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Based on observation, interview, and policy review, the facility failed to ensure supplies stocked in areas readily available for use were not expired. This deficient practice had the potential to allow expired items to be used, creating an unsafe procedure.

Findings include:

Review of the facility policy titled, "Environmental Safety Inspection" with a review date of 11/03/2023, revealed, "Environmental Safety Inspection, Purpose: To provide a standardized work procedure for the consistency and safety of the work environment regarding safety compliance issues. Completion of Form, Policy: Each Department Manager or designee to complete the Environmental Safety Inspection form (Attachment A) ... Review of Attachment A: Environmental Safety Inspection reviewed 11/03/2023 ...32. Did you find any expired supplies..."

During a tour of the Radiology Department on 06/18/2025 at 10:49 AM, in the Cardiac Stress room there was a basket with the following items:

- Saline filled syringes with four dated 02/28/24, one dated 03//31/24, one dated 10/31/24, one dated 12/31/24, and three dated 01/31/24.
- Two Intravenous Secure Sets dated 05/31/24.
- One Primary Plum Set dated 04/01/22.

During an interview on 06/18/2025 at 10:55 AM, Radiology Technician stated inventory was conducted monthly and the room was not used that much. The Radiology Technician verified there had not been an inventory check in the room.

During an interview on 06/18/2025 at 11:00 AM, the Risk Management (RM) stated the expired supplies should have been found during the monthly environmental rounds.

During an observation on 06/18/2025 at 2:00 PM in Emergency Room (ER) while in ER bed/room 4 there was a reagent tube out separate from the vaginal exam kit, which expired on 02/03/2021 and two complete "Xpert" swab vaginal specimen collection kits expired; one on 05/31/2025 and one on 03/31/2025.

During an interview and observation on 06/18/2025 at 2:00 PM, an ER Registered Nurse (RN) confirmed the above emergency supplies had expired.

Based on interview, observation, and policy review, the hospital failed to ensure supplies and equipment used in treating emergency cases had not expired in 3 emergency rooms (ER) observed. The failure to ensure equipment and supplies had not gone past their manufacturers beyond use date/expiration dates places ER patients at risk, for products that might be no longer safe or effective for use.

Findings include:

During the tour of the ER on 06/18/2025 between 1:30 PM and 2:00 PM the following expired or unlabeled ER supplies were identified:

1. In ER Room 1 identified as their isolation room:
a. A set of pediatric defibrillator pads "Zoll Defib Pads/Pediatric" expired on 12/04/2024.

b. Three packages in a drawer of ECG (electrocardiogram) pads [used in an emergency to assess cardiac/heart rhythm] expired 01/17/2025.

During an interview on 06/18/2025 at 1:45 PM, an ER Registered Nurse (RN) confirmed the above emergency supplies had expired. The RN stated the staff go through the ER supplies monthly.

2. In ER Room 4:
a. Three Neo-Tee T Piece Resuscitator mask and tubing expiration date of 09/26/2023

b. "Supra-pubic Introducer Foley Catheter Set" did not have a manufacturer's expiration, the directions for use (DFU) indicated the content was good until it was opened. The package was discolored and the glue seal that kept the package content sterile was peeling back and the corner curled back.

3. In ER Room 5:
a. A facility homemade "Trach (tracheotomy) Kit" contained, "Ready Prep Povidone Iodine 10% Solution that expired 01/2025, silk sutures that expired 04/30/2025, a 10-gauge angiocath expired 02/31/2025, and a disposable scalpel expired 11/2022.

b. two suction canisters, one on the adult emergency crash cart and one of the pediatric crash carts expired 02/01/2021.

Review of the hospital policy titled, "Environmental Safety Inspection" dated 11/03/2023 revealed, "Environmental Safety Inspection Purpose: To provide a standardized work procedure for the consistency and safety of the work environment regarding safety compliance issues. ... Attachment An Environmental Safety Inspection: ... Did you find any expired supplies?"

Based on observation, interview, record review, and policy review, the facility failed to follow facility policy for 1. open date on food products, 2. allowing personal beverages in the work area in the kitchen, 3. employee background checks, and 4. for infection control practices. This deficient practice had the potential to allow practices to occur without following facility policy.

Findings include:

1. Review of the facility policy titled, "Storing Open Packages" dated 06/18/2024 revealed, "Purpose: To provide secure and properly labeled foods. . . Seal baggie and write the opened date and identify product. . ."

