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Based on observation, interview, and record review, the Hospital A failed to ensure the condition of for Patient's Rights as evidence by the facility failing to:

1. Display notification of EMTALA rights (Emergency Medical Treatment & Labor Act, rights enabled by the Social Security Act to assure that patients entering Medicare participating emergency departments receive Medical Screening Exams [MSE] and stabilizing treatment regardless of ability to pay). (Reference A-0116).
2. Provide Patient Rights information regarding care and treatment to patients. (Reference A-0131).
3. Monitor the activities of patients who are at risk for elopement (wandering). (Reference A-0142).
4. Conduct ongoing monitoring and identifying of hazards in the 6th floor behavior health unit (specializing in the treatment of patients with mental disorders). (Reference A-0144).
5. Ensure patients were not subjected to abuse (Reference A-0145).
6. Follow facility's policy and procedure (P/P) for physical restraint (limited movement by physical contact from staff; held by staff to limit movement) and seclusion (private place, away from others) (Reference A-0178).

The cumulative effects of these systemic problems resulted in the hospital's inability to ensure the provision and protection of patient rights.

Based on observation and interview, Hospital A failed to display notification of EMTALA rights (Emergency Medical Treatment & Labor Act, rights enabled by the Social Security Act to assure that patients entering Medicare participating emergency departments receive Medical Screening Exams [MSE] and stabilizing treatment regardless of ability to pay) in a visible area of the facility.

This deficient practice had the potential to dissuade people from seeking care.

Findings:

During an observation, on 3/23/2022, at 10:35 a.m. with Vice President 100 (VP-100), there was signage along the street announcing that the Emergency Department was open for 24-hour service. The Emergency Department patient entrance and waiting area had postings of patients' rights to safe treatment and where to address grievances against the facility. There was no signage that noted EMTALA rights as described above.

During an interview, on 3/23/22, at 10:35 a.m., VP-100 acknowledged the EMTALA rights were not posted and stated they would be posted in the Emergency Department as soon as possible.

Based on interview and record review, Hospital A failed to ensure Patient Rights for information regarding care and treatment was provided to one of fifteen (15) sampled patients (Patient 210), who was unable to sign informed consent. Patient 210's representative was not notified of information regarding patient's health status that required care and treatment.

This deficient practice had the potential for critical care and/or treatment decisions not being made due to lack of information provided to Patient 210's representative, who was responsible to make care decisions for Patient 210.

Findings:

During a concurrent interview and record review on 3/23/2022, at 9:29 a.m., with Nursing Supervisor, Registered Nurse 203 (RN- 203), Patient 210's Conditions of Admission, dated 2/23/2022, was reviewed. RN-203 stated Patient 210 was unable to sign consent. RN-203 stated Patient 210's representative did not sign consent, either. RN-203 stated facility's staff at the admitting department should have followed-up with Patient 210's representative. Facility staff should have acquired a signature for a consent for admission from Patient 210's representative.

A review of Hospital A's policy and procedure (P&P), titled "Consent Form Requirements," dated 9/23/19, indicated the following:
1. Patient Access is responsible for completing the required consent forms with the patient or patient's legal representative.
2. The patient must then sign and date the consent forms.
3. Patient Access will act as a witness to the signatures and document this in legible writing with copies provided to the patient and/or representative.
4. Patient Access will make a reasonable effort to contact a family member, legal guardian, dual power of attorney, conservator, domestic partner, or public guardian, in the event the patient lacks the capacity to make health care decisions, upon admission.
5. Verbal Consent is for patients unable to physically sign the forms or if the legal representative is not available to sign. Verbal consents must be documented on the forms with the follow-up process outlines to try to obtain an actual signature, at a later time.
6. Legal representative is a person who may legally represent the patient - including the adult parent, nearest available relative, surrogate decision maker, agent, conservator, court-appointed surrogate decision maker, or multi-disciplinary committee.

Based on observation, interview, and record review the facility failed to monitor and provide security at the two hallways near the Day Room (sitting area of patients to sit and relax) and hallway that extended to Room 433 at Hospital A's Behavioral Health Unit (BHU) that had fifty-eight (58) patients in the unit.

This deficient practice had the potential for the fifty-eight patients exiting the BHU without staff knowledge.

Findings:

During an observation on 3/21/2022, at 10:55 a.m., on the 6th floor BHU, there was one (1) Security guard (Security-101) inside the facility's Day Room (sitting area of patients to sit and relax). Outside the Day Room, there were two (2) hallways that spread to either side (left or right). There were no other security guards located monitoring the two hallways of the BHU.

During an interview, on 3/21/2022, at 11:05 a.m., Security 101 stated there was only 1 security guard to cover these two hallways of the BHU.

During a concurrent observation and interview, on 3/21/2022, at 1:25 p.m., with Security 102, he (Security 102) was observed entering and exiting the area designated for COVID -19 (an infectious disease caused by the SARS-CoV-2 virus) patients near Room 433. There was no other security officer in the hallway of the BHU that extended from Room 433. Security 102 stated that he (Security 102) monitors the activity of patients in the designated COVID-19 unit.

During an interview on 3/21/2022, at 1:35 p.m., near room 433, with Registered Nurse 101 (RN-101), RN 101 stated that patients in the BHU were psychologically (mentally) handicapped.

A review of Hospital A's Security Department's document, titled "Post Order," dated 1/7/2022, indicated that the goal of the security department is to maintain safety of all persons on Pavilion 6 and 4 BHU (Behavioral Health Unit). The document indicated: "P6-1 security monitors the elevators preventing patients from leaving the unit without charge nurse authorization; P6-2 security monitors the service elevator preventing patients from leaving the unit without charge nurse authorization; P4 security monitors service elevator preventing patients leaving the unit without charge nurse authorization; security will patrol P4/P6 BHU and common areas including day room, hallways)."

43419

Based on observations, interviews, and record review, the Hospital A failed to provide a safe environment accessible or easily accessible to patients for thirty-one (31) patients of fifty-eight (58) patients at the facility Behavioral Health Unit (BHU) (Patient 109 and Patient 114, 115, 116, 117, 118, 119, 120, 121, 122, 123, 124, 125, 126, 127, 128, 129, 130, 131 , 132, 133, 134, 135, 136, 137, 138, 139, 140, 141, 142, and 143), who had diagnosis of suicidal ideation (thinking about or planning suicide). The facility failed by failing to ensure:

1. The men's patient bathroom, the television (TV) room, and women patient bathroom were safe and free from objects for ligature risks (anything which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation).
2. An area under construction on the 6th floor with direct access to the BHU should have a locked door where a claw hammer, extension cords, metal pipe brace, metal pipe, and a ladder were stored.

The deficient practice had the potential to result in thirty-one patients with suicidal ideation have access to objects that may be used to cause physical harm, injury, or death to self, other patients, staff, and visitors.

On March 21, 2022, at 4:43 p.m., the survey team called an immediate jeopardy (IJ) situation in the presence of the Director of Quality (DQR-100), Chief Executive Officer (CEO-100), Chief Nursing Officer (CNO-100), Regional Chief Medical Officer (CMO-100), Assistant Chief Nursing Officer (ACNO-100), and Chief Operating Officer (COO-100) for failing to ensure ongoing monitoring and identifying of hazards on the 6th floor behavior health unit.

On March 22, 2022, at 4:50 p.m., IJ situation was removed after verifying onsite an acceptable IJ removal plan based on observation, interview, and record review. The removal plan indicated the removal of the hazards, a process to monitor the patient common areas, and identify potential hazards, and orientating vendors.

The acceptable IJ Removal Plan were as follows:

1. On 3/21/2022, the risk for potential harm was mitigated.
a. A piece around the men's urinal flusher handle was secured at the attachment point to prevent a loop which posed a ligature risk.
b. The women's bathroom was locked and placed out of service to allow repairs.
c. TV cable was removed
d. All electrical outlets in the activity room were covered with electrical plates.

2. On 3/22/2022, the facility leadership met to review the current policy and documentation of new form for safety rounding in the behavior health unit.
a. The Patient Safety Monitor Checks form was revised to include all patient common areas.

3. DRQ-100 will develop a vendor orientation checklist to ensure vendors in the behavior health unit will understand the safety requirements.
a. Construction workers were educated on the importance of ensuring their area is secured from the behavior health patients.

4. Behavior Health Unit staff will be educated on updated policies and forms.

Findings:

1. During an observation on 3/21/2022, at 10:55 a.m., in the men's patient bathroom, an unsecured loop (a cord, rope, or other material) on the urinal flusher was observed.

During an observation on 3/21/2022, at 11:03 a.m., in the TV room, a TV cord about six feet long was exposed and four electrical outlets were without cover.

During an observation on 3/21/2022, at 11:05 a.m., in the women's patient bathroom, the bathroom sink holes (for the placement of the sink faucet fixtures) and toilet drainpipe were observed as a ligature risk.

A review of Patient 109 and Patient 114, 115, 116, 117, 118, 119, 120. 121, 122, 123, 124, 125, 126, 127, 128, 129, 130, 131 , 132, 133, 134, 135, 136, 137, 138, 139, 140, 141, 142, and 143 s', History and Physical indicated the patients were admitted to the behavior health unit with a diagnosis for suicidal ideation.

During an interview on 3/23/2022, at 9:04 a.m., with Behavior Health Nurse Manager (NM-100), stated that patients who are considering suicide or self-harm are at greater risk of harming themselves in the behavior health unit.

2. During the general observation, on 3/21/22, at 11:30 a.m., in the presence of the Plant Operations Director and Chief Operating Officer an enclosed construction area with a lockable access door located by the Nursing Station was observed. The access door observed had Duck taped (a type of multipurpose tape) to the door shut. The door was easily opened by pulling on the Duck tape. The door was able to be opened without unlocking the door allowing patients, staff, and visitors access to a claw hammer, extension cords, metal pipe brace, metal pipe, and a ladder. This enclosed construction area with a lockable access door was located adjacent Shower Room 2 and Nursing Station of the Behavioral Health Unit (BHU) on 6th floor. The access door had a sign on the front indicating, "Do not enter, authorized personnel only."

During an interview with the Plant Operations Director, on 3/21/2022, at 11:38 a.m., the Plant Operations Director stated that lockable access door to the enclosed construction area should have been locked at all times.

During a concurrent record review and interview on 3/23/2022, at 9:15 a.m., with NM-100, a completed Patient Safety Monitor Checks form, dated 3/20/2022, indicated the patient rooms were monitored and documented every hour for environmental hazards but it did not include documentation for monitoring the common areas of the behavior health unit. NM-100 stated the staff does not document the monitoring for environmental hazards in other areas of the behavior health unit

A review of the Hospital A's policy and procedure titled, Hourly Rounding, dated 4/2019, indicated every patient admitted to the behavior health unit is identified as being a danger to self, others or gravely disabled, and every effort is to be made to provide a safe therapeutic environment.

A review of the Hospital A's policy and procedure titled, Safety Management Plan, dated 9/2019, indicated The Safety Management Plan describes the programs used to manage and reduce the risk of injury for patients, staff, and visitors. Regular evaluation of the environment for work practices and hazards is required to identify risk and hazards.

Based on observation, interview, and record review, the Hospital A failed to ensure patients were not subjected to abuse (physical and sexual) for two of four patients, (Patient 110 and Patient 106) by failing to ensure the following:

1. Patient 110 was not subjected to physical abuse by facility staff (Security 103) after an altercation with each other (Patient 110 and Security 103) in the Emergency Department (ED) . This deficient practice resulted to Patient 110 sustaining injury to the face (mild swelling and tenderness to left lateral (side) eyebrow and abrasion (surface layers of the skin [epidermis] has been broken) inside the left ear, on 1/27/22.

2. Patient 106 was not subjected to sexual abuse by Patient 105 due to facility not monitoring Patient 105's behavior of sexual advances to staff and wandering in patient's room (Patient 106). The deficient practice resulted to Patient 105 found on top of Patient 106, who was unclothed. Patient 105 was attempting to have sex with Patient 106.

The deficient practice also had the potential for other patients being subjected to (sexual, physical, and verbal) abuse.

On 3/25/2022 at 5:07 p.m., an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the facility's Director of Risk and Quality 100 (DRQ 100), Regional Chief medical officer - 117 (CMO 117)-117, , Chief Executive Officer 100 (CEO 100), Regional Administrator 100 (RA 100), Assistant Chief Nursing Officer 100 (ACNO 100), Chief Operating Officer 100 (COO 100), and Quality Manager 100 (QM 100) regarding facility's failure to ensure Patient 110 was not subjected to physical abuse by facility staff (Security 103) and ensure Patient 106 was not subjected to sexual abuse from Patient 105.

On 3/29/2022, at 2 p.m., the IJ was removed after the facility submitted an acceptable IJ Removal Plan (interventions to correct the deficient practices). The surveyors verified and confirmed the implementations of the IJ Removal Plan during an onsite visit by observation, interview, and record review. The IJ was removed in the presence of the facility's DRQ 100.

The acceptable IJ Removal Plan were as follows:
1. IJ Removal Plan for Patient 110 (physical abuse):
a. On 1/27/2022, Security 103 was placed in immediate suspension and resigned on the same day.
b. On 1/27/2022, multidisciplinary leadership team met to develop next step:
i. Required all Security staff to complete Management of Assaultive Behavior training by March 1, 2022. All officers were trained by the deadline.
ii. Executed a contract with a 3rd party vendor to conduct a full security assessment and provide recommendations for improvement. Assessment was completed.
c. Policy review completed.
d. Job descriptions and hiring requirements were updated by the Manager of Human Resources to require a current Management of Assaultive Behavior Certification. Certification will be validated as part of the onboarding process.
e. Assaultive Behavior Certification is required to be completed at least annually
f. Incident reports involving physical abuse or altercation will be reported to the Environment of Care (EOC) committee.
g. A timecard lockout preventing Security Officers from clocking if their annual Assaultive Behavior Certification is not complete.

2. IJ Removal Plan for Patient 106 (sexual abuse):
a. On March 17, 2022, Patient 106 was moved to another wing of the hospital.
b. On March 17, 2022, Patient 105 had a sitter assigned to him for constant observation. The Police Department was called immediately following the incident, and Patient 105 was placed under arrest.
c. On March 25, 2022, nursing leaders met with the nursing staff at change of shift to inform them of the upcoming changes. The nursing staff were instructed to call their Nurse Manager/ Director and Risk Management if they identified any patient being sexually inappropriate over the weekend for direction.
d. On March 25, 2022, members of the leadership team which included the Chief Medical Officer, Sr. Director of Quality & Risk Management, Associate Chief Nursing Officer, Nursing Directors and Managers met to review the Initial Nursing Note and Nursing Plan of Care. Revisions to the Initial Nursing Note and Daily Care Plan were identified to include an assessment of every patient to determine if they are sexually inappropriate. If marked "yes" this will require a documented intervention from a drop-down menu as follows:
Interventions (Mandatory),
i. Social Services Consult (Mandatory);
ii. Notify Physician (Mandatory);
iii. Care Plan (Mandatory);
iv. Close Observation/ Monitoring;
v. Private Room;
vi. Cohort Care Providers;
vii. Closer to Nursing Station;
viii. Sitter.
e. The Director of Education will develop a training session by March 29, 2022, that will cover the following topics:
i. Assessing for verbal and physical sexual inappropriateness;
ii. Interventions to protect other patients and staff;
iii. Required documentation;
iv. Nursing report/handoff to include any precautions and interventions;
v. Preventing any patient from wandering into any other patient room.
f. All nursing staff on the acute care units will be assigned this education session on March 29th, in HealthStream with a due date of April 15, 2022. All active nursing staff members will not be scheduled to work if this education session has not been completed by the due date. Inactive nursing staff members will be required to complete this education within the first 3 days of returning to work. This education will be conducted for all new hires as part of the nursing orientation and on the first day of work for contracted nursing staff.
g. Monitoring for Compliance was the responsibility of the Chief Nursing Officer and included the following:
i. The EMR (Electronic Medical Record) will generate a report identifying all patients that have been assessed to be sexually inappropriate every hour. This report will be sent automatically to the Chief Nursing Officer and Sr. Director of Quality & Risk Management to ensure that the appropriate interventions are in place to protect the patients and staff.
ii. A monthly report of compliance will be reported up to and reviewed by the Quality Council, Medical Executive Committee, and Governing board to ensure sustained compliance.

Findings:

1. A review of Patient 110's document titled "Patient Information", (undated) indicated Patient 110 arrived to Facility A's ED, on 1/26/2022, at 11:26 p.m. Patient 110 readmitted to Hospital A's Emergency Department, on 1/27/2022 at 9:52 a.m.

A review of Patient 110's document titled, "EDMD General, Adult" , dated 1/27/2022, indicated Patient 110's chief complaint was head trauma. Patient 110 was, "Involved in altercation with security guard in ED." Patient 110 was punched on the face, head, and left ear by Security 103. The document of Patient 110's physical examination of injuries sustained from the physical abuse indicated mild swelling and tenderness to left lateral (side) eyebrow and abrasion (surface layers of the skin [epidermis] has been broken) inside the left ear.

A review of Patient 110's document titled "One Content", date of service 1/27/2022, document indicated Computed tomography (CT, medical imaging technique used in radiology to obtain detailed internal images of the body noninvasively for diagnostic purposes) Head without intravenous (IV-through the vein) Contrast (an iodine based colorless liquid; delivered into the body through a small plastic tube) was completed on 1/27/2022, at 10:43 am, indicated, test was performed for "Indication: Trauma" to the head.

During an interview, on 3/23/2022, at 4:07 p.m., DQR-100 stated, on 1/27/2022, at approximately 8 a.m., DQR-100 was notified of Patient 110's request to speak to administration regarding grievance against Security 103. DQR-100 stated, Patient 110 was observed with a black eye during interview. DQR-100 stated, Patient 110 was referred to the Emergency Department for evaluation.

During an interview, on 3/23/2022, at 4:17 p.m., DQR-100 stated Security Department head was notified of event and plan to suspend Security 103 pending completion of investigation. DQR-100 stated, Security-103 resigned, on 1/27/2022, and had stated, "I quit," during notification of suspension.

During a concurrent interview and record review on 3/23/2022, at 4:20 p.m., of the Hospital A's policy and procedure (P&P) titled "Elder and Dependent Adult Abuse, Neglect, and Abandonment," dated 6/2021, DQR-100 stated the policy and procedure indicated, abuse was defined as, "The infliction of injury, intimidation, cruel punishment or other treatment with resulting physical harm or pain or mental suffering, or the deprivation by a caregiver of goods or services which are necessary to avoid physical harm or mental suffering." DQR-100 stated, per facility investigation, incident was substantiated (to establish by proof or competent evidence). DQR-100 stated event was considered as abuse per policy definition.

