were discussed with E #1 (Director of Surgical Services). E #1 stated that the sideburns must be covered using beard coverings and should not be exposed.

7. On 06/14/2022 at approximately 10:50 AM, the findings were discussed with the Manager of OR (E# 14). E #14 stated that all hair must be covered with cap while in the OR to prevent cross-contamination.

B. Based on observation, document review, and interview, it was determined that for 1 of 1 Surgeon/MD #1 staff observed in OR (operating room) #22, the Hospital failed to ensure adherence to the surgical policies covering surgical care by not ensuring personal belongings were in the restricted area.

Findings include:

1. On 06/14/2022 between 9:15 AM and 11:45 AM, an observational tour of OR #22 was conducted. At approximately 11:20 AM, where a sterile field was opened, Surgeon/MD #1's backpack was inside the OR throughout the procedure.

2. On 06/14/2022 at approximately 12:30 PM, the Hospital's policy titled, "Surgical/Procedural Attire Requirements" dated 09/2018, was reviewed and required, "...if required to bring in a backpack or briefcase, they must be of a material that can be washed down and dried prior to bringing into the restricted area ..."

3. On 06/14/2022 at approximately 12:15 PM, the Surgeon/MD #1 was interviewed. MD #1 stated that he totally forgot and brought the backpack inside the OR unknowingly.