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Based on observation, record review, and staff interviews, the facility failed to construct, install and maintain the building systems to ensure a physical environment that was safe for patients and staff. The cumulative effects of the environment deficiencies result in the hospital's inability to ensure a safe environment for all patients and staff.

Findings include:

The facility was found to contain the following deficiencies. Refer to the full description at the cited K-tags:

K-0131: Multiple Occupancies
K-0222: Egress Doors
K-0255: Suite Separation, Hazardous Content, and Subdivision
K-0291: Emergency Lighting
K-0293: Exit Signage
K-0321: Hazardous Areas - Enclosure
K-0324: Cooking Facilities
K-0341: Fire Alarm System - Installation
K-0345: Fire Alarm System - Testing and Maintenance
K-0346: Fire Alarm - Out of Service
K-0353: Sprinkler System - Maintenance and Testing
K-0361: Corridors - Areas Open to Corridor
K-0363: Corridor - Doors
K-0372: Subdivision of Building Spaces - Smoke Barrier Construction
K-0511: Utilities - Gas and Electric
K-0711: Evacuation and Relocation Plan
K-0712: Fire Drills
K-0908: Gas and Vacuum Piped Systems - Inspection and Testing Operations
K-0914: Electrical Systems - Maintenance and Testing
K-0918: Electrical Systems - Essential Electric System Maintenance and Testing
K-0920: Electrical Equipment - Power Cords and Extension Cords

Based on observation, interview and record review the staff failed to assure availability and proper functioning of essential equipment in 2 of 10 departments (Pharmacy and Acute Care ) observed.

Findings include:

Record review of facility policy titled, "Emergency Eye Wash and Shower Stations" unnumbered, dated 10/01/2020 revealed, "Policy: Emergency Eye Wash and Shower Stations are to be used in the case of accidental splash in the eyes...Burnett Medical Center follows OSHA (Occupational Safety and Health Administration) guidelines by providing Emergency Eye Wash and Shower stations to its employees by placing them in areas where an employee may be exposed to injurious corrosive material..."

Under "Procedure: Departments are to check their plumbed eye wash station every week..."

On 11/9/2021 at 2:00 PM in the Pharmacy Department an eyewash station was observed with an attached card to be used for weekly checks. The card was blank. In interview at the time of observation with Pharmacist T when asked who checks the eye wash station, Pharmacist T stated, "I don't know, not us, I guess Maintenance does."

On 11/9/2021 at 2:05 PM in interview with Maintenance Director C, Maintenance Director C stated, "Each department is supposed to check their own eye wash station weekly. In fact that station in Pharmacy is broke, I have to get the part to fix it." When asked what the procedure is to take equipment out of service and notify the department, Maintenance Director C stated, "It should have a tag on it." Maintenance Director C confirmed that there is nothing on the eye wash station indicating that it is not working.

Record review of the facility "Lock Out/tag Out Policy and Procedure" undated, unnumbered, under "Lock out/Tag Out General Procedures" revealed, "the only time a tag out on a piece of equipment is acceptable is if there is absolutely no means of locking the equipment out..."

On 11/9/2021 at 2:10 PM in interview with Pharmacist T, Pharmacist T stated, "I had no idea that it wasn't working."

Observations on the acute care unit on 11/09/2021 at 11:10 AM revealed that an eyewash station was attached to the faucet at the sink in the nurse's station. Per observations, a torn yellow tag was hanging from the eye wash station and the writing on the tag was illegible.

Per interview with Nurse Manger H on 11/10/2021 at 12:17 PM, Manager H stated the eye wash station should be checked monthly and evidence of this check should be documented on the tag hanging from the eye wash station. Per Manager H evidence of the eye wash station checks were not documented anywhere else.


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Per observations on 11/09/2021 at 11:30 AM, observed a Bladder Scanner in the clean supply/storage room on the acute care unit.

Per interview with Nursing Manager H on 11/10/2021 at 11:50 AM, Manager H was unable to find any documented evidence of preventative maintenance completed on the Bladder Scanner. Manager H stated that he/she reached out to the company that should be performing preventative maintenance on the Bladder Scanner and was informed by the Field Service Technician that they had not performed preventative maintenance on the Bladder Scanner. Per interview with Manager H, the Field Service Technician stated that they would add this to their inventory.