During an interview, on 3/25/2022, at 11:15 a.m., RN-105 stated RN-105 observed the incident, on 1/27/2022. RN-105 stated Patient 105 was previously discharged from Emergency Department, on 1/27/2022 around 4 a.m. RN-105 was the triage nurse (registered nurse positioned in an ED or facility; responsible for assessing patients and determining their level of need for medical assistance) and observed Patient 110 yelling from ambulance bay door, yelling for his phone on 1/27/2022 around 8 a.m. RN-105 stated, on 1/27/2022, Patient 110 was observed pushing Security-103. Physician (MD-101) 101 came over to try to help, but by the time MD-101 was able to help, Security-103 had pushed Patient 110 to ambulance bay (parking area designed for ambulances). RN-105 stated Security-103 was observed on top of Patient 110, as patient was sitting by the wall. RN-105 observed MD-101 pulling Security-103 away from Patient 110.

A review of Hospital A's form titled, "Personnel Action Form: Resign," dated 1/27/2022, the action form indicated Security 103, "Resigned after being placed on suspension," and had a termination date of 1/27/2022.

A review of Hospital A's policy and procedure titled, "Patient Rights and Responsibilities," effective 9/2019, indicated the facility was, "To assure that regulatory guidelines are followed, and patient safety maintained ... b. The patient has the right to receive care in a safe setting. c. The patient has the right to be free from all forms of abuse or harassment."

A review of Hospital A's Employee Handbook, dated 2019, indicated, "Unacceptable conduct and performance: ...Threatening, intimidating or coercing other employees, customers, or visitors. Fighting or provoking a fight on Company time or property." Employee Handbook, dated 2019, indicated facility provides, "Zero tolerance" for "Actual or threatened violence against employees, customers, visitors, or any other person who has contact with employees in the course of their duties."

2. A review of Patient 105's History and Physical (H&P-report document providing information about a patient's history and exam findings at the time of admission in order to formulate a plan of patient treatment), dated 3/8/2022, indicated Patient 105 was admitted for respiratory distress (difficulty with breathing), schizophrenia (long-term mental disorder involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion), and bipolar (mental disorder that causes unusual shifts in mood, energy, activity levels) disorder.

A review of Patient 105's Psychiatric Evaluation, dated 3/11/2022, indicated Patient 105 had displayed rapid changes of mood and had no logical plan for his own treatment. Patient 105 had schizophrenia with extreme amount of psychomotor agitation (display of motions that service no purpose).

A review of Patient 105's Nursing Narrative Note, dated 3/15/2022, at 9:46 a.m., by Registered Nurse 104 (RN-104) indicated, on 3/15/2022 at 8:00 a.m., RN 104 went to Patient 105's room. Patient 105 had demanded his gown be changed by a female nurse. Patient 105 had a male Certified Nursing Assistant (CNA, unlicensed professionals who assist with care duties) was assigned to assist change Patient 105's gown. The note indicated Patient 105 was irritated, and Patient 105 had been pulling up his gown and touching his genitals. On 3/15/2022, at approximately 6:00 p.m., Patient 105 was transferred to Room 509 by wheelchair.

A review of Patient 105's Nursing Narrative Note, dated 3/16/2022, at 2:54 p.m., by RN-107 revealed Patient 105 had been constantly requesting snacks, ambulating hallways, looking for more food, and was caught in another patient's room. Patient 105 was found drinking another patient's juice. The note indicated Patient 105 had disrupted administration of IV medication (intravenous, medication given through a vein) being administered to patient 105 several times. Patient 105 had pushed RN 107 numerous times when RN 107 was in Patient 105's room.

A review of Patient 105's Nursing Narrative Note, dated 3/17/2022, at 5:39 a.m., by Charge Nurse 100 (CN-100) indicated that a nurse found Patient 105 to be naked and on top of Patient 106. CN-100 stated Patient 105 was attempting to have sex with her (Patient 106). The document details indicated CN-100 called for assistance, a code grey (message announced over a hospital's public address system indicating need for an emergency management response to violent or aggressive behavior), and Patient 105 was removed from Patient 106's room.

A review of Patient 106's History and Physical (H&P), dated 3/17/2022, indicated that Patient 106 was a 90 year old female who was admitted to the facility, on 3/16/2022, with complaints that included fall, hip pain, status post (occurring after) hip replacement (surgery to remove disease or damaged parts and the insertion of an artificial joint). Patient 106 had dementia (a chronic disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and social history could not be obtained from Patient 106 due to being confused. Patient 106 was able to move all 4 of her extremeties but was slightly weak.

During an observation on 3/22/2022, at 10:02 a.m., at the 5 West Medical/Surgical unit (med/surg, unit of hospital where wide range of conditions are treated outside of critical care), it was observed that the rooms where Patient 105 (Room 509) and Patient 106 (Room 501) had occupied were across from each other on the fifth floor medical/surgical unit. The nursing station was situated next to both Patient 105's and Patient 106' rooms and both rooms were not in direct line of sight from the nursing station.

During an interview on 3/22/2022, at 10:10 AM, accompanied by RN-140, Patient 106 appeared confused when Patient 106 was asked by RN-104 regarding being sexually assaulted, on 3/17/2022. Patient 106 stated not remembering being assaulted.

During an interview, on 3/24/2022, at 1:00 p.m., RN-104 stated she had been taking care of Patient 105 while on the 2nd floor telemetry unit (telemetry, remote monitoring of patient's heart rhythm and rate). Patient 105 was subsequently transferred to the 5th floor medical/surgical unit. RN-104 said Patient 105 had exhibited inappropriate behavior, such as asking if RN 104 can change his gown even though Patient 105 did not require for his gown to be changed. RN-104 stated Patient 105 would solicit sex from the female nurses on the floor. RN-104 stated Patient 105 had tried to touch her feet. RN-104 said Patient 105 was completely mobile. RN-104 stated that the Charge Nurse on duty would try to find a male nurse, but there was no male nurse available. RN 104 stated the charge nurse had stated to report any further misbehavior to her (charge nurse).

A review of Hospital A's policy and procedure (P&P) titled, "Elder and Dependent Adult Abuse, Neglect, and Abandonment," effective date 6/2021, indicated that the policy was established for reporting abuse and applies to all departments in the facility. The policy indicated, "Any administrator, supervisor, employee, or licensed staff who witnesses or suspects....must report abuse." Reporting requirements were, "To be made immediately or as soon as possible."







42379

Based on interview and record review, Hospital C failed to ensure that facility staff perform a face-to face assessment within 1 (one) hour of the initiation of restraint (something that restricts freedom or prevents someone from doing something) for one out of one sampled patient (Patient 306) in accordance with the facility's policy and procedure (P&P).

This deficient practice delayed the assessment of Patient 306's physical and psychological status and other patients on restraint had the potential for injury and/or psychological harm .

Findings:

A review of Patient 306's Patient Information Sheet (undated) indicated that Patient 306 was admitted to Hospital C from 2/3/2022 to 2/7/2022.

A review of Patient 306's History and Physical (H&P), dated 2/4/2022, indicated Patient 306 was admitted to the facility for suicidal ideation (thinking about suicide or wanting to take your own life). The H&P indicated Patient 306 was hearing voices and wanting to hurt herself. The H&P indicated Patient 306 was admitted to the facility for voluntary (own free will) psychiatric (mental disorder) admission.

A review of Patient 306's Order Status and Signature History (physician's order), printed 2/9/2022, the physician's order indicated a restraint order, on 2/3/2022, start time 6:15 pm. The physician's order indicated physical, seclusion (isolation of a patient in a locked room), and mechanical (application of device) restraint, bilateral (relating to two sides; affecting both sides), with polyurethane (a plastic material) ankle restraint and polyurethane wrist restraint.

A review of Patient 306's Nursing Narrative Note, dated 2/3/2022, indicated 4 (four) point restraint was used.

During a concurrent interview and record review on 3/22/2022, at 1:26 p.m., with Charge Nurse/Registered Nurse 302 (RN-302), Patient 306's Seclusion/Behavioral Restraint Management: Denial for Good Cause document, dated 2/3/2022, was reviewed. The document indicated Patient 306 was in physical restraint (limited movement by physical contact from staff; held by staff to limit movement) from 2/3/2022 at 6:07 p.m. to 2/3/2022 at 6:10 p.m. The document indicated Patient 306 was in seclusion (private place, away from others) from 2/3/2022 at 6:15 p.m. until 2/3/2022 at 8 p.m. RN 302 stated, Patient 306 was in seclusion room from 1 hour and 45 minutes.

During a concurrent interview and record review on 3/22/2022 at 1:35 p.m., with the Quality/Risk Manager 300 (QRM-300) , Patient 306's Seclusion/Behavioral Restraint Management: One Hour Face-to-Face Evaluation document, dated 2/3/2022, was reviewed. The document indicated a signature dated 2/3/2022 at 8 p.m. QRM-300 stated the face-to-face evaluation should have been completed before 2/3/2022 at 7:15 pm. QRM-300 stated the face-to-face evaluation was completed on 2/3/2022 at 8 p.m. per documentation which was more than one hour per facility policy.

During an interview on 3/23/2022, at 10:27 am, with QRM-300, QRM-300 stated Patient 306's Seclusion/Behavioral Restraint Management: One Hour Face-to-Face Evaluation document, dated 2/3/2022, one hour face to face documentation for 8 p.m. was completed by RN 304.

During a concurrent interview and record review on 3/23/2022, at 9:29 a.m., with Associate Chief Nursing Officer 300 (ACNO-300), Patient 306's Seclusion/Behavioral Restraint Management: One Hour Face-to-Face Evaluation document, dated 2/3/2022, was reviewed. The document indicated a signature on 2/3/2022 at 8 p.m. ACNO-300 stated the face-to-face evaluation should have been completed before 2/3/2022 at 7:15 p.m. ACNO-300 stated evaluation was to be completed by another staff member (RN-304) that was not involved in the restraint or seclusion. ACNO-300 stated, face-to-face evaluation was completed, on 2/3/2022 at 8 p.m. per documentation, more than 1 hour per facility policy. ACNO-300 stated, evaluation within 1 hour provides opportunity for timely evaluation of patient status and type of restraint needed. ACNO-300 stated timely evaluation was needed to determine, if possible, to change the number of restraints or if able to discontinue the restraint sooner.

A review of Hospital C's policy and procedure (P&P), titled, "Restraints and Seclusion," dated 11/2019, indicated, "The leaders recognize that the use of restraints has the potential to produce serious consequences, such as physical and psychological harm, loss of dignity, violation of an individual's rights, feelings of isolation, and even death." Policy indicated, assessment for violent behavior/ seclusion: responsible Licensed Independent Practitioner (LIP, individual permitted by law and by the organization to provide care and services, without direction or supervision within the scope of the individual's license and consistent with the individually granted clinical privileges) or Physician Assistant (PA) "shall perform a face-to-face assessment of the patient's physical and psychological status within 1 hour of the initiation of restraint or seclusion."

Based on interview and record review, Hospital A and Hospital B failed to collect data on its processes related to identifying patients at nutrition risk and when and who Registered Dietitian's completed a nutrition assessment for (prioritization) in order to measure, analyze and track whether the nutritional needs of patients were being met, in a timely manner. (Cross-Reference A-0629 and A-0620)

This deficient practice of lacking data collection and analysis of the hospital's policy and procedure related to prioritization schedule that drove when RDs completed a nutrition assessment impeded the hospital's ability to ensure systems were in place that would have identified and improved capturing patients at nutrition risk in order to ensure their nutritional needs were met in a timely manner.

Findings:

1. During a review of Patient 202's "Patient Information" (PI), dated March 2022, the PI indicated Patient 202 was admitted to the hospital (Hospital B), on 3/19/22, with diagnosis of atrial fibrillation (irregular heartbeat) and sepsis (a potentially life threatening condition that occurs when the body's response to an infection damages its own tissues).

During a concurrent interview and record review on 3/23/22 at 1:46 p.m., with Registered Dietitian (RD) 200, Patient 202's "Admission Note Nursing (ANN)," dated 3/19/22 was reviewed. RD 200 stated, there was no consult triggers for an RD based upon the "Malnutrition Screening Tool (MST) completed by a nurse. RD 200 stated that per the hospital's prioritization system, Patient 202 would meet the criteria for an RD to complete a nutrition assessment on 3/26/22 due to length of hospital stay of seven days. RD 200 stated, Patient 202 also had a history of chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs.). RD 200 was asked if COPD could place a patient at nutritional risk, and RD 200 stated, "Not always, but it could and the hospital would not know if the individual patient was meeting nutritional needs until assessed by an RD seven days after admission.

Concurrently, RD 200 stated the hospital's criteria or prioritization system for an RD to complete a nutrition assessment for a patient within three days included the following; when the nursing admission nutrition screen triggered a consult, wounds, tube feeding, TPN (total parenteral nutrition; receiving nutrition through a vein), or by MD (medical doctor; physician) consult order or RN referral. In addition, if a patient was NPO (no food by mouth) for five days. Otherwise, all other patients would be seen on day seven driven by length of stay, versus by therapeutic diet order and/or a diagnosis that is likely to place a patient at nutritional risk. RD 200 verified the hospital would not know if Patient 200's individual nutritional needs were being met during the hospital stay until an RD assessed seven days after admission.

During an interview on 3/23/22, at 2:15 p.m., with hospital Administrator (HA 200), HA 200 stated, the average length of patient stay at Hospital B was 5.7 days.

During an interview on 3/23/22, at 3:00 p.m.,with the Medical Director at Hospital B (MD 200), MD 200 verified that in addition to the nursing nutrition screen upon admission, and the ability for a physician or registered nurse to request an RD consult/referral, the RDs unique skill set and expertise should be utilized to screen patients at nutrition risk in order to help identify patients whose nutritional needs might not be met, or who have a change in medical status during the hospital stay that may necessitate a nutrition assessment, and nutrition care plan, in a timely manner.

During an interview on 3/24/22, at 10:01 a.m., with Regional Chief Medical Officer (CMO 117), CMO 117 verified the hospital's system for identifying patients at nutritional risk throughout the hospital stay needed to be improved.

During an interview on 3/24/22, at 10:47 a.m., with Quality Manager (QM 100) and Director of Quality and Risk Management (DQR 100), QM 100 stated, the Food Service Director's, credentialed as Certified Dietary Manager's for Hospital A (CDM 111), Hospital B (CDM 211) and Hospital C (CDM 311) attend the QAPI (Quality Assessment and Performance Improvement) meetings for the Food and Nutrition Service departments for all three hospital campuses. QM 100 and DQR 100 both stated the hospital's RDs do not attend QAPI.

During a concurrent interview and record review on 3/24/22 at 2:46 p.m., with Registered Dietitian (RD) 101 at Hospital A, Patient 112's "Admission Note Nursing (ANN)," dated 3/10/22 was reviewed. RD 101 stated, there was no consult triggers to the RD based upon the "Malnutrition Screening Tool (MST) completed by a nurse upon admission. Concurrently, RD 101 stated since there was not an RD consult trigger from the MST, nor an RD trigger from a wound consult, per the hospital's criteria or prioritization the RD would conduct a nutrition assessment for Patient 112 on the seventh day of admission driven by the criteria of "length of stay."

During a review of Patient 112's "History and Physical" (H&P), dated 3/10/22, the "H&P" indicated, "Medical Impression ...Problem 1: Acute congestive heart failure exacerbation [worsening of heart failure symptoms when your heart is unable to pump enough blood throughout your body]...Request cardiology [doctor who specializes in heart disease] consultation, Problem 2: Acute on chronic renal failure [gradual loss of kidney function]...Request nephrology [medical professionals who diagnose, treat, and manage acute and chronic kidney problems and diseases] consultation..., Problem 3: Monitor electrolytes [minerals in your body that have an electric charge] and correct accordingly..."

During a concurrent interview and record review on 3/24/22 at 2:50 p.m., with RD 101, Patient 112's "Nutrition Assessment" (NA), dated 3/17/22, was reviewed. The NA indicated, "Reason for Assessment: Length of Stay. Diagnoses/Problem List: Admitting Dx [diagnosis]: ESRD (end stage renal [kidney] disease) on dialysis [a substitute for the normal function of the kidney]: Hyperkalemia [a higher than normal level of potassium in the bloodstream]..., Diet Order start date 3/13/22: Double Portion; Renal with Dialysis (Hemodialysis [a treatment to filter wastes and water from your blood])..., Estimated needs [daily] Calories: 2,155 - 2,320, Protein: 93 - 101 g [grams] per day ...Diet: Renal with Dialysis [1578 calories and 67 g protein], PO (by mouth) intake: 100% intake over last 12 charted meals- current diet order provides less than 75% [percent] estimate nutrient needs. Nutrition Diagnosis: Impaired nutrient utilization related to renal dysfunction as evidenced by elevated BUN [blood urea nitrogen] /creatinine levels [could mean there is a lot of waste product that hasn't been removed by the kidneys] and need of hemodialysis. Inadequate protein related to higher metabolic [all the physical and chemical processes in the body that convert or use energy] demands secondary to hemodialysis as evidenced by current diet order providing insufficient protein (less than 75% estimated needs). Intervention: Add Nepro [to help meet the specialized nutrition needs of people on dialysis] oral [by mouth] shake 1 bottle/two times daily to help meet higher range of estimated nutrient needs. Add Nephrovite [Renal vitamins are specially made for people with chronic kidney disease (CKD) who are on dialysis] 1 tab/daily. Continue current diet order as tolerated."

Concurrently, RD 101 stated, the reason a nutrition assessment was conducted for Patient 112 was solely due to "length of stay of seven days." RD 101 verified that a renal hemodialysis therapeutic diet order, that was in place at time of admission, may indicate Patient 112 was at nutrition risk, and an RD would not know until the patient's nutrition needs were evaluated. RD 101 verified Patient 112's nutrition needs were not met during the hospital stay, in which the RD had not become aware until seven days after admission, as within the hospital's nutrition screening and prioritization system the patient had not been identified as at nutritional risk until the criteria of "Length of stay of seven days".

During an interview with CDM 100 and RD 100 on 3/22/22 at 11:35 A.M., CDM 100 and RD 100 each stated the average length of stay (LOS) at Hospital A was approximately 4.6 days. The hospital system's regional RD (RRD 112) acknowledged and confirmed this statement.