During a tour of the kitchen on 06/18/2025 at 11:18 AM, the following items were found to be open and not dated:

- In the freezer an open bag of chicken fingers and an open bag of meatballs.
- On the bread rack was an unsealed bag of hotdog buns.
- Over the food prep table were several bottles of Worcestershire sauce and vinegar.
- Above the three compartments sink several containers of spices such as rubbed sage, ground pepper, tenderizer seasoned, rotisserie chicken spice, allspice, Mexican sage, and sugar.

During an interview on 06/18/2025 at 11:32 AM, the Dietary Manager revealed staff should label an item with the open date once an item was opened

2. Review of the ServSafe guidelines presented by the facility as a policy with a date of 08/12/2022 revealed, "While general ServSafe guidelines outline proper food storage practices, specifically addressing employee food and beverages, they emphasize storing them in designated food-storage areas, separate from food intended for customers. Away from walls and at least six inches (15 centimeters) off the floor. ln a manner that prevents cross-contamination."

During a tour of the dishwashing area in the kitchen on 06/18/2025 at 12:00 PM, a drink was sitting on the shelf above the clean area of the dish room. The Dietary Manager stated the drink belonged to an employee.

During an interview on 06/18/2025 at 12:00 PM, the Dietary Manager provided an email from a Health Inspector that indicated beverages must be covered and stored below work/preparation areas.

3. Review of the facility policy titled, "Hiring Procedures", reviewed 10/17/2024 revealed, "Policy: To facilitate the hiring of competent staff and to ensure consistency throughout the Hospital, a summary of policy requirements and appropriate forms have been developed to assist supervisor, managers, and director in this process. . . Applicant Background Investigation. Verify all licensure and certification requirements for position. Human Resources will verify the last seven (7) years employment history. For written verifications, applicants sign authorization. . ."

Review of staff files provided by the facility revealed Registered Nurse (RN)32 was hired on 03/13/2013. There was no current background check.

Review of staff file for RN35 revealed the date of hire of 08/07/2023. There was no current background check.

During an interview on 06/20/2025 at 10:00 AM, the Human Resources Director revealed the background checks for RN32 and RN35 were not completed.

4. On 06/20/2025 at 7:41 AM, an Operating Room (OR) Registered Nurse (RN) started an intravenous (IV) catheter for Patient 13 in the pre-operative (pre-op) bay. The RN placed the needle used to insert the catheter into the plastic "IV start package" lying on the tray table, instead of in the sharp container on the wall behind P13's gurney. After removing the gloves, the RN picked up the used needle with bare hands, removed it from the plastic "IV start package," and laid the used needle directly onto the patient's tray table. After discarding the other supplies, the RN picked up the needle and discarded the used insertion needle in the sharp's box located on the wall behind another patient's pre-op bay.

During an interview on 06/20/2025 at 7:41 AM, the OR Manager revealed the nurse should not have handled a used needle with bare hands.

Review of the hospital's policy titled "Hand Hygiene Program" dated 04/11/2025 revealed, "Gloves should be donned whenever there is a possibility of contact with the patient's blood or body fluids, mucous membranes or non-intact skin and when manipulating or handling potentially contaminated patient care equipment and/or environmental surfaces Wearing gloves protects both the patient and the heath care workers."

On 06/20/25 at 8:31 AM, a Certified Registered Nurse Anesthetist (CRNA) was observed opening two new vials of medication (later identified as Propofol and 1% Lidocaine) without cleaning the septum, inserted a needle, and drew up the medication. Then without cleaning the intravenous (IV) port CRNA inserted the medication into the IV port for administration.

During an interview 06/20/2025 at 9:15 AM, the CRNA was not aware that a new vial needed to be cleaned after opening or the IV port needed to be cleaned prior to administering a medication.

Review of the hospital policy titled, "Safe Medication Practices" dated 06/17/25 revealed "Use aseptic techniques to avoid contamination of sterile injection equipment and medications. (Cleanse all puncture ports, IV connections prior to use.)"

Based on observation, interviews, review of direction for use (DFU), and policy review, the hospital failed to ensure that it had clear directions in the policy for safe medication practices that included multi-dose medication bottles identified in the Emergency Room (ER). The failure had the potential for staff to give emergency medications that were no longer safe or effective for use.