Based on observation, interview and record review the staff failed to secure drugs and biologics and failed to restrict access to areas where biologics and sharps are stored in 2 of 10 areas observed (Emergency Department and Acute care unit).

Findings include:

Review of facility policy titled, "Medication Security" number 351-061 dated 5/2020 revealed under "Procedure: 3. Crash cart medications will be stored in containers closed with pull tight seals..."

Examples in the ED (Emergency Department):

On 11/8/2021 at 2:10 PM observed the Pediatric Crash cart in ED room 7, drawer 1 contained Pediatric emergency medications and was not locked. This was confirmed at time of observation with ED Manager H who stated, "That should be locked."

On 11/8/2021 at 2:10 PM a bag of lactated ringers (intravenous solution) was observed in the warmer labeled with an expiration date of 10/13/2021. This was confirmed at time of observation with ED Manager H who stated, "The IV should have been pulled out of the warmer on the date that was on the label."

On 11/8/2021 at 2:15 PM observed the Dirty Utility Room, Clean Utility Room, Housekeeping closet and the Supply Room with open access and no locks on the doors. The dirty and clean utility rooms and housekeeping closet stored cleaning supplies, bleach, and enzymatic cleaner. Observed in the Supply room were storage of syringes and needles.

On 11/8/2021 at 2:15 PM in interview with ED Manager H, ED Manager H confirmed the items that are stored in those areas and stated, "Other than the housekeeping closet, the doors do not have the ability to lock, I think we should have key pad access to those doors."


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Per observations on the acute care unit on 11/09/2021 at 9:05 AM, observed a crash cart across from the nurse's station that contained the key in the lock. At the time of the observation, no staff were present at the nurses station. Per observations, the crash cart contained the following medications that were not secured from unauthorized access:
-Adenosine, Amiodarone, Atropine Sulfate, Calcium Chloride, Dextrose, Digoxin, Dopamine, Epinephrine, Flumazenil, Lidocaine, Magnesium Sulfate, Methylprednisolone, Narcan, and Sodium Bicarbonate.

Per interview with Nursing Manager H on 11/09/2021 at 10:40 AM, Manager H stated that staff are not always present at the nursing station.

Per observations on the acute care unit on 11/09/2021 at 9:45 AM, observed (11) 50 milliliter (ml) bags of Intravenous (IV) Sodium Chloride solution and (15) 50 ml bags of IV Dextrose solution (15) stored in a container in the cabinet (the cabinet was not locked). Per observations, the IV bags were not wrapped in the protective outer wrap. Per observations, the IV bags did not contain a date and time of when the packaging was removed.

Review of "Baxter" manufacturer guidelines for "Out of Overwrap Stability Parameters for Injection Solutions packaged in Viaflex plastic container" provided by Pharmacist T, revealed that IV solutions that are 50 ml's and less have "Stability" for 15 days after packaging is removed.

Per interview with Pharmacist T on 11/09/2021 at 10:45 AM, Pharmacist T was "not sure" why the IV bags were not in the packaging or when the packaging was removed from the IV bags. Pharmacist T stated that he/she "thinks they came like that from the manufacturer." Per Pharmacist T, the IV bags should be kept stored in packaging until ready to use by staff.

Based on observation, interview and record review the facility failed ensure monitoring of the temperature control and adequate ventilation in 2 of 10 departments. (Laboratory and Emergency Department)

Examples in the Laboratory Department:

Review of the facility policy titled, "DAILY TEMPERATURE AND MISCELLANEOUS CHECKS" dated 01/2021 revealed, "Temperatures and other functions are checked and recorded daily ...Documentation of the action taken when the readings are not within the acceptable range is required. This documentation occurs in the troubleshooting log of the temperature log book ...1. Thermometer readings with their acceptable ranges: Item: Lab Humidity Acceptable Range: 30-80%."

During a tour of the Laboratory Department (Lab) with Lab Manager M on 11/09/2021 at 11:30 AM, "Temps (temperatures) Log" revealed a Lab Humidity of '20%' documented on 11/09/2021; this is below the acceptable range of 30-80%, there was no documentation of troubleshooting on the "Temp Logs Troubleshooting" log.

During an interview with Laboratory Manager O on 11/09/2021 at 11:35 AM, when asked if he/she was aware the Lab Humidity reading was out of range today, Manager O stated "No I didn't, I wasn't made aware. When asked if there should have been corrective actions taken and documented, Manager O stated, "I should have been made aware of the Humidity reading, and there should have been corrective actions documented on the Troubleshooting log; I would have turned on the Humidifier."