During a review of the facility's policy and procedure (P&P) titled, "Initial Screening, Prioritization and Assessment," dated 3/19, the P&P indicated, "Purpose/Objective; Initial assessment and further prioritization program to identify patients who may need medical nutrition therapy. Scope: Applies to all Food & Nutrition Services Departments [Hospital A, B and C], Policy/Procedure; An initial screening assessment and prioritization is implemented to identify patients who may require medical nutrition therapy(ies). Patients identified at nutrition risk during the initial screening will be further evaluated with an assessment and receive nutrition interventions(s) when applicable. Initial Screening: Nursing; Gathers information from patients within a day of admission, based on pre-determined validated nutrition criteria and documents in the medical record. Based on results of initial screening, consults the dietitian. Prioritization; Registered Dietitian Nutritionist; Evaluates information from the following sources as it becomes available; Nursing: Pressure ulcer reports..., Information Services: Diet orders and changes; New enteral nutrition [A form of nutrition that is delivered into the digestive system as a liquid] orders; admission diagnosis(es). Pharmacy: New orders for parenteral nutrition. Consults from physicians, nurses, and other healthcare professionals. Multidisciplinary team conferences. Food & Nutrition Services: Meal rounds; number of days patient has been NPO/CL. Laboratory: Nutrition related values. Patients requiring nutrition education/survival skills training prior to discharge..., Assessment; Registered Dietitian Nutritionist (RDN)...When recommendations are made which require a physician order, the RDN will follow-up within three days to verify a response to the recommendation. The dietitian may ask nursing's assistance to notify the physician of the dietitian recommendation. If the physician does not respond to the recommendation by ordering the requested intervention or by another entry in the medical record, the dietitian will contact the physician to discuss the recommendation(s) made and document the results of the discussion ..., Within 3 days [an RD needs to complete a nutrition assessment] - Nutrition Consultants, TPN, Tube Feeding..., Education referral, Pressure injuries..., Calculate physician ordered calorie count, By Day 5 - NPO [nothing by mouth]/CL [clear liquid]= 5 days, Length of Stay Assessment Table Unit (Average LOS [ length of stay]) Critical Care - 3 days, Non-Critical Care - 5 days, Behavioral Care Unit = 13 days, LOS Assessment Date Critical Care 5 days (3 ALOS [average length of stay] +2), Non-Critical Care 7 days (5 ALOS +2), Behavioral Care Unit 15 days (13 ALOS +2)."

During a review of the facility's performance improvement plan (PI) for the Food and Nutrition Services for Hospital A and B, last reviewed by the hospital system's regional RD on 12/7/21, the PI objectives for 2021 were improving patient satisfaction scores, RD Recommendations [related to obtaining physician orders to carry out RD recommendations for patients], test tray quality and tray accuracy.

During a concurrent interview and record review, on 3/23/22, at 2:55 P.M.,conducted at Hospital A, with CDM 100, CNM 110, and RRD 112, RRD 112 stated, there were no QAPI projects by the Food and Nutrition Services Department to track the prioritization process for nutrition assessments of patients with a potential nutrition risk. RRD 112 acknowledged the current nutrition assessment prioritization included an initial screening with the malnutrition screening tool (MST) completed by nursing, but this screening tool may miss identifying patients with chronic health conditions in need of a nutrition consult and assessment within 3-5 days of hospital admission. RRD further stated CDM 100 attended the Quality Council meetings at Hospital A, and not CNM 110, CNM 110 confirmed she did not attend the Quality Council meetings.

During a telephone interview on 3/22/22, at 2:12 p.m., with Registered Dietitian (RD) 300 who is the RD for Hospital C, RD300 stated, she did not attend QAPI meetings.

During a review of the facility's job description for "Clinical Dietitian", dated January 2018, indicated, "Summary: Responsible for providing clinical nutrition services, including nutrition assessment, modified diet formulation, self-management training and nutrition intervention to patients/residents. Ensures...quality care, regulatory agency compliance..., Participates in facility-wide and department Quality Assurance/Performance Improvement (QAPI) Program and on QAPI teams to improve processes and patient care..."

During a review of the facility's Quality Performance Improvement Plan" (QPIP), date of review 1/25/22, the QPIP indicated, "Purpose: [name of facility] Performance Improvement (PI) Plan describes the systematic organization-wide approach to quality and patient safety that is used to plan, design, and measure, assess and improve organizational performance. Under this plan, our organization: Provides high-quality, clinical services and demonstrates the outcomes of services,...Provides a mechanism to assure that all patients receive the same level of care..."


38924

Based on observation, interview, and record review, the facility failed to ensure the condition of for Nursing Service as evidence by the facility failing to:

1. Hospital B, two (2) patients of fifty-three (53) sampled patients (Patient 208 and Patient 210), were not assessed for pain by nurses (Registered Nurses) after receiving medication for pain. (Referenced A-0392).

2. The hospitals failed to:

a. Ensure the nursing care plans for one of 53 sampled patients (Patient 210) at Hospital B were kept current and met the patients' changing needs.

b. Develop a pain management care plan for one of three sampled patients (Patient 303) at Hospital C. (Referenced A-0396).

3. Ensure licensed nurses to provided service according to facility policy and procedure as evidence by:

a. Notify the physician of a critical laboratory result (a laboratory test result that exceed established limits and are considered life threatening) and adhere to a physician's order for Patient 107 according to facility's P&P for Critical Test and Critical Result Notification and facility's Dialysis Services Agreement for one of fifty-four (54) sampled patient at Hospital A. This deficient practice resulted to Patient 107 not receiving the dialysis necessary to decrease the critically high potassium level (a dangerous chemical level in the blood which is critical to the function of the nerve and muscle, including those in the heart) which lead to Patient 107's death.

b. Follow facility's P&P for Pain Management by failing to treat pain or referred for treatment for pain, for one of twenty-two sampled patients at Hospital C (Patient 302). This deficient practice had the potential for untreated pain for Patient 302.

c. To label the glucometer test strips (used to measure the blood glucose level on patients) container with the opened and expiration dates according to facility's P&P for POCT (Point of Care Testing): Whole Blood Glucose at nursing station at Hospital A's Medical/Surgical floor with a total census of fifty (50) patients. This deficient practice had the potential to result in harm to the patients from inaccurate blood glucose test results. (Referenced A-0398).

The cumulative effects of these systemic problems resulted in the hospital's inability to ensure the provision and protection of patient care and treatments were provided under Nursing Services.

Based on interview and record review, at Hospital B, two (2) patients (Patient 208 and Patient 210) of fifty-three (53) sampled patients, were not assessed for pain by nurses (Registered Nurses) after receiving medication for pain.

This deficient practice had the potential for worsening pain condition and lack of relief from pain for the patients.

Findings:

a. During a concurrent inteview and record review on 3/23/2022, at 9:29 a.m., with Nursing Supervisor (RN 203), Patient 208's nursing assessment record and medication administration record (MAR), dated 3/21/2022, was reviewed. RN 203 stated Patient 208 had no documentation of pain, but Tylenol (pain medication) was administered to Patient 208 for mild pain. RN 203 stated there was no reassessment of pain documented for Patient 208, after pain medication was administered on the MAR and nursing flowsheet, to assess for the effectiveness of the pain medication.

A review of Patient 208's Patient Information, dated 3/16/2022, indicated patient was admitted with a diagnosis of syncope (temporary loss of consciousness caused by a fall in blood pressure).

A review of Patient 208's History and Physical (H&P-initial clinical evaluation and examination of the patient), dated March 16, 2022, indicated Patient 208 had failure to thrive (insufficient weight gain) for unknown period.

b. During a concurrent interview and record review on 3/23/2022, at 1:15 p.m., with Nursing Supervisor (RN 203), Patient 210's nursing assessment and medication administration record (MAR), dated 3/14/2022, was reviewed. RN 203 stated Patient 210 had no documentation of pain, but Tylenol (pain medication) for mild pain was administered. RN 203 stated there was no reassessment of pain documented for Patient 210, after pain medication was administered.

A review of Patient 210's Patient Information, dated 2/23/2022, indicated patient was admitted with a diagnosis, which included dyspnea (difficulty breathing) and dependent on BiPap (machine that helps with breathing).

A review of Patient 210's H&P, dated 2/23/2022, indicated patient was admitted with worsening breathing condition with BiPap.

A review of facility's job description for the Registered Nurse (RN), dated 6/1/2018, indicated the following:
1. The RN will perform nursing duties to assess, plan, intervene and advocate for the patient, on an ongoing basis throughout the continuum of care.
2. The RN administers medications, treatments and procedures in a safe, effective and appropriate manner that meets the scope of practice and standards of nursing practice.
3. The RN will evaluate the patient's response and outcomes.

A review of facility's Pain Management policy, dated 9/2019, indicated the following:
1. All patients admitted shall be questioned as whether they are experiencing pain.
2. The comprehensive assessment shall include intensity (based on the patient's statement of pain), site, quality, onset of pain.
3. A reassessment of pain consists of an interaction with the patient that includes intensity, impact of interventions, progress toward comfort, effect of pain on the patient's functionality, and ability for patient to achieve sleep or rest.
4. The reassessment of pain shall be performed at least once every twelve hours and following any intervention intended to lessen the patient's pain.

A review of facility's Standards of Nursing Practice Policy, dated 9/2019, indicated the following:
1. Every patient shall be assessed by the RN, including more frequent and/or in depth assessments, according to the specific standard of care identified.
2. Assessments will be completed a minimum of once per shift and documented in the medical record.
3. The RN shall seek multi disciplinary input regarding the patient's progress and the multi disciplinary approach will be used in assessing patients.
4. All nursing care shall be documented according to the hospital's standards and designated method of documentation, including care team notes and flowsheets.
5. The patient's response to and outcomes of nursing interventions shall be evaluated and documented in the patient's medical record and reflected in the patient's plan of care.


43400

Based on interview and record review, the hospital failed to:

1. Ensure the nursing care plans for one of 53 sampled patients (Patient 210) at Hospital B were kept current and met the patients' changing needs.

This deficient practice resulted in care that was not evaluated and revised to the patients' individualized needs.

2. Develop a pain management care plan for one of three sampled patients (Patient 303) at Hospital C.

This deficient practice had the potential for untreated pain for Patient 303.

Findings:

1. On 3/23/2022, at 1:15 p.m., during concurrent interview with Nursing Supervisor (RN 203) and record review of Patient 210's care plans for airway clearance and ineffective breathing, dated March 21, 2022, RN 203 stated there were no revisions to the care plans to indicate oxygen delivery methods of high flow nasal cannula and BiPap and no evaluations of the care provided to improve patient's breathing.

A review of Patient 210's face sheet, dated 2/23/2022, indicated patient was admitted with diagnoses, which included dyspnea (difficulty breathing) and dependance on BiPap (machine that helps with breathing).

A review of Patient 210's History and Physical (H&P initial clinical evaluation and examination of the patient), dated 2/23/2022, indicated the following:
1. The patient was admitted for Respiratory Distress with worsening breathing condition with BiPap.
2. Patient's chest x ray showed pneumonia (infection that inflames the air sacs in one or both lungs, which may fill with fluid).
3. Plan for patient included intravenous (IV within the vein) antibiotics, blood pressure medication, IV fluids, and BiPap.

A review of Patient 210's Pulmonary Consult (specialty physician in the care and management of the lungs), dated 2/24/2022, indicated the following:
1. Patient was dependent on BiPap with a worsening breathing condition.
2. Orders included arterial blood gas, continuous pulse oximetry, and start BiPap vent assist.

A review of Patient 210's Pulmonary Consult, dated 2/24/2022, indicated the physician orders to start Handheld Nebulizer treatments (breathing treatment with breathing in medication with a mist) every four hours with albuterol ipratropium inhalation (combination medication used to treat chronic obstructive pulmonary disease by inhaling the medication).

A review of Patient 210's Pulmonary Consult, dated 2/25/2022, indicated the physician orders for the following:
1. Oxygen therapy by High Flow (HFNC high flow nasal cannula) daily for oxygen (O2) saturation greater than 92%
2. BiPap during the night and as needed, to maintain O2 saturation greater than 92%. If patient doesn't tolerate this, restart high flow nasal cannula.

A review of Patient 210's Pulmonary Consult, dated 2/26/2022, indicated the physician orders to start Handheld Nebulizer treatments every four hours with Mucomyst 10% inhalation (a drug that loosens and thins mucus in the lungs to make breathing easier).

A review of facility's Standards of Nursing Practice Policy, dated 9/2019, indicated the following:
1. The RN, in collaboration with members of the health care team, shall utilize the nursing process, to identify and address the patient's biological, psychosocial, environmental, safety, spiritual, and discharge needs, in the delivery of patient care.
2. The RN shall implement accepted infection control measures to prevent the transmission of infection, including hand hygiene, universal precautions, barrier techniques, and isolation measures.
3. All nursing personnel shall use and maintain accepted aseptic techniques, during any procedure.
4. Every patient shall be assessed by the RN, including more frequent and/or in depth assessments, according to the specific standard of care identified.
5. Assessments will be completed a minimum of once per shift and documented in the medical record.
6. The RN shall seek multi disciplinary input regarding the patient's progress and the multi disciplinary approach will be used in assessing patients.
7. All nursing care shall be documented according to the hospital's standards and designated method of documentation, including care team notes and flowsheets.
8. The RN shall communicate significant findings and plan of care to the physician and other members of the multi disciplinary team.
9. The RN formulates a plan of care, based on collected data from admission and throughout hospitalization, and the plan of care will use nursing diagnosis, collaborative problems, and/or clinical pathways.
10. The plan of care shall be based on the assessment of the patient and shall include nursing interventions documented in the nursing record.
11. The RN shall be accountable for the individualized, delegation, and coordination of the plan of care, in collaboration with the patient and patient's representatives.
12. Nursing shall follow the plan of care and collaborate with the patient/patient's representatives, and the multi disciplinary team, in revising the plan of care.
13. The RN shall be accountable for evaluation of the nursing plan of care, using established standards of care and feedback from the patient/patient's representatives, and the multi disciplinary care team.
14. The patient's response to and outcomes of nursing interventions shall be evaluated and documented in the patient's medical record and reflected in the patient's plan of care.

A review of facility's job description for the Registered Nurse (RN), dated 6/1/2018, indicated the following:
1. The RN will collaborate with the inter disciplinary team to develop and implement a plan of care and will ensure the coordination of care between other disciplines.
2. The RN will perform nursing duties to assess, plan, intervene and advocate for the patient, on an ongoing basis throughout the continuum of care.
3. The RN will evaluate the patient's response and outcomes, effectiveness of plan of care, and readiness for discharge.
4. The RN will revise the plan of care or make referrals, as necessary.
5. The RN administers medications, treatments and procedures in a safe, effective, and appropriate manner that meets the scope of practice and standards of nursing practice.

2. During a review of Patient 303's Patient Information Sheet (undated) indicated Patient 303 was admitted to Facility C on 3/19/2022.

During a review of Patient 303's History and Physical (H&P), dated 3/19/2022, the H&P indicated Patient 303 was admitted to the facility for exacerbation of mental illness with suicidal ideation (thinking about suicide or wanting to take your own life). H&P indicated Patient 303's past medical history included arthritis (the swelling and tenderness of one or more joints; symptoms are joint pain and stiffness), with plan to provide medications as needed for pain.

During a concurrent interview and record review, on 3/22/2022 at 9:55 am, with Charge Nurse/ Registered Nurse (RN 302), Patient 303's EMAR (Electronic Medical Record) from 3/19/2022 at 7:07 pm until 3/22/2022 9 am. EMAR indicated, Patient 302 was provided Acetaminophen 650 mg (pain medication) on 3/19/2022 at 7:07 pm, 3/20/2022 at 2:43 am, 3/21/2022 12:35 am, and 3/21/2022 at 11:41 pm. RN 302 stated, medications were given to Patient 303 for pain.

During a concurrent interview and record review, on 3/22/2022 at 10:05 am, with RN 302, Patient 303's Care Plan list, printed 3/22/2022 was reviewed. RN 302 stated, unable to confirm if care plan for pain management was completed for Patient 303. RN 302 stated, care plan for pain management should have been initiated because Patient 303 was admitted with pain concerns and care planning can assist with pain management and pain interventions. RN 302 stated, care plan was not completed for Patient 303.

A review of Facility C's policy and procdedure titled, "Interdisciplinary Plan of Care", effective date 9/2019, policy indicated "Interdisciplinary Plan of Care shall be based upon the assessments performed by all disciplines, which describes the intentions, rationale, and interventions associated with identified issues". Policy indicated, "C. An individualized plan of care is developed for each patient; each patient's care plan identifies goals that: i. Reflect the patient's unique needs ii. Are realistic and measurable iii. Include a time frame for achievement, when appropriate."





42379

Based on observation, interview and record review, the facility failed to provide appropriate patient care according to facility policy and procedure (P&P) as evidenced by nurses failing to:

1. Notify the physician of a critical laboratory result (a laboratory test result that exceed established limits and are considered life threatening) and adhere to a physician's order for Patient 107 according to facility's P&P for Critical Test and Critical Result Notification and facility's Dialysis Services Agreement for one of fifty-four (54) sampled patient at Hospital A. This deficient practice resulted to Patient 107 not receiving the dialysis (procedure to remove waste products and excess fluid from the blood) necessary to decrease the critically high potassium level (a dangerous chemical level in the blood which is critical to the function of the nerve and muscle, including those in the heart) which led to Patient 107's death.

2. Follow facility's P&P for Pain Management by failing to treat pain or referred for treatment for pain, for one of twenty-two sampled patients at Hospital C (Patient 302). This deficient practice had the potential for untreated pain for Patient 302.

3. To label the glucometer test strips (used to measure the blood glucose level on patients) container with the opened and expiration dates according to facility's P&P for POCT (Point of Care Testing-bedside testing): Whole Blood Glucose at nursing station at Hospital A's Medical/Surgical (Med-Surg, unit that provides care to less critical patients) floor with a total census of fifty (50) patients. This deficient practice had the potential to result in harm to the patients from inaccurate blood glucose (blood sugar) test results.

On March 24, 2022, at 1:40 p.m., the survey team called an immediate jeopardy (IJ-a situation in which the provider's noncompliance has caused or is likely to cause serious injury, harm, impairment or death to a patient)) situation in the presence Director of Quality and Risk (DRQ-100), Chief Executive Officer (CEO-100), Chief Nursing Officer (CNO-100), Chief Medical Officer (CMO-100), Vice President of Quality (VP-102), and Chief Operating Officer (COO-100). The DQR-100, CEO-100, CNO-100, CMO-100, VP-102, COO-100 were informed of the IJ situation regarding the failure to ensure a physician order for Patient 107 was implemented which resulted in the death of Patient 107 and had the potential to harm other patients on dialysis at Hospital A.

On March 25, 2022, at 2:30 p.m. the IJ situation was removed after verifying an acceptable removal plan which was verified onsite through observation, interviews, and record reviews. The removal plan indicated a process to ensure the patient's physician is notified for all critical level laboratory results (a laboratory test result that exceed established limits and are considered life threatening) and that the physician orders are implemented.

The acceptable IJ Removal Plan were as follows:
1. On March 24, 2022, the facility leadership performed a risk assessment for areas at most risk for failure to follow the policy and procedures relating to reporting of critical laboratory values and following physician orders associated with critical laboratory values.
2. On March 24, 2022, the Critical Test and Critical Result Notification Policy was revised and a Critical Lab Value Log was implemented for monitoring.
3. Staff Education on the new polies and procedures began on March 24, 2022 and with target completion on 4/8/2022.