During an observation in the ER on 06/18/2025 at 2:35 PM the following was identified in the ER medication room:

a. An opened and partially used bottle of Diphenhydramine Hydrochloride (HCI) (Benadryl) used as a common antihistamine to address allergic reactions had a label placed on the bottle indicating the product had a new expiration date of "05/13." There was no month/date/year, and the label was a sticker, not a pharmacy label that would include the date opened and the date to be discarded.

b. An opened and partially used bottle of Lidocaine HCI a local anesthetic used to numb the mucous membranes of the mouth and/or throat, had no label to indicate who opened it, what date it was opened, or what the new expiration date was after it was opened.

During an interview and observation on 06/18/2025 at 2:35 PM, the ER RN confirmed the above emergency medications. The RN confirmed that the label on the Diphenhydramine HCI was a generic label that did not come from the pharmacy and confirmed the label did not include the month/day/year or when it was opened. The RN could not confirm if 05/13 was the month and day or the month and year. The RN was not sure what the hospital policy required or what the manufacturer's DFU was once the bottle was opened. The RN was not sure of the beyond use date after the liquid medications identified above were opened.

During an interview on 06/19/2025 at 9:00 AM, the Pharmacy Manager stated the policy required updating and did not include bottled medication. The Pharmacy Manager confirmed the Pharmacy Department needed review and revise the medication policies. The Pharmacy Manager confirmed that each department did have pharmacy labels and should be using them. The current policy required the date a multi-dose medication was opened and the date it would expire.

Review of the hospital policy titled "Safe Medication Practices" dated 06/17/25 revealed, it did not include bottled medication. The policy addressed vials that indicated "Label multi-dose vials with dates when opened and discard ..."

Based on record review, interview, and policy review, the hospital failed to ensure five of 21 medical records were legible, complete, and accurately documented for patients (Patient (P) 9, P10, P11, P12, and P5). The failure to have legible, complete, and accurate medical records had the potential for inaccurate or incomplete care and treatment.

Findings include:

1. During an interview 06/18/2025 at 11:15 AM, the Chief Nursing Officer (CNO) 1 confirmed the Geriatric Psychiatric Distinct Part Unit (DPU) admission packet was not legible and would bring a clean copy. CNO confirmed that admissions were done on the specific unit, and the Geriatric Psychiatric DPU would do their admissions of the unit.

During an interview on 06/18/2025 at 11:32 AM, the Swing Bed Program Manager brought in another Geriatric Psychiatric DPU's admission packet.

During a tour of the Geriatric Psychiatric DPU, a copy of the admission packet was requested and pulled from the drawer by a Registered Nurse (RN).

During an interview on 06/18/2025 at 2:45 PM, the RN confirmed that several forms within the admission packet had been scanned and copied and were not legible.

During an interview on 06/18/2025 at 2:50 PM, the Geriatric Psychiatric Director confirmed that the Geriatric Psychiatric DPU admission packets contained forms that were not legible, and the Patient Rights did not include all the psychiatric patient's "Patient Rights."

Review of the medical record confirmed the admission documents identified above for P9, P10, P11, and P12 were not legible.

2. Review of the medical record revealed P11 was admitted on 06/10/2024 for depression and suicidal thoughts and was a current inpatient. P11's medical record failed to have an admission psychiatric evaluation, and the cranial nerve assessment was not completed upon admission.

During an interview of 06/19/2025 at 10:00 AM, Geriatric Psychiatric Manager confirmed the psychiatric evaluation should have been done as a part of the patient's admission on 06/10/2025 and the cranial nerve assessment should have been completed by the hospitalist and was not.

3. Review of P10 was admitted 01/26/2025 for agitation and anxiety, there was no cranial nerve assessment performed as a part of the admission assessment.

During an interview on 06/20/2025 at 10:15 AM, Geriatric Psychiatric Manager confirmed that P10's admission assessment failed to include the cranial nerve assessment.

During an interview on 06/20/2025 at 1:40 PM, Geriatric Psychiatric Manager and the Geriatric Psychiatric Director confirmed the admission cranial nerve assessment was to be completed by the Hospitalists. Geriatric Psychiatric Manager and the Geriatric Psychiatric Director confirmed that for P10 and P11 the admission cranial nerve assessment should have been done but was not.

4.Review of P5's electronic medical record (EMR) revealed an admission date of 06/13/2025 with a diagnosis of debility for rehab. Further review of the chart revealed there was no history and physical assessment.