During an interview with Laboratory Medical Technologist O on 11/09/2021 at 11:48 AM, when asked if Technologist O recorded the Humidity Temperature today, Technologist O stated "Yes, I filled that out about 9:00 AM this morning." When asked if he/she was aware that the Humidity range was not in the 'acceptable range,' Technologist O stated "I knew it was out of range." When asked if he/she took any corrective actions, or brought it to anyone's attention, Technologist O stated "I didn't do anything and I didn't make anyone aware, it was a busy morning." When asked if he/she knows the process if a Temperature reading is out of range, Technologist O stated "I would let my Manager [Name], and he/she would give instructions what to do, and there would be documentation on the log."

Examples in the ED (Emergency Department):

On 11/8/2021 at 2:05 PM 4 cardboard boxes were observed on the floor of the PPE (Personal Protective Equipment) supply room. Clean patient supplies, intravenous poles and a hospital bed were also stored in this supply room.

On 11/8/2021 at 2:15 PM observed 2 pillows stored under the sink in exam room 8.

On 11/8/2021 at 2:15 PM in interview with ED Manager H, ED Manager H stated that the boxes of supplies should not be on the floor, nothing should be stored under the sinks, and the IV should have been pulled out of the warmer on the date that was on the label.

Based on observation and staff interviews, the facility failed to construct, install and maintain the building systems to ensure live safety from fire was safe for patients and staff. The cumulative effects of these deficiencies result in the hospital's inability to ensure a safe environment for all patients and staff.

Findings include:

The facility was found to contain the following deficiencies. Refer to the full description at the cited K-tags:

K-0131: Multiple Occupancies
K-0222: Egress Doors
K-0255: Suite Separation, Hazardous Content, and Subdivision
K-0291: Emergency Lighting
K-0293: Exit Signage
K-0321: Hazardous Areas – Enclosure
K-0324: Cooking Facilities
K-0341: Fire Alarm System – Installation
K-0345: Fire Alarm System – Testing and Maintenance
K-0346: Fire Alarm – Out of Service
K-0353: Sprinkler System – Maintenance and Testing
K-0361: Corridors – Areas Open to Corridor
K-0363: Corridor – Doors
K-0372: Subdivision of Building Spaces – Smoke Barrier Construction
K-0511: Utilities – Gas and Electric
K-0711: Evacuation and Relocation Plan
K-0712: Fire Drills
K-0908: Gas and Vacuum Piped Systems – Inspection and Testing Operations
K-0914: Electrical Systems – Maintenance and Testing
K-0918: Electrical Systems – Essential Electric System Maintenance and Testing
K-0920: Electrical Equipment – Power Cords and Extension Cords

Based on observation, interview and record review the facility failed to ensure patients receive safe quality food by failing to properly monitor freezer temperatures, label and date food and drinks, and ensure food was not expired in 1 of 1 kitchens observed.

Findings include:

Review of policy and procedure titled, "Storing: Food and Equipment" version 090619 revealed the following:
-Team members must store food in a manner that ensures quality, freshness, and safeguards against foodborne illness.
-An assigned team member will check the temperature of all refrigerators and freezers two times per day or three times for sites open more than 10 hours.
-Verify that freezer temperature is between 0 degrees Fahrenheit (F) and -10 degrees F. If temperature is above 0 degrees F, keep the door closed for 15 minutes. If temperature decreases ensure it reaches 0 degrees F within two hours. If temperature does not decrease after 2 hours, report to supervisor to call maintenance and take food temperatures.
-Ensure all food items are labeled, each label must contain the following information; product name, use-by-date, date the product was prepared or opened, date frozen, date thawed.
-Food should be discarded or used by the use-by-date (expiration date).

Per review of policy and procedure titled, "Maximum Storage Period of Dried Goods" last reviewed 03/2020 revealed that spices and herbs should be kept for no more than 6 months after opening.