Findings:

1. A review of the physician's progress note , dated 1/15/2022, indicated Patient 107 was admitted to the acute rehabilitation unit (specializing in the treatment of patients who will benefit from intensive, multidisciplinary rehabilitation program including physical, occupational, and/or speech therapy) on 1/14/2022. Patient 107 had congestive heart failure (a condition in which the heart doesn't pump blood as efficiently), end stage renal disease (a condition in which a person's kidneys cease functioning) and required hemodialysis (a treatment to filter wastes and water from the blood due to the kidneys not functioning).

A review of the physician's order, dated 1/23/2022, indicated Patient 107 was ordered hemodialysis to be done on 1/24/2022. The order included parameters for hemodialysis to be done immediately if Patient 107's potassium ([K] an essential mineral that is needed by all tissues in the body, including the heart) laboratory test result was greater than 5.1 millimoles per liter (mmol/L, unit of measurement).

A review of the laboratory test results dated 1/24/2022, at 11:56 a.m., indicated that Patient's 107's potassium level was 6.8 mmol/L (normal level: 3.6 to 5.2 mmol/L, dangerous level is above 6.0 mmol/L).

A review of the nursing narrative note, dated 1/25/2022, indicated Registered Nurse 102 (RN 102) called a code blue (medical emergency in the hospital indicating patient stopped breathing or without a heartbeat) on 1/24/2022, at 5:35 p.m. because Patient 107 went into cardiac arrest (when the heart stops beating suddenly).

A review of the Death Summary, dated 2/10/2022, indicated Patient 107 was transferred to the intensive care unit (ICU-a specialized area of the hsopital that provides treatment and monitoring for patients who are very ill) on 1/24/2022. Patient 107 conditioned worsened and Patient 107 expired on 2/1/2022 due to cardiac arrest.

During an interview on 3/23/2022, at 9:47 a.m., with RN 102, she (RN 102) stated that she (RN 102) did not notify the physician or document notifying the physician of Patient 107's elevated potassium level on 1/24/2022 after she (RN 102) was received the potassium lab result for Patient 107.

During an interview on 3/23/2022, at 3:06 p.m., with Physician 102 (MD 102), MD 102 stated that he (MD 102) was not notified that Patient 107's potassium level was 6.8 mmol/L until after learning of Patient 107's cardiac arrest on 1/24/2022. MD 102 stated elevated potassium level is considered life threatening and it was reasonable to believe that the elevated potassium level contributed to Patient's 107's demise.

A review of MD 102's progress notes, dated 1/24/2022, indicated Patient 107's hemodialysis order was not carried out on time on 1/24/2022.

During an interview on 3/24/2022, at 9:34 a.m., with Nurse Manager (RN 130), RN-130 stated that RN 102 received disciplinary action (corrective action in response to employee misconduct or poor performane) for failing to notify the physician of critical laboratory test results. RN-130 also said that the acute rehabilitation unit (takes care of patients who have expereinced some major injury or illness regain the skills needed to return to everyday living) nursing staff received in-service training (education training).

A review of the facility's policy and procedure (P&P) titled, "Critical Test and Critical Result Notification," dated 9/2019, indicated "a test result with a critical value is to be reported to the physician within 60 minutes of the time the result is released and documented in the progress notes."

A review of the facility's Dialysis Services Agreement, dated 1/1/2021, indicated that immediate dialysis orders will be initiated within four hours.

2. A review of Patient 302's Patient Information Sheet (undated), indicated that Patient 302 was admitted to Hospital C from 3/16/2022 to 3/21/2022.

During a review of Patient 302's History and Physical (H&P), dated 3/17/2022, the H&P indicated that Patient 302 was admitted Hospital C for suicidal ideation (thinking about suicide or wanting to take your own life). The H&P also indicated that Patient 302 had feelings of severe depression (common and serious medical illness that negatively affects how a person feel, think, and act) and suicidal thoughts. H&P indicated that Patient 302 was admitted to the facility for voluntary (own free will) psychiatric (mental disorder) admission.

During a concurrent interview and record review, on 3/22/2022 at 9:48 am, with Charge Nurse/Registered Nurse (RN) 302, Patient 302's Vital Sign Measurement (VS, show how well a body is functioning that includes measurement of temperature, blood pressure, heart rate, and respiratory rate) dated 3/20/2022 at 4 p.m. was reviewed. VS document indicated, "Pain Assessment: 4 (rating of pain for 0 [no pain at al] to 10 [worst imaginable pain]) pain upper back." RN 302 stated, there was no documentation if pain medication was offered to Patient 302. RN 302 also stated that there was no documentation if interventions were completed for Patient 302's upper back pain. RN 302 stated documentation of interventions was needed to know what was done for the Patient 302, and if anything was offered to relieve Patient 302's upper back pain.

During a concurrent interview and record review, on 3/22/2022, at 9:50 am, with RN 302, Patient 302's EMAR (Electronic Medical Record), dated 3/20/2022, was reviewed. RN 302 stated there was no documentation for any pain medication administered to Patient 302. RN 302 stated that she (RN 302) was unable to confirm if medication or interventions were carried out for the documented upper back pain assessment that was peformed on patient 302, on 3/20/2022, at 4 p.m.

A review of Hospital C's policy and procedure (P&P), titled "Pain Management," dated 9/2019, indicated that the P&P's purpose was to "addresses the assessment and reassessment of pain in all settings throughout the organization". The P&P also indicated, "When pain is identified, the patient shall be treated or referred for treatment as clinically pertinent".

3. A review of the Medical/Surgical unit census dated 3/21/2022, indicated there were fifty (50) patients receiving care by nursing personnel that may require use of a glucometer machine (a medical tool that measures glucose in human blood and requires used of a glucometer strip).

During a concurrent observation and interview on 3/21/2022, at 12:14 p.m., with Medical Surgical Charge Nurse 108 (RN 108), at the nurses' station at Hospital A, one glucometer strips container did not have the open and discard dates labeled on the outside container. RN 108 stated the nurse who initially opened the glucometer test strip container should have labeled the container with the open and expiration dates.

A review of the facility's policy and procedure (P&P), titled "POCT (Point of Care Testing): Whole Blood Glucose," dated 3/2018, indicated "to assure the accuracy of test results, the glucometer strips container will be dated with open date and discard date."


43400




43419

Based on observation, interview, and record review, the Hospital B failed to ensure medications were administered in accordance with physician orders, acceptable standards of practice, and facility policy and procedure as evidence by:

1.1 A STAT (immediately) physician order for azithromycin (an antibiotic) for Patient 216 at facility 2's Urgent Care did not have documentation as to why it was not administered to the patient immediately;
1.2 Two medications for Patient 214 did not have documentation of administration and one of them was not administered correctly.
1.3. During a medication pass observation, one morning medication dose for Patient 216 was prepared and administered incorrectly.

These deficient practices had the potential to cause harm to patients from treatment delays and ineffective treatment.

2. Failing to ensure one of seventeen sampled patients (Patient 212)'s intravenous (IV) medication was disinfect at the rubber septum after removing a foil cover, prior to administering the IV medication.

This deficient practice had the potential for cross contamination and transmission of infectious diseases to the patient.

Findings:

1.1 On 3/22/2022, during a review of Patient 216's medical record, there was a physician order dated 3/14/2022, at 2:58 p.m., for azithromycin IVPB (intravenous piggyback) 500 mg (milligram) to be infused at 250 ml/hr (milliliter per hour) once. This order was reviewed and verified by a pharmacist at 3:06 p.m.

A review of the electronic medication administration record (eMAR) indicated this order had STAT (immediately) time of administration but no documentation of administration or reason for the medication not being administered.

In an interview on 3/22/2022, at 11 a.m., Registered Nurse 203 (RN 203) confirmed the eMAR did not have nursing documentation of administration and stated there was no additional nursing notes to explain the reason for this order to be not carried out in the patient's medical record.

The facility's policy and procedure titled, "Ordering, Preparation and Administration of Medications," last reviewed 10/20, indicated:
"...All time critical medications must be administered within 30 minutes before or after the scheduled time...
Each nurse administering medications is to document in eMAR...Omission of scheduled medication is to be charted by documenting the reason using the corresponding code..."

1.2 On 3/23/2022, at 2:10 p.m., facility 2's Pharmacy Night Locker for storage of larger and bulky IV (intravenous - into vein) fluids and refrigerated medications was observed.

On 3/22/2022, review of the facility 2's "Night Locker After-Hours Sign Out Log" indicated RN 201 removed one, 1000-ml (milliliter) IV bag of 5% Dextrose in 0.45% NS (normal saline) with 20 mEq (milliequivalants - unit of measure) KCl (potassium chloride - electrolyte) [D5W+1/2NS-20mEq KCl] for Patient 214 on 3/22/2022, at 12 a.m. (midnight).

Patient 214's medical record was reviewed and the following were noted:

There were two physician orders on 3/21/2022, at 9:23 p.m., for D5W+1/2NS-20mEq KCl 1000 ml IV infusion to run at 80 ml/hr and piperacillin+tazobactam (Zosyn - antibiotic) IVPB (IV piggyback) 3.375 gram every 8 hours.
The electronic medication administration record (eMAR) indicated there was no documentation these two medication doses were initiated.

During an interview on 3/22/2022, at 11:30 a.m., Registered Pharmacist 201 (RPH 201) and Pharmacy Technician 200 (PT 200) stated no additional bags of D5W+1/2NS-20mEq KCl 1000 ml were dispensed by the Pharmacy or removed from the night locker.

On 3/22/2022, at 11:45 a.m., it was observed the bag of D5W+1/2NS-20mEq KCl 1000 ml was being infused to the Patient 214's vein with the help of an IV infusion pump which indicated the infusion was started on 3/21/2022, at 10 p.m., running at 80 ml/hr with the volume of 771.5 ml remaining in the bag.

In a concurrent interview, RN 200 observed the volume of D5W+1/2NS-20mEq KCl still remaining after more than 13 hours had elapsed and stated D5W+1/2NS-20mEq KCl was running continuously but it looked like it had not been infusing correctly. RN 200 confirmed there was no documentation of administration of these medications by the night nurse for Zosyn and D5W+1/2NS-20mEq KCl.

The facility's policy and procedure titled, "Ordering, Preparation and Administration of Medications," last reviewed 10/20, indicated:
"...All time critical medications must be administered within 30 minutes before or after the scheduled time...
Each nurse administering medications is to document in eMAR...Omission of scheduled medication is to be charted by documenting the reason using the corresponding code..."

1.3 A medication pass observation was conducted with RN 200 on 3/22/2022, at 9:05 a.m.. It was observed that RN 200 removed two 30-ml cups containing lactulose (drug used for constipation) 20 grams per 30 ml (milliliter - unit of measure) from the Omnicell (an automated drug delivery system for medications). RN 200 was observed to make several transfers of the liquid lactulose from the original manufacturer's cup to an empty plastic medication cup and back, measuring the amount of liquid poured in and out of the plastic medication cup.

It was observed there was lactulose liquid remaining in one of the original manufacturer's cup after the morning dose was given to patient 216. RN 200 was asked to measure the lactulose liquid remaining after the administration in an empty plastic medication cup. The measured amount was 30 ml (equal to 20 grams).

Review of Patient 216's medical record indicated there was a physician order on 3/20/2022, for lactulose 30 grams syrup to be given to the patient by mouth three times a day.

In a concurrent interview, RN 200 stated the lactulose dose should have been 45 ml which would equal to 30 grams and acknowledged she did not give the right dose.

The facility's policy and procedure titled, "Ordering, Preparation and Administration of Medications," last reviewed 10/20, indicated:
" ...An MD, RN, LVN or student nurse under the direct supervision of an RN, may administer FDA approved and investigational medications in accordance with the Seven Rights of medication administration. An RT or PT may administer FDA approved mediations within the scope of their practices: i. Right patient ii. Right drug iii. Right dose iv. Right route v. Right time vi. Right reason vii. Documentation ..."

2. On 3/21/2022, at 1:38 p..m, during concurrent observation of medication administration for Patient 212 and interview with RN 204, RN 104 did not disinfect the rubber septum after removing a foil cover, prior to handing an intravenous (IV - within a vein) medication. Concurrently, RN 204 stated he did not have to disinfect the rubber septum of the IV set-up if the septum was covered with a foil covering.

On 3/29/2022, at 1:57 p.m, during interview with Nurse Manager (RN 203), RN 203 stated prior to connecting an IV piggy-back to hand a medication, the nurse must disinfect the rubber septum. RN 203 stated that RN 204 should have disinfected the rubber septum of the tubing prior to hanging the IV medication for the patient (Patient 212).

A review of Patient 212's face sheet, dated 3/21/2022, indicated patient was admitted with a chief complaint of wound infection.

A review of Patient 212's emergency physician note, dated 3/20/2022, indicated the following:
1. Chief complaint was bilateral leg wounds
2. Past medical history included psychoactive substance abuse
3. Patient had multiple large necrotic wounds with redness and foul-smelling drainage from both legs.
4. Plan to admit patient to the hospital.

A review of Patient 212's History and Physical, dated 3/21/2022, indicated the following:
1. Social history of homelessness.
2. Past medical history of polysubstance abuse and no teeth.
3. Physical exam indicated patient was alert and oriented and in no acute distress.
4. Plan included wound care and culture, antibiotics, infectious disease consultation.

A review of Patient 212's medication administration record, dated 3/21/2022, indicated RN 204 administered an IV antibiotic (medication for infection) at 1:02 p.m.

A review of facility's policy for Ordering, Preparation and Administration of Medications, dated 11/2020, indicated the following:
1. An RN may administer medication in accordance with seven rights of medication administration (patient, drug, dose, route, time, reason, documentation).
2. All injectable vials or ampuls will be cleaned with sterile alcohol swab before withdrawing medication.

A review of Centers for Disease Control and Prevention - Safe Injection Practices, dated 3/25/2016, indicated the following:
1. Prepare injections using aseptic technique in a clean area.
2. Disinfect the rubber septum on a medication vial with alcohol before piercing.




38310

Based on observation interview and record review Hospital A failed to:

1. Ensure hemodialysis (a medical procedure for cleaning the blood with a special filter) services were provided in a safe environment for one of 10 sampled patients (Patient 147) at Hospital A's Intensive Care Unit (ICU, a unit in a hospital providing intensive care for critically ill or injured patients). The facility staffs do not do handoff communication (up-to-date information regarding patient care, treatment and service, condition, and any recent or anticipated changes) and do not provided training for emergency care during hemodialysis (a medical procedure for cleaning the blood with a special filter) care for an incapacitated nurse (according to facility's policy and procedure (P&P).

2. Ensure nursing staff monitored and prevent one of 10 sampled patients from receiving expired intravenous fluid (IVF) at Hospital A according to facility P&P.

These deficient practices resulted to Patient 146 receiving expired medication and had the potential for dialysis patients not receiving adequate care during an emergency and receiving expired IVF fluid.

Finding #1:

On 3/24/2022 at 11:05 a.m., during an observation with Associate Chief Nursing Officer (ACNO) in the ICU, Patient 147 was observed undergoing hemodialysis. Registered Nurse 132 (RN-132) observed providing care for Patient 147.

On 3/24/22 at 11:05 a.m., during an interview RN-132 stated patient care for during a power outage and/or during an emergency if a dialysis nurse became incapacitated was not discussed during the hand off communication (up-to-date information regarding patient care, treatment and service, condition, and any recent or anticipated changes) prior to starting dialysis care for Patient 147.

On 3/24/2022 at 11:15 a.m., during an interview, RN-136 not receiving training or in-service for an emergency event during a Patients' dialysis including power outage and/or an incapacitated dialysis nurse.

During an interview, (DQR-100) on 3/29/2022 at 2:00 p.m., Director of Quality and Risk 100 (DQR-100) stated during hemodialysis, including emergency instructions if the dialysis nurse became incapacitated and/or a power outage, the facility had no documentation of any nurses in-services on how to turn off the hemodialysis dialysis machine or what lines to clamp in case of an emergency.

A review of the Hospital A's hemodialysis Quality Assurance and Performance Improvement (QAPI) studies did not include any studies or facility nurse training for emergencies during hemodialysis including emergency instructions on how to safely stop the dialysis.

A review of Hospital A's P&P for Emergency procedure for an incapacitated acute dialysis nurse, dated 7/1/2019, indicated interventions that included not to attempt to returned the blood to the patient, contact the charge nurse and/or hospital administrator, and notify the nephrologist (a kidney specialist).

2. On 3/22/2022 at 2:10 p.m., during an observation in the ICU with the Chief Nursing Officer (CNO) and Coronary Care Manager 100 (MG-100), Patient 146 was receiving 9 % Normal Saline (NS)intravenous fluids. The handwritten label on the 9% NS IVF bag indicated a start time documented and dated 3/21/2022 at 6 a.m. and had an expiration date and time for 3/22/22 at 6 a.m. MG-100 and the CNO confirmed the observation. The RN that cared for patient 146 was not available for an interview. (IVF as being administered 8 hours and 10 minutes after expired time).

On 3/29/2022 at 9:30 a.m., during an interview with the CNO and the Assistant Chief Nursing Officer (ACNO), the ACNO stated that each shift, RNs do patient bedside assessment in the room and this assessment included checking all IV fluids and medications to assure IVF were not administered when expired.

A review of the Hospital A's P&P for Intravenous Therapy Initiation and management of peripheral intravenous lines, dated 3/2022 indicated, "Intravenous fluid solutions should be changed every 24 hours."

Based on observation, interview, and record review, Hospital C failed to implement facility's policy and procedure (P&P) for Self-Administration of Medications as evidence by Registered Nurse 303 (RN-303) failing to:

1. Ensured Patient 316 was able to properly self administer the prescribed Albuterol inhaler (a medication used to prevent and treat difficulty breathing, wheezing, shortness of breath, coughing, and chest tightness caused by lung diseases such as asthma and chronic obstructive pulmonary disease [COPD; a group of diseases that affect the lungs and airways]).

2. Train Patient 316 how to accurately administer the Albuterol inhaler.

3. Ensure Patient 316 had a physician order to self administer any medications.

These deficient practice resulted to Patient 316 receiving subtherapeutic (lower than that usually prescribed to treat a disease effectively) dose of Albuterol and had the potential for poor health outcome.

Findings:

During the medical record review, on 3/22/22, the review indicated Patient 316 was admitted to Hospital C, on 3/17/22. Record review indicated a medication order for Albuterol 90 microgram/inhalation for 2 puffs inhalation every 6 hours as needed for shortness of breath.

During an observation of the medication administration process, on 3/22/22 at 9:15 a.m., RN 303 gently shakes Albuterol inhaler and handed the Albuterol inhaler to Patient 316 to self-administer. Patient 316 took the inhaler, immediately administered a puff, then the second puff without waiting at least one minute between the puffs. During a concurrent interview, RN 303 acknowledged Patient 316 did not self-administer Albuterol inhaler correctly and acknowledged not instructing the patient on how to use the inhaler correctly.