During an interview on 06/20/2025 at 9:41 AM, the House Supervisor said there should be a history and physical assessment one within 24 hours of admission.

Review of the admission packet for the Geriatric Psychiatric Distinct Part Unit (DPU) revealed the patient rights were incomplete and did not include the patient rights specific to psychiatric patients. The Geriatric Psychiatric DPU 's admission packet had been scanned and copied 11 of the 24 documents multiple times that the wording was illegible on the following forms in the admission packet:
"Patient Rights"
"Authorization For the Release of Patient Information"
The "Boulder City Lay Caregiver Designation Form"
"Gender Identity and Expression, Sexual Orientation Questionnaire"
"Video Acknowledgement and Consent to Video Monitoring"
"Tele Psychiatry Consent"
"Consent to Participate in the Pet Therapy Program"
"Important Message from Medicare"
"Acknowledgement of Patient Information Medical Psychiatric Advanced Directives"
"Crisrs Prevention Plan"
"Interdisciplinary Treatment Plan"

Review of the Medical Staff Rule and Regulations approved by the Medical Executive Committee on 12/02/2024 and approved by the Governing Board on 01/09/2025 revealed, "The attending physician shall be responsible for the preparation of a complete medical record for each patient. This record shall include: ... Personal & Social History, ... History of Present Illness, Physical Examination, ... A complete history & physical examination in all cases shall be completed within twenty-four (24) hours of an acute care admission. ... Inpatient Psychiatric Hospital Services: Admission: All medical records, including progress notes and treatment plans, shall be legible, complete. ... Psychiatric Evaluation: Each patient shall receive a psychiatric evaluation that must: (1) be completed within 60 hours of admission (2) Include a medical history (3) Contain a record of mental status (4) Note the onset of illness and the circumstances leading to admission (5) Describe attitudes and behavior (6) Estimate intellectual functioning, memory functioning, and orientation and (7) Include a descriptive inventory of the patient's assets."

Based on observations, interviews, and policy reviews, the hospital failed to ensure adherence to the policies and procedures for infection prevention and control including surveillance, for two of six inpatient and outpatient services (Operating Room (OR) and inpatient/swing bed). The failure to follow the hospital infection control program and policies and procedures placed patients at risk for cross contamination.

Findings include:

1. On 06/20/2025 at 7:41 AM, an Operating Room (OR) Registered Nurse (RN) started an intravenous (IV) catheter for patient (P) 13 in the pre-operative (pre-op) bay. The RN placed the needle used to insert the catheter into the plastic "IV start package" lying on the tray table, instead of in the sharp container on the wall behind P13's gurney. After removing the gloves, the RN picked up the used needle with bare hands, removed it from the plastic "IV start package," and laid the used needle directly onto the patient's tray table. After discarding the other supplies, the RN picked up the needle and discarded the used insertion needle in the sharp's box located on the wall behind another patient's pre-op bay.

During an interview on 06/20/2025 at 7:41 AM, the OR Manager revealed the nurse should not have handled a used needle with bare hands.

Review of the hospital policy titled "Hand Hygiene Program" dated 04/11/25 revealed, "To provide guidelines for the prevention of the spread of infection by removing potentially pathogenic organisms through hand washing and the use of alcohol-based hand sanitizers. To outline nail care expectations and care that reduce the transmission of bacteria. ... Gloves should be donned whenever there is a possibility of contact with the patient's blood or body fluids, mucous membranes or non-intact skin and when manipulating or handling potentially contaminated patient care equipment and/or environmental surfaces. Wearing gloves protects both the patient and the heath care workers."

Review of the facility's policy titled, "How to Use the Glucometer" review 05/29/24 revealed, ". . . Maintenance and storage . . . the monitor must be visibly wet and allowed to sit 5 minutes then wipe down with a dry cloth. . . "

2. During an observation on 06/20/2025 at 8:00 AM, a Registered Nurse (RN) was observed to leave a random patients' room and set the glucometer on the cabinet without a barrier. The RN proceeded to spray down the glucometer. The RN got a cloth and wiped the glucometer.

During an interview on 06/20/2025 at 8:10 AM, the RN stated, "there should have been a barrier placed down and then spray it and leave for three minutes."

During an interview on 06/20/2025 at 8:15 AM, the House Supervisor stated, "There should have been a barrier placed down, and the glucometer placed on top, The RN should have sprayed it and let it stay wet and not wiped it down."