Per review of Freezer Temperature Logs from October 1st, 2021 to November 9th, 2021, there was no evidence of staff implementing corrective actions when freezer temperatures were greater than 0 degrees F (log showed temperatures between 1 and 20 degrees F) on the following days:
-October 2, 3, 6, 7, 8, 11, 12, 14, 15, 16, 18, 19, 20, 22, 23, 24, 25, 26, 28, 29, 31
-November 1, 2, 4, 5, 6, 7, 8, 9

Observations of the kitchen on 11/09/2021 between 11:40 AM and 1:15 PM revealed the following:

1. Kitchen items were not labeled with the date opened and/or product name:
-Paprika, Ground Thyme, Ground Nutmeg, Molasses, and Starbucks Dark Roast Coffee.
-Seven drinks in the refrigerator

2. Spices and herbs were opened greater than 6 months ago:
-Curry powder opened 04/18/2018
-Poppy Seed opened 08/12/2019
-Chive powder opened 06/17/2019
-Cayenne pepper opened 02/01/2019
-Dill Weed opened 10/15/2019
-Ground Cloves opened 02/07/2016

3. Food was expired
-Italian Bread expired 10/23/2021

Per interview with Dietary Manager U on 11/09/2021 at 1:00 PM, Manager U confirmed that staff should be documenting corrective actions on the freezer log when freezer temperatures are out of range. Per manager U, he/she could not find any documented evidence of dietary staff taking actions when freezer temperatures were out of range. Per Manager U, staff should label food with the product name and the date opened, and spices/herbs should be discarded 6 months after being opened.

Based on observations, record review, and interview the facility failed to have a process in place to ensure Registered Nurses (RNs) complete initial and annual training and skills competencies to ensure nurses are competent to perform job duties in 13 of 13 RN personnel files reviewed (RN CC, RN DD, RN EE, RN FF, RN GG, RN HH, RN II, RN JJ, RN KK, RN LL, RN MM, RN NN, RN OO).

Findings Include:

Per observations on 11/09/2021 from 9:30 AM to 10:00 AM and 11/10/2021 from 8:45 AM to 9:30 AM, RN Z was assigned Pt 17 on 11/9/2021 and Pt #13 on 11/10/2021. Per observations, RN Z worked independently providing care and medications to Pt #17 and Pt # 13 including providing respiratory treatments/assessments and intravenous (IV) medications.

Per interview with RN Z on 11/10/2021 at 9:00 AM, RN Z stated he/she was currently in the 4th week of nursing orientation at the facility and was a brand new nurse. RN Z stated that he/she was assigned patients to take care of independently and if RN Z had questions or needed help RN Z would ask an available nurse.

Per review of RN Z's "Date started" and "Date of 1st patient" provided by Nurse Manager H, RN Z's start date was 10/11/2021 and date of 1st patient was 10/22/2021 (2 weeks later).

Review of RN Z's "Registered Nurse Orientation" binder provided by Nurse Manager H, revealed that the documents in RN Z's Orientation binder were blank. There was no documented evidence that RN Z was signed off as being trained and competent on the nursing competencies listed in RN Z's binder, including but not limited to, the following:
-Policies and Procedures
-Charting
-Medication Resources
-Omnicell Training (medication dispenser)
-Floor Orientation
-Soiled Linen, Clean Linen, Storage rooms
-IV Pumps
-Crash Cart
-Emergency Preparedness Procedure Folder
-EKG (Electrocardiogram)
-Admission Orientation
-Discharges
-Code Responses
-Equipment--Telemetry, Blood Pressure Machine, Cardiac Monitor, Hoyer lift, Bladder Scanner, Wall Suction, Feeding pump.

Per interview with Nursing Manager H on 11/10/2021 at 10:05 AM, Manager H confirmed that RN Zs Orientation/competencies check offs were blank. Per Manager H, RN and preceptor should be filling out the new orientation binder as the nurse completes tasks and is observed by preceptor.

Review of RN personnel files revealed there was no documented evidence of staff completing new employee nursing orientation training and competencies for the following RNs:
-RN OO, Start date 01/25/2021
-RN DD, Start date 11/29/2019
-RN FF, Start Date 09/24/2018
-RN HH, Start Date 07/16/2020
-RN MM, Start Date 06/21/2021
-RN NN, Start Date 08/30/2021

Review of RN personnel files revealed there was no documented evidence of nursing competencies/skills check lists completed annually for the following nurses:
-RN CC
-RN DD
-RN EE
-RN FF
-RN GG
-RN HH
-RN II
-RN JJ
-RN KK
-RN LL

Per interview with Nursing Manager H on 11/10/2021 at 10:05 AM, the facility does not have a written policy and procedure for nursing orientation and competency requirements. Per Manager H, staff should complete training and nursing competencies at least annually.