During a review of Patient 316 medical record, on 3/22/22 at 2:15 p.m., in the presence of House Supervisor (HS-300), Patient 316 had no physician order to self-administer any medication. The review also failed to show any documentation of Patient 316 was able to self administer the Albuterol inhaler prior to being allowed to self-administer. Patient 316's had no documentation indicating Patient 316 has trained on how to accurately use the Albuterol inhaler. House Supervisor 300 (HS 300) acknowledged above.

During an interview, on 3/22/22 at 2:40 p.m., RN-303 acknowledged he should not have allowed Patient 316 to self-administer the Albuterol inhaler. Assistant Chief Nursing Officer 300 (ACNO-300) acknowledged all the stated the Facility C's P&P for Self-Administration of Medications was not implemented.

A review of the Hospital C's P&P for Self-Administration of Medications, revised date 3/2019, indicated self-administration of a medication by a patient, or patient's support person was permitted only on the specific order of a practitioner responsible for the care of the patient; however, it was highly discouraged. The capacity of the person or support person to administer the specified medication(s) was assessed prior to allowing self-administration of a medication(s) by the provider. Physician must approve the patient or patient's support person to self-administer the non-controlled medication. The physician's request must be documented in the electronic medical record. The patient or patient's support person must be educated on the proper use of the medication.

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

1. Medications were properly stored in the Pharmacy at Facility B to protect them from light as recommended by the manufacturers.

2. Safe handling and disposal of hazardous drugs (HD) by the Pharmacy staff were practiced in accordance with acceptable standards by having a proper HD waste container readily available in the Pharmacy at Facility B.

3. Facility A's Adult Emergency Cart (crash cart which contains medications and equipment needed for life-threatening emergencies) Medications was protected from light in accordance with the facility's policy titled, "Crash Cart Inspection, Maintenance, Exchange."

These deficient practices had the potential for patients to receive ineffective medications during a medical emergency that may increase the risk of harm to patients. Also, for patients receiving ineffective medications and staff not being protected from exposure to harmful drugs.

Findings:

1. During a tour of the Hospital B's Pharmacy, on 3/21/2022 at 1:40 p.m., injectable vials of dexamethasone (drug used to decrease swelling) 10 mg/ml (milligram per milliliter - unit of measure) and Solu-Cortef (drug used to decrease swelling) 100 mg Actovial were stored on the Pharmacy shelves exposed to ambient light.

The manufacturers' labels on the vials indicated the the medications were to be protected from light.

During a concurrent interview, on 3/21/2022 at 1:40 p.m. Registered Pharmacist 200 (RPH-200) agreed the vials should have been stored protected from light.

The Facility B's policy and procedure titled, "Medication Storage," last reviewed, "2/2019," indicated, "...Drugs shall be stored under the proper conditions of sanitation, temperature, light, moisture, ventilation, organization, segregation and security..."

2. During a tour of the Hospital B's Pharmacy, on 3/23/2022, at 8:30 a.m., there were several medication bins on the Pharmacy shelf containing hazardous medications. The labels on the medications indicated the medications were chemotherapy drugs (medication to treat cancer).

During an interview, on 3/23/2022, at 12:05 p.m., RPH-200 stated hazardous drugs, including chemotherapy drugs would be handled and dispensed by the Pharmacy. The Pharmacy did not have yellow chemo waste bins for the gloves to be placed in after handling hazardous drugs.

A review of Hospital B's policy and procedure titled, "Drug Distribution-Unit Dose System," last reviewed on 5/2019, indicated, "...Oral chemo drugs if unit dose...Chemo gloves or double gloves will be used when preparing unit dose. The gloves used to prepare oral chemo drugs will be disposed in yellow chemo waste bin..."

A review of Hospital B's policy and procedure titled, "Return, Handling and Disposal of Medication Waste," last reviewed on 2/2019, indicated, "Hazardous Pharmaceutical Waste: all waste generated by the pharmacy department...included chemotherapy waste." Hospital B had three types of hazardous pharmaceutical waste and indicated waste that were "Chronically toxic ( frequent exposures where effects may be delayed (even for years) and were generally irreversible)..include chemotherapy agents."


3. During a tour of Hospital A's Pharmacy, on 3/21/2022 at 11:51 a.m., two of three Adult Emergency Cart Medication were observed inside the pharmacy sealed, initialed in the space marked, "Checked by," pharmacist and dated 3/18/2022 and 3/19/2022. The Adult Emergency Cart Medication check list identified medications that required protection from light. The following medications were exposed and not protected from light as indicated on the medication checklist:

1. Diphenhydramine (used to treat allergic reactions) 50 mg/ml (milligram [mg] per milliliter [ml] - unit of measure), quantity two - 1 ml vials
2. Amiodarone (medications used to slow heart rate) 50 mg/ml, quantity three - 3 ml vials
3. Flumazenil (used to reverse the effects of a benzodiazepine, a type of sedative medication) 0.1 mg/ml, quantity one - 1 ml vial
4. Naloxone (a medicine that rapidly reverses an opioid [narcotic] overdose) 0.4 mg/ml, quantity four - 1 ml vials
5. Norepinephrine (used to treat life-threatening low blood pressure) 1 mg/ml - two - 4 ml ampoules
5. Verapamil used to control rapid heartbeats or abnormal heart rhythms 2.5 mg/ml - two - 2 ml vials

During an interview on 3/21/2022 at 11:53 pm, with registered pharmacist (RPH 100), RPH 100 stated, the Adult Emergency Cart Medication should have been protected from light.

A review of Hospital A's policy titled, "Crash Cart Inspection, Maintenance, Exchange", effective 10/2019, indicated, "The contents of the medication tray shall be listed on the 'Adult Emergency Cart Medication List' ...The entire tray will be light protected."


31333

Based on observation, interview, and record review, the hospital failed to ensure staff implemented their policy and procedure (P&P) regarding accurate records of the disposition of controlled medications as evidence by:

1. Hospital A failed to ensure an accurate record of disposition of Fentanyl (a synthetic opioid typically used to treat patients with chronic severe pain or severe pain) drip.

2. Hospital C nursing staff failed to ensure disposition of Lorazepam (a medication used to treat anxiety and seizures) tablet was witnessed prior to cosigning wastage.

These deficient practices had the potential to result in controlled medication diversion which may lead to poor patients' outcome.

Findings:

1. During a review of Patient 108's medical record review, on 3/23/2022. indicated Patient 108 was admitted at Hospital A, on 3/7/2022.

(a) The record review indicated a Fentanyl infusion drip (given directly to the vein) order for 1000 microgram (mcg) /100 milliter (ml, unit of measurement), on 3/18/2022 at 8:23 a.m., start 1 mcg/kilogram (kg)/hour (hr.), titrate 0.5 mcg/kg/hr every 30 minutes, max dose 10 mcg/kg/hr. Patient 108's weight was 59 kg.

A record review of Patient 108 medication administration flow sheet indicated there was no documentation that the Fentanyl drip was administered before it was discontinued on 3/18/2022 at 6:16 p.m.

A review of the narcotic waste/completion documentation form for Patient 108's Fentanyl drip was returned to the pharmacy and showed a blank form with no documentation of the disposition.

During an interview on 3/24/2022 at 12:45 p.m., the Pharmacist in Charge 11 (PIC- 100) acknowledged that the blank narcotic waste form was returned. PIC-100 also stated the Hospital A's P&P titled, "Patient Controlled Analgesia," should be implemented for Fentanyl drip waste. Corporate Vice President Pharmacy 200 (VP- 200) also acknowledged the blank narcotic waste form. PIC-100 stated a pharmacy staff was looking for the staff responsible for completing the form.

(b) A record review also showed Fentanyl 2500 mcg/250 ml was ordered, on 3/19/2022 at 1:57 a.m., to administer 1 mcg/kg/hr, titrate 0.5 mcg/kg/hr every 30 minutes, max dose 10 mcg/kg/hr.

A record review showed the Fentanyl drip administration was initiated on 3/19/2022 at 7:00 p.m., at various rates from 0.5 mcg/kg/hr to 1 mcg/kg/hr until 3/21/2022 at 8:00 p.m. The drip was restarted on 3/22/2022 at 8:00 a.m., running at 0.5 mcg/kg/hr until it was stopped.

A review of the narcotic waste/completion documentation form for Fentanyl 2500 mcg/250 ml returned to the pharmacy also showed a blank form with no documentation of waste.

During an interview on 3/24/2022 at 12:45 p.m., the PIC-100 acknowledged the blank narcotic waste form was returned and stated the bag was probably used up. VP 200 also acknowledged the blank narcotic waste form.

A review of the Hospital A's P&P titled, "Patient Controlled Analgesia," last reviewed 2/2022, showed disposal of unused narcotic (PCA or Drips) shall be documented on the Narcotic waste/Completion Documentation Form. The Registered Nurse (RN) will note date, time and volume remaining in the syringe or bag, if the remaining volume was greater than zero (0). Two licensed nurses would sign for any volume > zero (0). The Narcotic waste /Completion Documentation Form will be returned to the pharmacy upon completion.

2. During a review of Patient 315's medical record review, on 3/22/2022,, indicated Patient 315 was admitted to Hospital C, on 3/18/2022.

Record review showed a medication order for Lorazepam 1 milligram (mg) tablet oral every six (6) hours as needed for anxiety/agitation on 3/17/2022.

During an observation of the medication administration process, on 3/22/22 at 9:05 a.m., in Unit 2, Licensed Vocational Nurse 300 (LVN-300) handed Patient 315 a Lorazepam 1 mg tablet. Patient 315 observed placing the tablet in her mouth and Patient 315 dropped the Lorazepam tablet on the floor. LVN- 300 picked up the tablet on the floor and discarded the tablet in the stericycle CsRx (CsRx Service was for controlled substances that have been dispensed to a patient and need to be wasted) located in the Unit 2 medication room. LVN-300 then logged into the automated dispensing machine (ADM) and asked Registered Nurse 303 (RN 303) to cosign wasting the Lorazepam tablet. RN 303 cosigned the wastage without witnessing that LVN 300 disposed the Lorazepam tablet into stericycle CsRx.

During an interview on 3/22/22 at 9:45 a.m., in the presence of Assistant Chief Nursing Officer 300 (ACNO-300), RN 303, and LVN-300, RN 303 acknowledged not witnessing the disposal of Lorazepam tablet into stericycle. ACNO-300 stated that you (RN 303) should witness the disposal of medication before you (RN 303) can cosign.

A review of the Hospital C's P&P titled, "Ordering, Preparation and Administration of Medications," last reviewed 10/2020, indicated if the controlled substance was not administered and it was not in its original packaging, the nurse must waste the controlled substance. The waste option was used on the automated dispensing machine. A second nurse/physician must witness the wasting of the controlled substance and co-sign in the automated dispensing system. The controlled substances should be disposed in CsRx container which was available in nursing units.

Based on interview and record review, the Hospital B failed to ensure drugs were controlled and distributed to ensure:

1. Antibiotic medications were made accessible to nursing staff during pharmacy off-hours after pharmacy review and verification without using the override function to access medications in the Omnicell (an automated drug delivery system for medications).

2. The Omnicell list of overridable medications were updated annually to accurately reflect the currently accessible medications via Omnicell override by authorized staff.

These had the potential for inappropriate and unnecessary access to medications prior to pharmacist review and verification for safe use by patients.

Findings:

1. A review of the Pharmacy daily report titled, "Omnicell Medication Order Override Report" for the month of March, 2022 indicated there were antibiotics injectable vials removed by nursing staff via override function during the hours the Pharmacy was closed.

During an interview on 3/21/2022, at 11:50 a.m., Registered Pharmacist (RPH-200) stated the Pharmacy was open from 7:30 a.m. to 9 p.m. on weekdays and from 7:30 a.m. to 4 p.m. on weekends.

During an interview, on 3/23/2022 at 10:35 a.m., RPH-200 explained new medication orders were reviewed and verified by the pharmacist from a 24-hour sister hospital pharmacy when the Pharmacy was closed. After the electronic medication orders were verified by the pharmacist, the medications order would be released to Omnicell (an automated drug deliver system for medications) so that the medications would be available to access by nursing staff for specif patients for whom they were intended.

During an interview, on 3/23/2022 at 10:35 a.m. RPH-200 explained antibiotic orders verified by pharmacists were for the connected system of the antibiotic injectable vials and the necessary diluents by a connecting device which was not made available in the Omnicell by the Pharmacy. Instead, Omnicell stocked only the injectable antibiotic vials. Nursing staff would have to remove the antibiotic vials from the Omnicell by using the override function and connect them to the diluents themselves using the connecting device to complete the piggyback system for administration.
During an interive, on 3/23/2022 at 10:35 a.m., Registered Nurse 200 (RN-200) agreed the current process created opportunities for unnecessary overrides to access medications and nursing staff should not have to use the override to access the medications for which medication orders were already verified by the pharmacist.

A review of the Hospital B's policy and procedure (P&P) titled, "Automated Dispensing Cabinets: Override of Medications," last reviewed 8/2019, indicated, "...For safe administration of medication utilizing the Automated Dispensing Cabinets (ADC), the over-ride capabilities will be limited to situations where significant patient harm could result from delay caused by the pharmacist review..."

2. On 3/23/2022 at 10:30 a.m., the overridable list for Facility B's Omnicells was reviewed and it was noted, compared to the list attached to the Facility B's P&P titled, "Automated Dispensing Cabinets: Override of Medications," there were significantly more medications accessible by authorized staff via override than the list in the P&P. There were overridable medications that belonged outside the class of overridable medications included in Facility B's P&P.

On 3/23/2022 at 10:30 a.m., during a concurrent interview, RPH-200 and Assitance Director of Quality (ADQ) agreed there were more medications that could be accessed via override. They were not aware if the list was reviewed and updated annually.

A review of the Hospital B's P&P titled, "Automated Dispensing Cabinets: Override of Medications," last reviewed 8/2019, indicated, "...The overridable medications will be reviewed by the P&T and MEC annually....Medications used for the following situations will be available to all staff nurses via over-ride: 1. Management of anaphylactic reactions or adverse drug reactions. 2. Management of an allergic reaction. 3. Management of pain. 4. Management of hypertensive crises. 5. Management of severe hypoglycemia. 6. Management of seizures. 7. Emergency behavioral management."

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

1. Ensure an intravenous (IV) medication was labeled with the patient's name, name of medication, dosage of medication, expiration date of medication, and the medication has a label indicating specific usage for one (1) of fifty three (53) sampled patients (Patient 103) at Hospital A.

2. Ensure expired medications were not available in Hospital B's Pharmacy for use for patients that had a census of the fifty-five (55) patients, who were serviced by the facility's pharmacy .

This deficient practice had the potential for incorrect medication given to Patient 103 at Hospital A, and the potential for the fifty-five patients at Hospital B to receive expired medication from the pharmacy

Findings:

1. During an observation with Registered Nurse 100 (RN-100), on 3/21/2022 at 12:20 p.m., in Room 537, a 50 milliliter (ml, unit of measurement) empty bag of Levaquin (antibiotic medication typically given to patient with lung infections) was hanging on an IV pole that was intended for use by Patient 103. The bag was only labeled with the name of the medication.

During an interview, on 3/21/22 at 12:20 p.m., RN-100, who was caring for Patient 103, stated she was caring for Patient 103. RN-100 stated the medication bag (Levaquin) came from the pharmacy without any labeling indicating the patient's name, name of medication, dosage of medication, expiration date of medication, and the medication has a label indicating specific usage.

During an observation of the trash can in the nearby medication room, on 3/21/2022 at 12:22 p.m., the packaging that the bag of Levaquin came in was not accompanied by any label that identified the patient or administration instructions.

A review of facility's policy and procedure for Ordering, Preparation and Administration of Medications, dated 11/2/20 and effective 10/2010, indicated labeling of intravenous medications may be performed by a pharmacist, a supervised licensed pharmacy intern, or a registered nurse (RN). The policy and procedure indicated confirmed that medication may not be used unless the medication label included the following: "..Name of the patient, the name of the medication or parenteral (injectable) solution, the dosage, the expiration date (if applicable), and specific directions or caution statements for storage, usage, and/or administration."

2. During a tour of the Hospital B's Pharmacy with Registered Pharmacist (RPH-200), on 3/21/2022, at 1:40 p.m., diazepam (drug used for sleep, anxiety, or seizure) was noted in the Scheduled II Controlled Substance Vault (C-II Vault), there were 25 unit-dosed tablets containing diazepam 5 milligram (mg, unit of measurement) with the expiration date of 3/20/2022.

During an interview, on 3/21/2022 at 1:40 p.m., RPH-200 stated the tablets were expired and should have been removed from the C-II Vault.

The facility's policy and procedure titled, "Medication Storage," last reviewed 2/2019, indicated, "...The hospital removes all expired, damaged, and/or contaminated medications. They are stored separately from medications available for administration..."

The facility's policy and procedure titled, "Returns, Handling and Disposal of Medication Waste," last reviewed 2/2019, indicated, " ...All expired, recalled or contaminated medications placed in the "RETURNS BOX" will be quarantined from Pharmacy stock and destroyed via a certified pharmaceutical recovery service (a reverse wholesaler)."



36329

Based on observation, interview, and record review, Hospital A failed to ensure oversight and implementation facility's annual preventative maintenance for radiology equipment used for Radiologic services (services rendered to provide medical imaging) were conducted in a safe manner according to facility's policy and procedure by the following not:

1. Ensuring a radiologic equipment (C-Arm 100, special x-ray equipment to help assess internal organs in the body) ) that failed was promptly evaluated by a Physicist ( a scientist who specializes in the field of physics, which encompasses the interactions of matter and energy) within the recommended time frame of 30 days.

2. Completing a risk assessment (an evaluation of how much potential danger a hazard can have to a person) was completed for sixty-eight (68) patients that had radiologic exams with the radiology equipment (C-Arm 100) that was out of compliance from 2/23/2022 to 3/23/2022.

This deficient practice resulted to sixty eight patients having radiologic exams with a radiology equipment (C-Arm 100) that was out of compliance and had the potential for examination conducted with the out of compliance radiology equipment not provide an accurate diagnostic exam (a test used to identify a condition or its cause).

Findings:

On 3/24/2022 at 9:10 a.m., during an interview with Director of Quality and Risk (DRQ-100), stated the Radiology Director reviews the facility's yearly, "Medical Physicists Annual Survey."

A review of Radiology Department document titled, "Medical Physicist Annual Survey," dated 2/23/2022, for Radiologic equipment OEC dash 9800# (C-Arm 100) Fluoroscopic Test Summary indicated C-Arm 100 failed the DAP (dose area product) that was a method of radiation dose monitoring parameter .

