HospitalInspections.org

Based on a review of hospital policies and procedures, observations, document review, and interviews, it was determined the Governing Body failed to ensure compliance with the Conditions of Participation was maintained and that quality patient care was provided, in a safe environment. These deficient practices had the potential to affect all patients served by this hospital.

Findings:

Refer to tags A 0053, A 0144, A 0154, A 0169, A 0173, A 0263, A 0273, A 0286, A 0297, A 0308, A 0309, A 0392, A 0449, A 0505, A 0620, A 0700, A 0701, A 0724, A 0747, A 0748, A 0749, A 0750, A 0751, A 0761, A 0770, A 0773, A 0776 and A 781.

Based on review of the hospital organizational chart, Board of Directors and Shareholders action documentation, and interview, it was determined the governing body failed to consult directly with the hospital's medical staff related to quality of medical care provided to the patients of the hospital periodically throughout the fiscal or calendar year:

This had the potential to negatively affect all patients served by the facility.

Findings include:

1. Review of the hospital organizational chart revealed Gilliard Health Services Corporation was documented as the Governing Body of the hospital.

Review of the Board of Directors and Shareholders action documentation dated 10/10/17 revealed one person was appointed the sole member of the board of director for the corporation.

On 10/31/23, the surveyor requested documentation of Governing Body meetings with the hospital's medical staff. The surveyor was notified by Employee Identifier (EI) # 1, Administrator, there was no documentation of meetings between the hospital's governing body and the medical staff.

An interview was conducted on 10/31/23 at 2:45 PM with EI # 1, who confirmed there was no documentation the sole member of the hospital's governing body had consulted directly with the hospital's medical staff related to quality of medical care provided to the patients of the hospital for the last five years.

Based on review of medical records (MR), hospital policy and interview it was determined the hospital failed to ensure patients at risk for self harm were assessed for suicide risk and provided care in a safe setting. This affected one of one record reviewed with suicidal ideation, Patient Identifier (PI) # 18, and had the potential to affect all patients at risk for self harm.

Findings include:

Hospital policy: Psychiatric Patients/Suicide Precautions
Policy Number: None
Review Date: 7/2022

Evergreen Medical Center will admit patients...who may have an underlying second mental health need...Any patient admitted with psychiatric/mental health conditions must have a responsible adult accompany him/her during...entire stay...

Suicide Precautions:
...4. The following will be removed...
a. All sharp objects...
b. Glassware
c. Shaving equipment
d. Matches, cigarette lighters...
e. Belts, ties, electrical cords...
f. Jewelry
g. All medications
h. Remove sharps/needle containers

Hospital Policy: Assessment - Initial Patient Assessment and Reassessment
Policy Number: None
Review Date: 07/2022

Policy:

The Registered Nurse is responsible for the care the patient receives...

Assessment
Assessment of patients is the primary function of the professional nurse...All patients are assessed upon admission and at least once per shift...The full assessment will be documented...

1. PI # 18 was admitted on 10/3/23 at 5:56 PM with a diagnosis of Suicidal Ideation.

Review of the inpatient medical record revealed no documentation a suicide risk assessment was completed.

Review of the admission nursing assessment dated 10/3/23 at 4:40 PM revealed PI # 18 was a smoker, lived alone, had suicidal ideations and there was no documentation a family member or adult accompanied the patient. There was no further documentation regarding the patient's risk for suicide and no documentation of interventions to ensure a safe environment.

Review of the nursing assessment dated 10/3/23 at 8:15 PM revealed PI # 18 was hearing voices to kill him/herself and was agitated. Orders were received for Haldol 5 milligram (mg) injection, Benadryl 50 mg injection and Ativan 2 mg injection as a chemical restraint to prevent self harm. There was no documentation a suicide risk assessment was completed and no interventions to ensure a safe environment.

Review of the hospital policies provided revealed no policy or guidance for how and when to conduct a suicide risk assessment for patients at risk for self harm.

An interview conducted 11/2/23 at 9:55 AM with Employee Identifier (EI) # 6, Director of Nursing, confirmed there was no documentation of the suicide precaution implemented for PI # 18 and there was no policy for suicide risk assessments. EI # 6 provided the Emergency Room (ER) documentation dated 10/3/23 which revealed a Self Harm Assessment was completed in the ER in which PI # 18 answered Yes to "Have you recently felt down, depressed, or hopeless?", "Do you have thoughts of harming or killing yourself?", "Have you lost interest or pleasure in doing things?" and "Have you ever tried to hurt yourself before today?".

Based on review of medical records, hospital policy and procedure, and interview, it was determined the hospital failed to ensure patients were released from restraints as soon as possible, as directed per hospital policy.

This deficient practice affected one of two medical records of patients in restraints including Patient Identifier (PI) # 19 and had the potential to affect all patients admitted to this hospital requiring restraint.

Findings include:

Hospital Policy: Use of Restraints
Policy Number: Not included
Reviewed: 7/22

Purpose:

...Our goal is an organization wide approach that protects the patient's health, safety and preserves his or her dignity, rights, and well-being.

Policy:

...ii. Preventing, reduce and eliminate the use of restraints by basing use on the patient's assessed needs:
...Limiting the use of restraints to emergencies...
v. Reassess and encourage the release of restraints as soon as possible.