Per interview with Chief Nursing Officer (CNO) D on 11/10/2021 at 11:40 AM, CNO D stated that nursing competencies/skills check lists should be completed by RNs annually by October 1st of each year. Per interview, CNO D confirmed that there was no policy and procedure for nursing orientation of new/experienced staff and RN annual skills and competency requirements. Per interview with CNO D, he/she had been with the facility for only 6 months and CNO D was not aware of the issues with the lack of documentation of completion of new employee nursing orientations and annual nursing competencies.

Based on observation, record review, and interview, staff at this facility failed to
maintain a sanitary environment free of potential contamination to patients and staff by not adhering to infection prevention of the facility and nationally recognized standards of practice in 3 of 3 patient care observations (Patient's #6, #13, #15).

Findings include:

Per review of policy and procedure titled, "Hand Hygiene" last reviewed 08/02/2021, hand hygiene is indicated for the following "clinical situations":
-Before having direct contact with patients
-After contact with patient intact skin
-After contact with body fluids or excretions
-After contact with inanimate objects in the immediate vicinity of the patient
-After removing gloves

Examples in the OR (Operating Room):

On 11/9/2021 at 11:10 AM observed CRNA (Certified Registered Nurse Anesthetist) I administer 3 intravenous medications, then intubate (place a breathing tube) in Patient #15 without changing gloves. After intubation CRNA I donned new gloves without performing hand hygiene first.

On 11/9/2021 at 11:20 AM in interview with OR Manager K, when discussing the missed hand hygiene, OR Manager K stated, "Yeah, I saw that. Of course he should have changed his gloves before intubation and washed his hand between glove changes."




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Examples on acute care unit:

Observations on 11/09/2021 between 8:50 AM and 11:00 AM revealed the following:
-Gowns, blankets, towels, sheets, and pillows (located in the clean linen room) were not covered and protected from potential contamination with dust and debris.
-Cabinet under sink in nurse's station contained cracks in laminate and yellow and brown residue on floor of cabinet.

Per interview with Maintenance Director C on 11/10/2021 at 12:14 PM, Director C stated that linen should be covered when stored. Per Director C, the facility does not have an approved policy and procedure that addresses linen storage on the acute unit.

Per interview with Maintenance Director C on 11/09/2021 at 11:40 AM, Director C stated that he/she identified that there was a "leak in the hot water shut off valve" that created residue build up on the surface under the sink.

Per observations on 11/09/2021 at 9:15 AM, observed Registered Nurse (RN) Q administer medications to Patient (Pt) #6. RN Q removed Pt #6's oxygen mask and applied nasal cannula without wearing gloves. RN Q obtained a clipboard that he/she brought into Pt #6's room and took it to Pt #6's bedside to discuss the medication list; RN Q then placed the clipboard on the counter in the Pt #6's room. RN Q proceeded to retrieve Pt #6's medication from RN Q's pocket, scanned Pt #6 wrist band and medications, then donned gloves without performing hand hygiene. Per observations, RN Q administered oral medications, flushed Intravenous (IV) catheter then proceeded to remove gloves; after glove removal, RN Q washed hands with soap and water for approximately 5 seconds and not 15 seconds or more as per Hand Hygiene policy.

Per above observations, RN Q exited Pt #6's room with the clipboard then placed the clipboard on the counter at the nurse's station without being cleaned and disinfected before returning to a "clean" area.

Per observations on 11/10/2021 at 8:47 AM, observed RN Z administer medications to Pt #13. RN Z did not perform hand hygiene before donning gloves and then proceeded to access Pt #13's IV to administer IV antibiotics. RN Z obtained clean supplies out of drawers with the same gloves used to access Pt #13's IV; RN Z did not remove gloves and perform hand hygiene before retrieving clean supplies as per policy.

Per interview with Nursing Manager H on 11/09/2021 at 11:05 AM, Manager H stated that the clipboards should be disinfected after exiting the patients room and prior to returning to a "clean" area. Per Manager H staff should not keep medications in their pockets.

Per interview with Manager H on 11/10/2021 at 11:50 AM, Manager H stated that the facility does not have a policy and procedure for the cleaning/disinfection of patient equipment and supplies.




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