On 3/24/2022 at 9:15 a.m. ,during a phone interview with Physicist (Phys-138) and DQR-100 were asked about the annual physicist report, dated 2/23/ 2022, that indicated C-Arm 100's fluoroscopy test summary documented DAP failed. Phys-138 explained the DAP failed test was related to radiation output beam was outside of the acceptable range, and the display needed to be adjusted . Phys-138 indicated usually the facility has 30 days to correct the problem.

Hospital A had no Preventative Maintenance (PM) to indicated to correct the Medical Physicist repot findings for C-Arm 100 from 2/23/2022 to 3/24/2022.

On 3/24/2022 at 9:15 a.m., DRQ-100 indicated PM would be completed, on 3/24/2022, for C-Arm 100. DRQ-100 stated the C-Arm 100 had been in use and was in a surgery operation room (OR) from 2/23/2022 to 3/23/2022 .

On 3/24/2022 at 3:30 p.m., during an interview and record review of a log of patients with diagnostic radiologic exams completed on C-Arm 100 from 2/23/22 to 3/23/2022 provided by DRQ-100, indicated 68 Patients that had diagnostic tests completed with C-Arm 100. DRQ verified that 68 patients were tested by C-Arm 100, and facility was unable to provide completed risk assessment of the 68 Patients.

On 3/29/2022 at 10:30 a.m. ,during a telephone interview with Chief Radiologist (MD-118), with Chief Medical Officer (CMO) and Regional Administrator (RA-100) present, MD-118 stated the Physicist recommendations should be followed.

A review of a radiology department policy and procedure titled, " Preventative Maintenance of Equipment," dated 9 /2019 indicated the imaging departments oversee condition, safety, and preventative maintenance of radiologic equipment . The medical physicist survey annually was conducted for safety of radiology equipment.

Based on observation, staff interview, and review of facility documents, the hospital failed to ensure the food and dietetic department was organized in a manner appropriate to the scope and complexity of the food service operations by:

1. The Food and Nutrition Services department failed to ensure the patient menus for regular and therapeutic diets met the Dietary Reference Intakes (DRIs) and Recommended Dietary Allowance (RDAs) for the specific population served at Hospital A, and Hospital B in accordance with acceptable standards of practice, in order to meet patients' nutritional needs (Cross Reference A-0629 and A-0630).

2. The hospital failed to ensure their nutrition screening and prioritization system was effective at identifying patients who were at nutritional risk to ensure patients nutritional needs were met in a timely manner. (Cross Reference A-0629 and A-0630)

3. The hospital failed to ensure the qualified dietitians who should supervise the nutritional aspects of patient care attended the QAPI (Quality Assurance Performance Improvement) meetings. The hospital failed to ensure systems were in place that would have identified and improved capturing patients at nutrition risk in order to ensure their nutritional needs were met in a timely manner which had the potential to negatively impact the medically fragile patients.(Cross-Reference A-0620, A-0629, A-0630, and A-0273)

The cumulative effects of systemic problems resulted in the inability of the hospital's food and nutrition services to direct and staff in such a manner to ensure the provision of food and nutrition services for the health, nutritional, and safety needs of patients.

Based on observation, interview and record review, the facility failed to ensure the Director of Food and Dietetic Services assured the policies and procedures related to dating and labeling of food (Hospital C) and use of mechanical ware washing (Hospital A and B) were followed, and failed to ensure Registered Dietitian's were effectively integrated with the hospital's QAPI (Quality Assurance and Performance Improvement). (Cross Reference A-0273 and A-0629)

These failures resulted in potential for cross-contamination that placed the patients at risk of foodborne illness, and for patient's nutritional needs to not be met in a timely manner.

Findings:

1. During a concurrent observation and interview on 3/22/22, at 8:24 a.m., with Certified Dietary Manager (CDM) 311, in a reach-in refrigerator in the kitchen, an opened bag of deli meat was observed. CDM 311 stated, "This should have been dated once opened and it wasn't sealed."

During a concurrent observation and interview on 3/22/22, at 8:41 a.m., with CDM 311, in the kitchen, inside the reach-in freezer was a bag of vegetarian sausage that was covered in a coating of ice. CDM 311 stated, "This should have been dated once opened and thrown away before looking like that."

During a review of the facility's policy and procedure (P&P) titled, "Production, Purchasing, Storage," dated 1/22, the P&P indicated, "Policies: 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...Cover, label and date unused portions and open packages...Refer to the Food Storage Chart in this policy to determine discard dates for food items..., Frozen storage...Once the packaging around the food has been opened, food must be used within 3 months..." The P & P indicated shelf life storage for the deli meat was for three days (from thaw date, if frozen).

2. During a concurrent observation and interview on 3/22/22, at 9:15 a.m., with a Cook (Cook 300) at Hospital C, in the presence of Certified Dietary Manager (CDM) 311, in the kitchen, Cook 300 was observed to place a foodservice equipment utensil in a green bucket of soapy solution, remove the utensil and rinse it off with a sprayer nozzle located over dirty dishes and proceed back to her cooking station. Cook 300 stated the solution in the green bucket was soapy water, and Cook 300 verified she had not sanitized the utensil. Cook 300 verified she was about to use the utensil again for food preparation. Cook 300 stated she used the utensil for both vegetables and meat during her food preparation and that was how she washed the utensil between uses.

During a concurrent observation and interview on 3/22/22, at 9:18 a.m., with CDM 311, CDM 311 used a digital thermometer to obtain the temperature of the soapy water in the green bucket used by Cook 300, and CDM 311 stated, "It's 99 degrees [F-Fahrenheit] and it should be 110 degrees F." CDM 311 verified that washing the utensil in wash water not at required temperature, and located intermingled with a pile up of dirty dishes and without sanitizing the utensil was not sanitary. CDM 311 verified Cook 300 should have used the designated three-compartment sink known by the hospital the pot and pan sink for proper wash, rinse and sanitize of foodservice equipment.

During a concurrent observation and interview on 3/23/22, at 11:22 a.m., with a food service worker (FSW 220) at Hospital B, in the presence of Certified Dietary Manager (CDM) 211, in the kitchen, FSW 220 was observed washing foodservice utensils in the three-compartment sink. CDM 211 used a digital thermometer to check the wash water temperature at the three compartment sink, and CDM 211 stated, "It's 104 degrees [F]." CDM 211 verified the wash water temperature was not at required temperature while in use.

During a review of the facility's policy and procedure (P&P) titled, "Sanitation and Infection Prevention/Control; Cleaning of Food and Nonfood Contact Surfaces", 1/21, the P&P indicated, "...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 the food-contact surfaces of equipment shall be washed, rinsed and sanitized before and after each use with raw animal products; when changing from raw to read-to-eat products; between uses with raw fruits and vegetables and with potentially hazardous food; at any time contamination is suspected; or at least every 4 hours during continuous use (example: can opener)..., Ware washing sinks must be equipped with detergent and sanitizer. When a three-compartment sink is used, the first compartment must contain the cleaning solution, the second must contain clean rinsing water and the third must contain sanitizer solution at proper concentration..., the temperature of the water in the wash sink must be 110 degrees F or greater..."

3. During a review of the facility's performance improvement plan (PI) for the Food and Nutrition Services for Hospital A and B, last reviewed by the hospital system's regional RD (Registered Dietitian) on 12/7/21, the PI objectives for 2021 were improving patient satisfaction scores, RD Recommendations [related to obtaining physician orders to carry out RD recommendations for patients], test tray quality and tray accuracy.

During a telephone interview on 3/22/22, at 2:12 p.m., with Registered Dietitian (RD) 300 who is the RD for Hospital C, RD300 stated, she did not attend QAPI meetings.

During a concurrent interview and record review, on 3/23/22, at 2:55 p.m.,conducted at Hospital A, with CDM 100, CNM 110, and RRD 112, RRD 112 stated, there were no QAPI projects by the Food and Nutrition Services Department to track the prioritization process for nutrition assessments of patients with a potential nutrition risk. RRD 112 acknowledged the current nutrition assessment prioritization included an initial screening with the malnutrition screwing tool (MST) completed by nursing upon patient admission, but this screening tool may miss identifying patients with chronic health conditions in need of a nutrition consult and assessment within 3-5 days of hospital admission. RRD further stated CDM 100 attended the Quality Council meetings at Hospital A, and not CNM 110, CNM 110 confirmed she did not attend the Quality Council meetings.

During an interview on 3/24/22, at 10:01 a.m., with Regional Chief Medical Officer (CMO 117), CMO 117 verified the hospital's system for identifying patients at nutritional risk throughout the hospital stay needed to be improved.

During an interview on 3/24/22, at 10:47 a.m., with Quality Manager (QM-100) and Director of Quality and Risk Management (DQR 100), QM 100 stated, the Food Service Director's, credentialed as Certified Dietary Manager's for Hospital A (CDM-111), Hospital B (CDM-211) and Hospital C (CDM-311) attend the QAPI (Quality Assessment and Performance Improvement) meetings for the Food and Nutrition Service departments for all three hospital campuses. QM-100 and DQR-100 both stated the hospital's RDs do not attend QAPI.

During a review of the facility's job description for Clinical Dietitian dated January 2018, indicated, "Summary: Responsible for providing clinical nutrition services, including nutrition assessment, modified diet formulation, self-management training and nutrition intervention to patients/residents. Ensures...quality care, regulatory agency compliance..., Participates in facility-wide and department Quality Assurance/Performance Improvement (QAPI) Program and on QAPI teams to improve processes and patient care..."

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

1. Ensure the therapeutic diet order met the nutritional needs, for two of 93 sampled patients (Patient 112 and Patient 202) who lacked an assessment of nutritional needs by the Registered Dietitian until seven days after admission. Hospital A and Hospital B failed to ensure an effective system to identify patients who were at nutritional risk (aside from the nursing nutrition screen upon admission), in a timely manner, to determine patients who may require a detailed nutrition assessment. (Patient 112, Patient 202)

2. Ensure a mechanism of communication was in place alerting hospital staff to any food allergies and/or mechanically altered food needs of patients being given sack meals while they waited in the lobby to be admitted, for the health and safety of those individuals.

Failure to ensure patients nutritional needs are met, and in a safe and timely manner, could negatively impact the health and safety of medically fragile patients.

Findings:

1a. During a review of Patient 202's "Patient Information" (PI), dated March 2022, the "PI" indicated, Patient 202 was admitted to the hospital (Hospital B) on 3/19/22 with diagnosis of atrial fibrillation (irregular heartbeat) and sepsis (a potentially life-threatening condition that occurs when the body's response to an infection damages its own tissues.)

During a concurrent interview and record review on 3/23/22 at 1:46 p.m., with Registered Dietitian (RD) 200, Patient 202's "Admission Note Nursing (ANN)," dated 3/19/22 was reviewed. RD 200 stated, there was no consult triggers for an RD based upon the "Malnutrition Screening Tool (MST) completed by a nurse. RD 200 stated that per the hospital's prioritization system, Patient 202 would meet the criteria for an RD to complete a nutrition assessment on 3/26/22 due to length of hospital stay of seven days. RD 200 stated, Patient 202 also had a history of chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs.). RD 200 was asked if COPD could place a patient at nutritional risk, and RD 200 stated, "Not always, but it could."

Concurrently, RD 200 stated the hospital's criteria or prioritization system for an RD to complete a nutrition assessment for a patient within three days included the following; when the nursing admission nutrition screen triggered a consult, wounds, tube feeding, TPN (total parenteral nutrition; receiving nutrition through a vein), or by MD or RN nutrition consultant order. In addition, if a patient was NPO (no food by mouth) for five days. Otherwise, all other patients would be seen on day seven driven by length of stay, versus by therapeutic diet order and/or a diagnosis that is likely to place a patient at nutritional risk.

During an interview on 3/23/22, at 2:15 p.m., with hospital Administrator (HA 200), HA 200 stated, the average length of patient stays at Hospital B was 5.7 days.

During an interview on 6/3/18, at 12:15 p.m., with the Medical Director at Hospital B (MD 200), MD 200 verified that in addition to the nursing nutrition screen upon admission, and the ability for a physician or registered nurse to request an RD consult, the RDs unique skill set and expertise should be utilized to screen patients at nutrition risk in order to help identify patients whose nutritional needs might not be met, or who have a change in medical status throughout the hospital stay that may necessitate a nutrition assessment, and nutrition care plan, in a timely manner.

1b. During an interview on 3/24/22, at 10:01 a.m., with Regional Chief Medical Officer (CMO 117), CMO 117 verified the hospital's system for identifying patients at nutritional risk throughout the hospital stay needed to be improved.

During an interview on 3/24/22, at 10:47 a.m., with Quality Manager (QM 100) and Director of Quality and Risk Management (DQR 100), QM 100 stated, the Food Service Director's, credentialed as Certified Dietary Manager's for Hospital A (CDM 111), Hospital B (CDM 211) and Hospital C (CDM 311) attend the QAPI (Quality Assessment and Performance Improvement) meetings for the Food and Nutrition Service departments for all three hospital campuses. QM 100 and DQR 100 both stated the hospital's RDs do not attend QAPI.

During a concurrent interview and record review on 3/24/22 at 2:46 p.m., with Registered Dietitian (RD) 101 at Hospital A, Patient 112's "Admission Note Nursing (ANN)," dated 3/10/22 was reviewed. RD 101 stated, there was no consult triggers to the RD based upon the "Malnutrition Screening Tool (MST) completed by a nurse upon admission. Concurrently, RD 101 stated since there was not an RD consult trigger from the MST, nor an RD trigger from a wound consult, per the hospital's criteria or prioritization the RD would conduct a nutrition assessment for Patient 112 on the seventh day of admission driven by the criteria of "length of stay."

During a review of Patient 112's "History and Physical" (H&P), dated 3/10/22, the "H&P" indicated, "Medical Impression ...Problem 1: Acute congestive heart failure exacerbation [worsening of heart failure symptoms when your heart is unable to pump enough blood throughout your body]...Request cardiology [doctor who specializes in heart disease] consultation, Problem 2: Acute on chronic renal failure [gradual loss of kidney function]...Request nephrology [medical professionals who diagnose, treat, and manage acute and chronic kidney problems and diseases] consultation..., Problem 3: Monitor electrolytes [minerals in your body that have an electric charge] and correct accordingly..."

During a concurrent interview and record review on 3/24/22 at 2:50 p.m., with RD 101, Patient 112's "Nutrition Assessment" (NA), dated 3/17/22, was reviewed. The NA indicated, "Reason for Assessment: Length of Stay. Diagnoses/Problem List: Admitting Dx [diagnosis]: ESRD (end stage renal [kidney] disease) on dialysis [a substitute for the normal function of the kidney]: Hyperkalemia [a higher than normal level of potassium in the bloodstream]..., Diet Order start date 3/13/22: Double Portion; Renal with Dialysis (Hemodialysis [a treatment to filter wastes and water from your blood])..., Estimated needs [daily] Calories: 2,155 - 2,320, Protein: 93 - 101 g [grams] per day ...Diet: Renal with Dialysis [1578 calories and 67 g protein], PO intake: 100% intake over last 12 charted meals- current diet order provides less than 75% [percent] estimate nutrient needs. Nutrition Diagnosis: Impaired nutrient utilization related to renal dysfunction as evidenced by elevated BUN [blood urea nitrogen] /creatinine levels [could mean there is a lot of waste product that hasn't been removed by the kidneys] and need of hemodialysis. Inadequate protein related to higher metabolic [all the physical and chemical processes in the body that convert or use energy] demands secondary to hemodialysis as evidenced by current diet order providing insufficient protein (less than 75% estimated needs). Intervention: Add Nepro [to help meet the specialized nutrition needs of people on dialysis] oral [by mouth] shake 1 bottle/two times daily to help meet higher range of estimated nutrient needs. Add Nephrovite [Renal vitamins are specially made for people with chronic kidney disease (CKD) who are on dialysis] 1 tab/daily. Continue current diet order as tolerated." RD 101 stated, the reason a nutrition assessment was conducted for Patient 112 was solely due to "length of stay of seven days." RD 101 verified that a renal hemodialysis therapeutic diet order, that was in place at time of admission, may indicate Patient 112 was at nutrition risk, and an RD would not know until the patient's nutrition needs were evaluated. RD 101 verified Patient 112's nutrition needs were not met during the hospital stay, in which the RD had not become aware until seven days after admission, as within the hospital's nutrition screening and prioritization system the patient had not been identified as at nutritional risk until the criteria of "Length of stay of seven days".

During an interview with CDM 100 and RD 100 on 3/22/22 at 11:35 A.M., CDM 100 and RD 100 each stated the average length of stay (LOS) at Hospital A was approximately 4.6 days. The hospital system's regional RD acknowledged and confirmed this statement.

During a review of Patient 112's "NA", dated 3/24/22, the "NA" indicated, Patient 112 continued to meet less than 75% of estimated daily nutritional needs. The NA included, "Nutrition Recommendation: Add Nepro oral shake 1 bottle/two times daily to help meet higher range of estimated nutrient needs. Add Nephrovite 1 tab/daily", which was recommended one week earlier to meet the nutritional needs of the patient. The Nutrition Recommendations included, "Monitor potassium - consider K-oxalate to help with hyperkalemic state..."

During a review of the facility's policy and procedure (P&P) titled, "Initial Screening, Prioritization and Assessment," dated 3/19, the P&P indicated, "Purpose/Objective; Initial assessment and further prioritization program to identify patients who may need medical nutrition therapy. Scope: Applies to all Food & Nutrition Services Departments [Hospital A, B and C], Policy/Procedure; An initial screening assessment and prioritization is implemented to identify patients who may require medical nutrition therapy(ies). Patients identified at nutrition risk during the initial screening will be further evaluated with an assessment and receive nutrition interventions(s) when applicable. Initial Screening: Nursing; Gathers information from patients within a day of admission, based on pre-determined validated nutrition criteria and documents in the medical record. Based on results of initial screening, consults the dietitian. Prioritization; Registered Dietitian Nutritionist; Evaluates information from the following sources as it becomes available; Nursing: Pressure ulcer reports..., Information Services: Diet orders and changes; New enteral nutrition orders; admission diagnosis(es). Pharmacy: New orders for parenteral nutrition. Consults from physicians, nurses, and other healthcare professionals. Multidisciplinary team conferences. Food & Nutrition Services: Meal rounds; number of days patient has been NPO/CL. Laboratory: Nutrition related values. Patients requiring nutrition education/survival skills training prior to discharge..., Assessment; Registered Dietitian Nutritionist (RDN)...When recommendations are made which require a physician order, the RDN will follow-up within three days to verify a response to the recommendation. The dietitian may ask nursing's assistance to notify the physician of the dietitian recommendation. If the physician does not respond to the recommendation by ordering the requested intervention or by another entry in the medical record, the dietitian will contact the physician to discuss the recommendation(s) made and document the results of the discussion ..., Within 3 days [an RD needs to complete a nutrition assessment] - Nutrition Consultants, TPN, Tube Feeding..., Education referral, Pressure injuries..., Calculate physician ordered calorie count, By Day 5 - NPO [nothing by mouth]/CL [clear liquid]= 5 days, Length of Stay Assessment Table Unit (Average LOS [ length of stay]) Critical Care - 3 days, Non-Critical Care - 5 days, Behavioral Care Unit = 13 days, LOS Assessment Date Critical Care 5 days (3 ALOS [average length of stay] +2), Non-Critical Care 7 days (5 ALOS +2), Behavioral Care Unit 15 days (13 ALOS +2)."

2. During a concurrent observation and interview on 3/22/22, at 8:41 a.m., with Certified Dietary Manager (CDM) 311 at Hospital C, in the reach-in refrigerator in the kitchen, were brown paper bags. CDM 311 stated, the brown paper bags were "lobby meals" that contained a sandwich, juice, and crackers. CDM 311 stated the "lobby meals" were given to patients waiting in the lobby to be admitted to Hospital C. CDM 311 was asked how she knew what foods to serve in the "lobby meals" to the patients. CDM 311 stated the "lobby meals" always consist of a sandwich that can be any kind, such as tuna, turkey or ham, any kind of juice and crackers. CDM was asked if there was more information available to the kitchen staff, such as if a person had a food allergy or needed a certain type of texture or therapeutic diet, prior to providing the "lobby meals", and CDM 311, stated no. CDM 311 explained that the person receiving the "lobby meal" would already be "medically cleared" by another provider, and was given a "lobby meal" while waiting to be admitted to Hospital C.

During a concurrent interview and record review on 3/22/22 at 10:48 a.m., with Registered Dietitian (RD) 300, Patient 307's diet order and food allergies were reviewed from RD 300's "Active Diet Orders" list that indicated, "Diet Order: Regular, Instruction 1. No Graham crackers, Allergies: Graham Crackers." RD 300 reviewed Patient 307's electronic health record (EHR) and verified the EHR indicated Patient 307 had a food allergy to graham crackers. RD 300 stated she was aware of the "lobby meals" in the kitchen and stated they have graham crackers in the brown paper bags for the "lobby meals." RD 300 verified it was a concern that CDM 311 and/or kitchen staff, would not have patient information such as a diet order and food allergy available to them prior to handing out a "lobby meal." RD 300 stated she was not aware that the kitchen staff would not have that pertinent information prior to providing food to a patient. Further review of the "Active Diet Orders" list provided by RD 300 indicated Patient 318 had a food allergy to seafood, Patient 319 had a food allergy to fish, Patient 320 had a food allergy to turkey, and Patient 321 had a food allergy to fish.

During an interview on 3/22/22 at 12:20 p.m., with a Registered Nurse (RN) 305, and RN 302, they both stated that the patients waiting in the lobby are medically cleared prior to admission to Hospital C. RN 302 stated the nursing staff already have "intake" information for the patient that would include any known food allergies that is electronically transferred via a patient's electronic health record. However, both RN 305 and RN 302 stated it is either a receptionist or a security guard who go to the kitchen to get the "lobby meal" and give it to the person waiting in the lobby. Both RN 305 and RN 302 verified that neither the receptionist nor the security guard checks with a nurse first to see if it is safe to provide a "lobby meal" to a patient in the lobby. Both RN 305 and RN 302 verified there was potential a patient may not self-report a food allergy while waiting to be admitted to Hospital C due to potential behaviors or symptoms a patient may be experiencing at that time. Both RN 305 and RN 302 verified there was potential to serve a food allergen to a person with a known food allergy listed in the EHR, as it was frequent to have known patients re-admitted to hospital C.

During an interview on 3/23/22 at 10:00 a.m., with Hospital Administrator (HA) 300, HA 300 verified the hospital's process for providing lobby meals needed to be improved to ensure the health and safety of patients.

During a review of the facility's policy and procedure (P&P) titled, "Diet Orders", dated 1/21,
the P&P indicated, "Policies: Diets are ordered in writing by the responsible physician prior to the service of the diet ...,Procedures: ...Specifies any cultural, religious or allergies/intolerances to food, in addition to diet order when appropriate, ...Clinical Nutrition Manager/Designee arranges a Diet Census Report to be printed ...at a minimum, the report includes the patient's name, diet order ...food allergies ..., Food/Nutrition ...Uses the information on the Diet Census report to manage the accuracy of the menu for each patient ...accommodates special diets and altered diet schedules ..."

During a concurrent interview and record review on 3/23/22 at 11:22 a.m., with RD 300, RD 300 stated she provided a general in-service to dietary staff titled "Food Allergies" on October 2021. RD 300 provided a copy of the curriculum used which indicated, "11 million people in the United States suffer from food allergies..., When a person has an allergic reaction to a food, the body mistakenly recognizes the food as being harmful..., Here are just some of the specific symptoms that can be caused by this medical disorder; itchy skin or eyes, hives and welts, runny or stuffy nose, itching or swelling of the throat, difficulty swallowing,...wheezing..., difficulty breathing,...drop in blood pressure, increased heart rate, loss of consciousness, anaphylaxis (symptoms that are severe or life threatening)...An estimated 200 people each year die from food-allergic reactions..."

Based on interview and record review, Hospital A failed to ensure an accurate system for documenting ordered nutrition supplements for one of 93 sampled patients. (Patient 113), to ensure the order is provided as prescribed by the practitioner responsible for the care of the patient.

The deficient practice to fail to document a nutrition supplement ordered by the practitioner and quantity consumed impeded the ability of the Registered Dietitian's to accurately evaluate intake and monitor, in order to re-evaluate when an alternative nutrition intervention approach may be necessary.

Findings:

During a concurrent interview and record review on 3/24/22 at 2:38 p.m., with Registered Dietitian (RD) 101, Patient 113's "MST [Malnutrition Screening Tool] Consult (MSTC)," dated 3/12/22 was reviewed. The MSTC indicated Patient 113 was not meeting estimated nutrient needs. RD 101 stated, one of the nutrition recommendations was to add Glucerna oral shake (an oral nutrition supplement to increase calorie and protein intake) one bottle three times a day to help meet estimated nutrient needs.

During a review of Patient 113's "Nutrition Assessment and Plan" (NAP), dated 3/16/22, the "NAP" indicated, "Nutrition Recommendation:...remove Ensure Enlive oral nutrition supplement (to increase calorie and protein intake) - not appropriate due to diabetes mellitus (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), change Glucerna 1.5 oral supplement to Glucerna therapeutic Nutrition Shake oral supplement one bottle/three times daily ..."

During a review of Patient 113's "Nutrition Assessment and Plan" (NAP), dated 3/19/22, the "NAP" indicated, "Nutrition Recommendation:...remove Ensure Enlive oral nutrition supplement - not appropriate due to diabetes mellitus, change Glucerna 1.5 oral supplement to Glucerna therapeutic Nutrition Shake oral supplement one bottle/three times daily..."

During a review of Patient 113's "Patient Orders" (PO), dated 3/12/22, the "PO" indicated, "Glucerna 1.5 Cal [calories] Oral Supplement 3 times per day, one bottle, route: oral", the order was discontinued on 3/22/22.

During a review of Patient 113's "Patient Orders" (PO), dated 3/16/22, the "PO" indicated, "Ensure Enlive Oral Supplement 3 times a day, one bottle, route: oral.", the order was discontinued on 3/22/22.

During a review of Patient 113's "Patient Orders" (PO), dated 3/18/22, the "PO" indicated, "Calorie Count x 3 days.", the order was discontinued on 3/22/22.

During a review of Patient 113's "Patient Orders" (PO), dated 3/19/22, the "PO" indicated, "Glucerna Therapeutic Nutrition Shake Oral Supplement, one bottle three times a day, route: oral.", the order was discontinued on 3/22/22.

During a concurrent interview and record review on 3/24/22 at 2:45 p.m., with RD 101, RD 101 was asked the location in the medical record that RDs review to evaluate intake of ordered nutrition supplements that were recommended to meet a patient's nutritional needs. RD 101 reviewed Patient 113's "Intake Output" screen on the flowsheet that had a column titled "Diet Intake (%); Amount Consumed %" and a column titled "Oral Fluids." RD 101 verified the Glucerna bottle would be provided by the kitchen and served with meals on the meal tray. RD 101 stated the quantity of fluid documented under the "Oral Fluids" column would not provide the RD information in regard to quantity of the specific nutrition intervention ordered (Glucerna) to monitor effectiveness and determine calories and protein consumed as compared to assessed needs. RD 101 stated, I ask the nurses and/or patient's if they are drinking the supplement. RD 101 stated, the column for "Diet Intake" is the quantity of breakfast, lunch or dinner meal consumed, and not specific to the ordered nutrition intervention.

During a concurrent interview and record review on 3/24/22 at 2:38 p.m., with Associate Chief Nursing Officer (ACNO) 100, ACNO 100 reviewed Patient 113's "Medication Administration Record (MAR), and flowsheet and was unable to locate documentation that Glucerna was provided as ordered. Concurrently, ACNO spoke to a nurse (RN 107) on the "Step Down" unit, in the presence of RN106, and RN 107 reviewed the nursing task screen in the electronic health record. ACNO, RN 106 and RN 107 verified the column next to "Glucerna 1.5 Cal Oral Supplement", dated 3/13/22, had "TY" documented. RN 107 stated, "TY" would be the initials of the nurse signifying the Glucerna order was provided to the patient. RN 107 verified the hospital had not had a system for nursing to document quantity of an ordered nutrition supplement consumed by a patient. ACNO, RN 106 and RN 107 verified the column next to Glucerna was blank for breakfast, lunch and dinner times on March 14, 2022, which indicated there was no documentation the Glucerna was implemented as ordered on that day. ACNO was asked how the hospital would evaluate the effectiveness of a planned nutrition intervention to meet patients' nutritional needs, such as a Glucerna order, when quantity consumed was not documented, and ACNO stated, "We can monitor for weight loss." RN 106 and RN 107 acknowledged Glucerna nutrition supplement was to help meet a patient's nutritional needs to avoid weight loss, not to wait for weight loss and then evaluate if an alternative nutrition approach may be needed.

During a review of Patient 113's "Nursing Narrative Notes" (NNN), dated 3/13/22, the "NNN" indicated, "...Patient has poor appetite, able to tolerate fluids but needs encouragement." The "NNN", dated 3/14/22, indicated, "...has poor appetite. He needs frequent reminders to get the ensure, which I did."

During a review of the Hospital A's policy and procedure (P&P) titled, "Intake Support", dated 10/17, the P&P indicated, "Intake support is defined as a provision of appropriate food/beverages, oral nutrition supplementation ...designed to improve nutrition intake...Patients who are unable to meet their nutrition needs from his/her active diet will receive Nutrition Intervention. Patients may be offered food/beverages support and/or oral nutrition supplement to help meet their adequate nutrition intake..., Nursing delivers food/beverage, oral nutrition supplement,...and regularly communicates patient's acceptance, tolerance, and intake to dietitian..., Dietitians continue to monitor intake and adjust intake support as patient's intake changes..."

Based on observation, interview, and document review, the hospital failed to

1. Maintain its physical plant and environment, including water leaks, damaged walls, stairwell lights not lighted, damaged cabinets, showers out of order at Hospital A.

The deficiencies had the potential for growth of microorganisms, accidents, slips and falls.

2. Provide a safe, comfortable, and sanitary environment always for patients, staff, and visitors as follows:

2.1. By not locking, a lockable door access, always to an enclosed construction area at Hospital A.

2.2 By not maintaining the facility water piping line systems and equipment in good repair always to prevent leaks of water, wastewater, hazardous wastewater, and foreign debris from entering inside surfaces and outside the Hospital A.

2.3 By not maintaining the hot water temperature at a comfortable level for hand washing and patient hygiene. Failure to maintain the hot water temperature between one hundred five (105) and one hundred ten (110) degrees Fahrenheit (F) at Hosital B.

The deficient practice had the potential to result in patients' causing physical harm, injury, or death to self, other patients, staff and visitors.

Findings:

1. During the Hospital Recertification survey tour at Hospital A, from 03/21/20022 to 3/29/2022, the evaluator observed that the following physical environment conditions existed:

On 3/21/2022, at 10:45 a.m., at the 1st floor temporary food preparation area, the evaluator observed a stain (water damage) on the ceiling tile above the special diet food preparation area.

During a concurrent interview, the Plant Operations Director stated that he did not know what caused the water staining on the ceiling tile and that he would have someone investigate the cause of the water-stained ceiling tile.

On 3/21/2022, at 11:20 a.m., at the 6th floor B wing, room 625 bed A, the evaluator observed a two-inch by 4-inch section of damaged wall. There was also an accumulation of wall material debris behind the bed.

During a concurrent interview, the Plant Operations Director was informed of the damaged wall and debris.

On 3/21/2022, between 11:35 a.m. and 12:20 p.m., the evaluator observed landing lights were not lighted in the following areas:

a. 5th floor northwest exit stairwell.
b. 6th floor northwest exit stairwell.
c. 5th floor northeast exit stairwell.
d. 5th floor southwest exit stairwell.

During a concurrent interview, the Plant Operations Director and the Lead Man were informed of the deficiency. The Plant Operations Director stated that he believed security walked the exit stairwells to check the lights.

On 3/21/2022, at 11:57 a.m., at the 6th floor C wing seclusion room, the evaluator observed the bathroom sink cabinet had 2/3rd of its plywood front panel broken off, leaving exposed, splintered, and jagged sections of plywood on the broken section of plywood left within the cabinet and a one-third section of plywood, that was still attached to the cabinet.

During a concurrent interview the Chief Operating Officer stated that the room was "blocked" from admitting patients and that there was a work order to repair the cabinet.

Hospital A was unable to provide a copy of the work order to repair the cabinet that was requested, on 03/21/2022, at 11:57 a.m., by the end of the survey.

On 3/21/2022, at 12:15 p.m., at the 6th floor A, wing room 607, the evaluator observed there was a four-inch by four-inch hole in the wall.

During a concurrent interview, the Plant Operations Director stated that it was an "everyday occurrence."

On 3/21/2022, at 12:20 p.m., at the 6th floor shower, room 2, the evaluator observed there was a sign on the door that read, "do not use leaks out into the hallway".

During a concurrent interview, the Plant Operations Director stated there was a work order to repair the shower.

Hospital A was unable to provide a copy of the work order to repair the shower that was requested, on 3/21/2022, at 12:20 p.m., by the end of the survey.

On 3/21/2022, at 12:20 p.m., at the 6th floor shower room 5, the evaluator observed there was a sign on the door that read, "out of order".

During a concurrent interview, the Plant Operations Director stated there was a work order to repair the shower.

Hospital A was unable to provide a copy of the work order to repair the shower that was requested, 3/21/2022, at 12:20 p.m., by the end of the survey.

On 3/22/2022, at 10:34 a.m., at the 3rd floor SDU North step-down unit, room 311, the evaluator observed the sink edge had a two-inch section of damaged enamel exposing the metal base of the sink that was not smooth and easily cleanable. Closer observation revealed there was also a six-inch section of missing laminate, and a 4-inch section of loose laminate veneer at the sink's cabinet that exposed the particle board beneath, creating an absorbent surface that is not easily cleanable.

During a concurrent interview, the Plant Operations Director stated that dialysis was conducted in that room and that it "looks like the dialysis machine is hitting" the sink and cabinet.

On 3/22/2022, between 10:34 a.m. and 11:15 a.m., on the 3rd floor, room 317, the evaluator observed there was peeling paint at the head-board wall.

Closer observation revealed there was also a missing catch base under the hand sanitizer dispenser, leaving two ¼-inch holes, peeling paint and exposed plaster at the wall near the room entrance door.

During a concurrent interview, the Plant Operations Director stated that the catch base was damaged and had not been replaced.

On 3/22/2022, between 10:34 a.m. and 11:15 a.m., at the 3rd floor, room 316, the evaluator observed a stain (water damage) on a ceiling tile.

During a concurrent interview, the Plant Operations Director stated that he thought it was "condensation" and that he would have someone investigate the cause of the water-stained ceiling tile.

On 3/22/2022, between 10:34 a.m. and 11:15 a.m., on the 3rd floor, room 315 A, the evaluator observed that at the base of the sink counter, there was an one inch by two-inch section of broken laminate veneer that exposed the particle board beneath, creating an absorbent surface that is not easily cleanable.

During a concurrent interview, the Plant Operations Director was informed of the condition of the cabinet.

On 3/22/2022, between 10:34 a.m. and 11:15 a.m., on the 3rd floor, room 314 A, the evaluator observed that the sink next to bed B had a broken hot water pedal.

During a concurrent interview, the Plant Operations Director was informed of the broken pedal.

On 3/22/2022, at 11:15 a.m., during an interview, the Plant Operations Director stated there was an active water leak that was being investigated at the ceiling of the 3rd floor CCU corridor.

During a concurrent observation, the evaluator observed a containment barrier at the 3rd floor CCU corridor next to room 333 L. Closer observation revealed there was an active water leak at the ceiling.

On 3/22/2022, at 11:45 a.m., on the 3rd floor, room 332 A, the evaluator observed there was a two-inch by one-inch section gauge on the wall.

During a concurrent interview, the Plant Operations Director was informed of the gauged wall.

On 3/22/2022, at 11:55 a.m., on the 3rd floor, room 332 F, the evaluator observed a hole in the wall.

During a concurrent interview, the Plant Operations Director stated that there used to be a thermostat where the hole was and that he would have to investigate what happened.

On 3/22/2022, at 12:05 p.m., on the 2nd floor Telemetry unit corridor near room 227, the evaluator observed a broken ceiling light diffuser.

During a concurrent interview, the Plant Operations Director was informed of the broken ceiling light diffuser.

On 3/22/2022, at 12:28 p.m., on the 2nd floor, room 210, that was being used as a temporary nurse's station, the evaluator observed an active water leak at the ceiling.

During a concurrent interview, the Plant Operations Director stated that the water leak migrated from a water leak at the 3rd floor CCU corridor, and that a plumber had been called to come out the same day.

Hospital A was unable to provide a copy of the work order, invoice, and/or report from the plumbers visit that was requested, on 3/22/2022, at 12:28 p.m., by the end of the survey.

On 3/22/2022, at 12:37 p.m., at the 2nd floor corridor next to room 244, the evaluator observed a six-inch section of wall coving separated from the wall.

During a concurrent interview, the Plant Operations Director was informed of the separated wall coving.

On 3/22/2022, at 2:45 p.m., at the basement central supply room and the corridor next to the storage room, the evaluator observed a water leak at the ceilings.

During a concurrent interview, the Plant Operations Director stated that the leak initiated from a pipe repair in the kitchen.

On 3/22/2022, at 3:00 p.m., the evaluator observed a plumber repairing a copper pipe in a wall cavity located between the kitchen and the cafeteria, and that the cafeteria floor was flooded.

During a concurrent interview, the Plant Operations Director stated that they were trying to repair a "gauge leak" and the cap "popped off the pipe." The Plant Operations Director also stated that a water damage remediation company was called.

Hospital A was unable to provide a copy of the work order, invoice, and/or report from the remediation company visit that was requested, on 03/22/2022, at 3:00 p.m., by the end of the survey.

On 3/22/2022, at 4:00 p.m., at the exterior main front entrance to the hospital, the evaluator observed there was a water leak at the canopy located above the ramp.

During a concurrent interview, the Plant Operations Director stated that the leak initiated from the 5th floor women's public bathroom located by the elevators and that the water faucet at the 5th floor bathroom was left running and overflowed.

On 3/22/2022, at 4:12 p.m., the evaluator observed the 5th floor women's public bathroom had a damp floor and steamed mirror.

On 3/22/2022, at 4:15 p.m., the evaluator observed the 4th floor women's public bathroom had an "out of service" sign on the door. Closer observation revealed the inside of the bathroom had water leaking through the ceiling light fixture and water on the floor.

On 3/22/2022, at 4:15 p.m., the evaluator observed the 3rd floor women's public bathroom had an "out of service" sign on the door. Closer observation revealed the inside of the bathroom had water leaking through the ceiling light fixture and there was water on the floor.

Hospital A was unable to provide a copy of any work order, invoice, and/or report from the incident that was requested from the Plant Operations Director, on 3/22/2022 at 4:15 p.m., by the end of the survey.

2. 1 On 3/21/2022, from 10:30 a.m. to 4:30 p.m., during a general observation tour of the Hospital A, the evaluators, in the presence of the Plant Operations Director and Chief Operating Officer observed an enclosed construction area with a lockable access door located by the Nursing Station. The evaluators also observed that the lockable access door had a makeshift "Duck" tape pull tab taped to the door frame. The door was easily opened by the evaluators and Plant Operations Director by pulling on the Duck- tape pull tab. The door was able to be opened without unlocking the door with keys allowing patients, staff, and visitors access to a claw hammer, extension cords, metal pipe brace, metal pipe, and a ladder. This enclosed construction area, with a lockable access door, was adjacent to Shower Room 2 and the Nursing Station of the Behavioral Health Unit (BHU) on 6th floor. The access lockable door had a sign on the front "do not enter, authorized personnel only"

On 3/21/2022, at 11:38 a.m., during an interview with the Plant Operations Director, he stated that the lockable access door to the enclosed construction area should always have been locked .

2.2 On 3/21/2021, 2022, at 2:40 p.m., and 4:00 p.m., during an observed in the presence of the Plant Operations Director and Chief Operating Officer water leaking from a smoke detector, fire sprinkler head, and light fixture of the ceiling in the Central Supply Room located in the Basement level of Hospital A.

On 3/21/2022, at 2:55 p.m., during an interview with the Plant Operations Director, he stated that the source of the water leaks in the Central Supply Room was in the cafeteria on the 1st floor level of the facility. He also stated that the water leaks in the Central Supply room was due to a cap attached to the water pipeline, inside the wall, that had burst opened. There was water leaking from a ceiling panel and light fixture outside the main entrance to the facility.

On 3/21/2022. at 4:15 p.m., during an interview with the Plant Operations Director, he stated that the source of the water leaks from the ceiling outside the main entrance was in a bathroom on the 3rd floor. He also stated the water leaks at the main entrance of the facility was due to a staff that had turn on the cold and hot water fixture in the bathroom and had left the cold and hot water fixture in the "on" position, therefore the water overflowed continuously.

2.3 On 3/23/2022, at 1:40 p.m., during a tour of Hospital C, the evaluator, in the presence of the Maintenance Engineer, and Regional Director of Operations observed the following:

a. The hot water temperature was measured at 141 degrees Fahrenheit at the staff hand washing sink in the tub room, located in the Intensive Care Unit (ICU).

b. The hot water temperature was measured at 131 degrees Fahrenheit at the bathroom hand washing sink, in Patient Room 319, located in the, "Critical," Care Unit.

c. The hot water temperature was measured at 132 degrees Fahrenheit at the entry room hand washing sink located in Patient Room 308.

d. The main hand washing sink for staff, located in the Intensive Care Unit (ICU) was inoperable.

On 3/23/2022, at 1:50 p.m., during an interview with the Maintenance Engineer, he stated that there was a problem with the mixing valve that regulates the water temperature control for the hot water at the staff main hand washing sink located in the ICU. He also stated that the staff have been instructed to use the other staff hand washing sink in the tub room, located in the ICU, however he was not aware that the hot water temperature exceeded 120 degrees Fahrenheit.

On 3/23/2022, at 2:00 p.m., during an interview with the Regional Director of Operations, he stated the hot water temperatures that exceeded 120 degrees Fahrenheit at the hand washing sinks in the Patient rooms and staff hand washing sink at the ICU tub room was due to the temperature gauge set at 140 degrees Fahrenheit at the water boilers.

On 3/23/2022, a review of the facility's policy and procedure (Policy 4.0.1), titled "Control Domestic Hot Water Temperature" last reviewed and dated November 2012, stipulated the following: "It is the policy of the Plant Operations Department that temperature controls or control valves shall be provided to automatically regulate the temperature and pressure of hot water delivered to plumbing fixtures used by patients with a range of 105 F. minimum to 120 F. maximum."


28045




38310

Based on observation, interview, and document reviews the hospital failed to ensure an acceptable level of safety and quality:
1. The ice-machine at Hospital A was not sanitized in accordance with the ice-machine manufacturer's guidelines.
2. The ice-machine at Hospital C was not cleaned in accordance with the ice-machine manufacturer's guidelines.

The deficient practice of failing to maintain the ice-machines in accordance with manufacturer's guidelines, had the potential to place patients at risk for cross-contamination and foodborne illnesses.

Findings:

1. During a concurrent observation and interview at Hospital A on 3/22/1022 at 1:50 p.m. with Certified Dietary Manager 100 (CDM-100), Regional Director of Operations 112 (RRD-112), and Engineering Staff 100 (ECK 100), the ECK-100 stated the ice machine bin, which stores ice, was last cleaned in 1/2022 using the food and nutrition department's procedure, which indicated to use a chlorine sanitizer solution to wipe the inside of the bin. The CDM-100 and RRD-112 acknowledged and verified this process for ice machine cleaning.

During a concurrent observation and interview at Hospital A on 3/23/2022 at 2:00 p.m. with CDM-100, RRD-112, and Food Service Worker 101 (FSW-101), the FSW-101 stated he typically cleans and sanitizes the ice machine every two months using the food and nutrition services department ice machine cleaning procedure. FSW-101 further stated he used a sanitizer chlorine packet dissolved in water to clean and sanitize the ice machine bin. FSW-101 stated he was unaware of the manufacturer's guidance on ice machine bin cleaning or to use the manufacturer's cleaning and sanitizing solution. The CDM-100 and RRD-112 each acknowledged and verified the cleaning and sanitizing process described by FSW-101.

2. During a concurrent observation and interview, on 3/22/2022 at 9:30 p.m., with Engineering
Staff (ES-300), in the cafeteria in front of the kitchen at Hospital C, ES-300 stated, he cleaned the ice-machine with bleach. ES-300 verified there were no further products used in the ice-machine, and verified again he circulated bleach through the ice-machine and no further products were used. ES-300 stated an outside company used to clean the ice-machine but they would not go to the hospital because of COVID pandemic. ES-300 showed the last invoice from the outside company indicated the ice-machine was cleaned and sanitized on 1/21/2020. ES 300 stated he was responsible for cleaning the ice-machine as of 1/21/2020 and the only product used to circulate through the ice-machine internal ice-making apparatus was bleach, since 1/21/2020.

During a concurrent interview and record review on 3/22/2022 at 9:40 a.m., with ES-300, the ice machine's manufacturer's guidelines (IMG) were reviewed. The IMG indicated, "The appliance must be cleaned and sanitized at least twice a year. More frequent cleaning and sanitizing may be required in some conditions..., 1. Cleaning Solution; Dilute 6.0 fl. (fluid) oz. (ounce) of (name of ice-machine manufacturer) "Scale Away"...." The IMG indicated after the cleaning procedure was a sanitizing procedure...,"Sanitizing Solution...Dilute 1.5 fl.oz. of a 5.25% sodium hypochlorite solution (chlorine bleach) with 3 gal. (gallon) warm water..." ES-300 verified this cleaning step had been missed.

During an interview on 3/22/22, at 9:49 a.m., with Director of Plant Operations 300 (DPO-300) at Facility C , DPO-300 stated, "I will get the cleaner from the manufacturer for the ice-machine."

A review of the Hospital A's food and nutrition services department document titled, "Section 4 Maintenance", indicated, "Equipment Manufacturer's (name withheld) Ice Machine Cleaner and Sanitizer are the only products approved for use in the Equipment Manufacturer's (name withheld) Ice Machines...Use only equipment manufacturer's approved machine cleaner and sanitizer for this application..."

A review of the hospital systems' food and nutrition services policy and procedure document, dated 07/2021, titled "Cleaning and Maintenance of Ice Machines", indicated "...To provide a mechanism for the regular maintenance, cleaning, and disinfection of the ice machines to assure sanitary and safe operation..., 2.0 Scope All ice machines throughout the organization..."

A review of the hospital systems' food and nutrition services policy and procedure document dated 5/18, titled "Area and Equipment Cleaning", indicated "...the facility maintenance department is scheduled to clean equipment...such as the ice maker..., all Food and Nutrition Services Associates...refers to manual...when cleaning areas and equipment..."

A review of the hospital systems' food and nutrition services policy and procedure dated 4/8/14, titled "Ice Machine Cleaning Procedure", indicated "...Ice machines are cleaned and sanitized on a regular basis according the manufacturer's procedures...Bin Cleaning Procedures...5. Mix one packet Kay 5 or Triplet Plus chlorine sanitizer with 2.5 gallons of water in designated bucket..."

A review of the facility's policy and procedure (P&P) from the engineering policy and procedure manual titled, "Cleaning and Monitoring of Refrigerators, Ice Machines", dated 1/5/11 indicated, "Ice machine Cleaning and Maintenance Instructions...Cleaning Procedure...dilute approximately 6 fl. oz. of recommended cleaner, "Lime-A-Way" with 1 gal. of water...Sanitizing Solution Dilute 1.5 fl. oz. of a 5.25% sodium hypochlorite solution (chlorine bleach)..."


38924

Based on observation, interview, and record review, Hospital A failed to use the proper personal protective equipment (PPE, equipment worn to minimize exposure to hazards that can cause workplace injuries and illnesses) while entering and exiting an area of the facility designated for the care of Covid-19 (infectious disease caused by the SARS-CoV-2 virus that is spread by airborne particles and contact with the organism) patients. Also, the facility failed to ensure:

1. A corrugated box (cardboard material with ridges and grooves) was not stored with patient care supplies in a patient care area for 15 of 15 patients.

2. An endoscope (slender, tubular instrument used to visualize the inside of the body by way of mouth or anus) cabinet HEPA filter (a type of air filter that can remove dust, pollen, mold, bacteria, and any airborne particles) was changed per manufacturer's guidelines for 51 patients.

3. An operating room (OR) scrub sink did not have heavy brownish discoloration for three patients.

4. Two packages of sterile (free from bacteria or other living microorganisms) and disposable medical supplies were not found open in the mobile computed tomography scanner (CT, a series of X-ray images taken from different angles around the body)

These deficient practices had the potential to:
1. To spread infection among other patients in the facility.
2. Spread of infection from harmful microorganisms on or within the corrugated box.
3. Infection from growth of harmful microorganisms on medical instruments used for patients.
4. Spread of infection from growth of harmful microorganisms on the OR scrub sink.
5. Infection from use of unsterile medical supplies.

Findings:

1. During an observation on 3/21/2022 at 1:25 p.m., Security 102, entered and exited the area designated for Covid -19 patients near room 433, without sanitizing his hands before entering or wearing the proper PPE. Posted at the entrance this area was signage that stated Special Droplet/Contact Precautions (preventions to prevent spread of organisms that cause infection through contact and by airborne means) must be followed. The posting indicated that all entering this area must cleans hands when entering and leaving the are must, wear eye protection, gown, gloves, and a face mask. A trash can was located outside this designated area which contained used PPE.

During a interview on 3/21/2022 at 1:30 p.m., Security 102 stated that his duties did not involve in-person care of patients, that he was only in this area a short time, and that he also performed security duties on this floor of the facility.

2. During an observation on 3/21/2022, at 1:15 p.m., in the 5th floor medication room, a corrugated box contained approximately 20 luerlock (connector locks and unlocks with a twist) disposable syringes.

During a review of the Hospital A's policy and procedure (P&P) titled, "Guidelines for Storage of Patient Care Supplies and Corrugated Boxes", dated 07/2018, the P&P indicated, "7. Cardboard corrugated material delivered to healthcare areas should be broken down and the cardboard removed immediately."

3. During an observation on 3/22/2022, at 10:10 a.m., in OR 3, one endoscope (a flexible devce used to view the esophagus or colon of a patient) cabinet held six disinfected endoscopes. The HEPA filter sticker outside of the cabinet indicated it was last changed on 5/25/2021.

During an interview on 3/23/2022, at 10:15 a.m., with Director of Plant Operations (DoPO), DoPO stated, he contacted the manufacturer and verified that HEPA filters should be changed every six months. DoPO stated, there is only one scope cabinet in the OR and that the HEPA filter had been changed that morning.

During a review of the facility's "Secure-A-Scope Instruction Manual," (Scope Manual), undated, the "Scope Manual" indicated, "Cabinets with HEPA Filters, HEPA filters should be replaced every six months."

4. During an observation on 3/22/2022, at 10:18 a.m., outside OR 3, the bottom and sides of one of two scrub sinks had heavy brownish staining.

5. During an observation on 3/22/2022, at 12:10 p.m., in the mobile CT scanner, two packages of sterile and disposable syringe were found open inside one of the storage cabinets.

During a record review of the document 'Patient Safety -Covid 19' issued 9/10/2020, standard and transmission based precautions, facemasks, eye protection, and N-95 masks are required when in proximity to Covid 19 patients. Standard precautions are those that should be used relative to the expected environment encountered by the user. Transmission precautions are those taken to prevent infections that are spread through contact, droplets, or contact.

During a review of the facility's policy and procedure (P&P) titled, "Infection Prevention and Control Plan", dated 02/2021, the P&P indicated, "Surveillance, Environmental Safety inspections are used for detection of hazards, problems or situations which have potential to cause facility-acquired transmission of infection."



43400

Based on observation and record review, the Hospital A failed to maintain clean floors on the sixth floor of the facility.

This deficient practice had the potential to spread infection among patients on the unit.

Findings:

During a tour of the 6th floor behavioral health unit, on 3/21/2022 at 11:35 a.m., the floors near a construction area and the adjacent area were covered with black heel marks and dust. This area was near a door that was used by construction workers that entered and exited frequently throughout the day. During the tour of the floor, between 10:55 AM and 11:45 AM, two patients were observed walking around the unit and they were not wearing socks or any other foot coverings.

A review of the document titled, "Crothall Healthcare, Inc.," issued 10/1/2021, indicated that daily cleaning should consist of dry mopping and damp mopping the floor (including corners, edges, behind doors, and baseboards) using an approved neutral floor cleaner or germicidal solution or vacuum.

Based on observation, interview and record review, Hospital A's Governing Body failed to assure medical staff had documented Hepatitis B status or waiver on file to provide patient care in a safe and sanitary environment.

This deficient practice had the potential to expose patient being treated by the medical staff at the facility to Hepatitis B.

Findings:

On 3/24/2022 at 1:45 p.m., during the Medical Staff Credential File review with the Medical Staff Service Director (MSSD) at Hospital A, a review of 10 of 10 medical staff credential files reviewed did not have documentation of Hepatitis B vaccination, Hepatitis B status or a waiver on file.

A review of Hospital A document, "Medical Staff Bylaw," dated September 29, 2021, under the section "Review of medical staff qualifications for membership," did not include a requirement of Hepatitis B status or waiver for medical staff qualification for employment.

On 3/24/2022 at 3:30 p.m., during an interview the Chief Medical Officer (CMO) stated that Hepatitis B status or waiver documentation had not been a requirement for Medical Staff.

On 3/22/2022 at 10:30 a.m., during an interview the Infection Control Director (ICP-100) stated the facility followed CDC guidelines for infection control, and all healthcare employees are required to document COVID, Flu, TB, and Hepatitis B vaccination status.

A review of a document titled, "Pre-Employment Employee Health Policy," dated 7/2021, indicated: "Hepatitis B; Measles and Rubella immune status will be tested for all hospital employees and immunization will be provided to the employee if there is no documentation of immunity based on CDC guidelines."

.

Based on observation, interview, and record review, the Hospital B failed to ensure a sufficient supply of surgical instruments was available for 10 of 10 patients.

This deficient practice had the potential to result in delay of patient care.

Findings:

During a concurrent observation and interview on 3/23/2022, at 2:25 p.m., with the Director of Sterile Processing Department (SPD), there was one autoclave (a device that sterilizes or eliminates all bacteria, viruses, fungi, and spores) in the main operating room (OR) hallway. SPD stated the autoclave is used for immediate use steam sterilization (IUSS, a shortened sterilization cycle used before a surgical instrument may be returned to the sterile field in the OR) for eight rooms in the OR. SPD stated the autoclave was last used earlier that day for a power drill since there are only three power drills in the OR and the other two were in use.

During an interview on 3/24/2022, 10:15 a.m., the SPD stated IUSS was done yesterday because a surgeon dropped one of the power drills that was being used during a procedure, and there are insufficient surgical instruments for the number of cases performed daily in the OR.

During an interview on 3/24/2022, at 12:30 p.m, the SPD stated there are insufficient surgical instruments for different services including vascular (a branch of medicine relating to the blood vessels), genitourinary (a branch of medicine relating to the genital and urinary organs), gastrointestinal (a branch of medicine relating to the stomach and intestines), and orthopedics (a branch of medicine relating to bones and muscles). The SPD stated instruments needing to go through IUSS are sterilized one at a time, for each patient, and do not cross cases or ORs. The SPD stated, IUSS differs from flashing (a method of sterilizing surgical instruments with little to no drying time) because every instrument needing IUSS must go through decontamination and pass biological testing (an indicator that sterilization was achieved) prior to returning to the OR for use on patients. The SPD stated surgeons have been bringing in more OR cases recently, and both surgeons and surgical technicians (medical personnel assisting with procedures in the OR as part of the surgical team) sometimes drop surgical instruments in the OR during the procedure. The SPD stated, the facility does not flash but IUSS should still not be done frequently.

During a review of the Hospital B's policy and procedure (P&P) titled, "Flash (Immediate Use) Sterilization," last reviewed 11/2012, the P&P indicated, "Flash sterilization should be used only when there is insufficient time to process by the preferred wrapped or container method. Use of flash sterilization should be kept to a minimum."