...Procedures:

vi. Early release - may be released...if the condition that necessitated the order have subsided...

1. PI # 19 was admitted to the hospital on 7/31/23 with diagnoses including Altered Mental Status and Severe Leg and Back Pain.

Review of the physician's orders revealed a written order dated 8/2/23 at 4:30 AM, "apply restraints for the safety of patient and staff".

Review of the nursing documentation revealed PI # 19 was agitated, grabbing at lines/equipment, verbally threatening...striking out at people...vest and wrist/arm restraints were applied on 8/2/23 at 4:30 AM.

Nursing documentation dated 8/2/23 at 5:36 AM revealed the patient (pt) was sleeping, restraints were not discontinued and effect of restraint was adequate.

Nursing documentation dated 8/2/23 at 7:30 AM on the restraint flowsheet revealed restraints were released, pt not combative and not at risk for harm of self or others.

There was no documentation restraints were released as soon as possible and PI # 19 remained restrained from 5:36 AM to 7:30 AM.

Further review of the nursing documentation revealed on 8/2/23 at 7:30 AM the pt was irate and screaming, attempting to fight staff...orders received for injection of Haldol and Benadryl...

Nursing documentation dated 8/2/23 at 9:20 AM revealed pt released from vest, wrist restraints at this time...

There was no documentation of when the vest and wrist restraints were reapplied after previously being released at 7:30 AM.

An interview was conducted on 11/2/23 at 10:36 AM with Employee Identifier (EI) # 6, Director of Nursing, who confirmed the documentation revealed the patient was sleeping and restrained at 5:36 and stated the staff were "waiting to see" how the patient responded when awake. EI # 6 further confirmed the documentation was not clear.

Based on review of medical records, hospital policy and procedure, and interview, it was determined the hospital failed to ensure orders for restraints were not written as a PRN (as needed) order and indicated the type of restraint, reason for use and the time limit, as directed per hospital policy.

This deficient practice affected two of two medical records of patients in restraints including Patient Identifier (PI) # 20, PI # 19 and had the potential to affect all patients admitted to this hospital requiring reatraint.

Findings include:

Hospital Policy: Use of Restraints
Policy Number: Not included
Reviewed: 7/22

Purpose:

...Our goal is an organization wide approach that protects the patient's health, safety and preserves his or her dignity, rights, and well-being.

...Procedures:

...e. Orders for Restraint

Written or verbal orders for initial and continuing use of restraint are time limited:

...Initial Physician Orders

...All initial restraint orders will include...the medically indicated reason for the restraint, the type of device, and the appropriate time limit...

v. ...Standing or PRN orders for restraints are not acceptable.

...viii. Content of Individual Orders:

... Reason for restraint device.

1. PI # 20 was admitted to the hospital on 7/12/23 with diagnoses including, Abdominal Pain, Fecal Impaction with Vomiting, Dehydration, Seizure Disorder and Cerebral Palsy.

Review of the Physician's Order Sheet revealed a written order dated 7/13/23 at 6:30 AM, "Soft restraints if needed".

The hospital failed to ensure physician orders were not written as PRN for restraints and the order included the reason for the restraint.

An interview was conducted on 11/2/23 at 11:14 AM with Employee Identifier # 6, Director of Nursing, who confirmed restraint orders should not be written as PRN and should contain the reason for the restraint.



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2. PI # 19 was admitted to the hospital on 7/31/23 with diagnoses including Altered Mental Status and Severe Leg and Back Pain.

Review of the physician's orders revealed a written order dated 8/2/23 at 4:30 AM, "apply restraints for the safety of patient and staff."

The hospital failed to ensure physician orders for restraints included the reason for the restraint, the type of restraint and the appropriate time limit.

An interview was conducted on 11/2/23 at 10:36 AM with Employee Identifier # 6, who confirmed restraint orders should include the reason for the restraint, type of restraint and the time limit.

Based on review of medical records, hospital policy and procedure, and interview, it was determined the hospital failed to ensure orders for restraints were renewed for nonviolent/non-self-destructive behaviors within 24 hours of the initial order for a restraint.

This deficient practice affected one of two medical records of patients in restraints including Patient Identifier (PI) # 20 and had the potential to affect all patients admitted to this hospital.

Findings include:

Hospital Policy: Use of Restraints
Policy Number: Not included
Reviewed: 7/22

Purpose:

...Our goal is an organization wide approach that protects the patient's health, safety and preserves his or her dignity, rights, and well-being.

...Procedures:

...e. Orders for Restraint

Written or verbal orders for initial and continuing use of restraint are time limited:

...Initial Physician Orders

A physician order for restraints for nonviolent/non-self-destructive behaviors: ...is valid for 24 hours.

1. PI # 20 was admitted to the hospital on 7/12/23 with diagnoses including, Abdominal Pain, Fecal Impaction with Vomiting, Dehydration, Seizure Disorder and Cerebral Palsy.

Review of the Physician's Order Sheet revealed a written order dated 7/13/23 at 6:30 AM, "Soft restraints if needed".

Review of the 7/14/23 at 6:00 AM Patient Progress Note revealed, "Effect of Restraint: Adequate".

Review of the next Patient Progress Note on 7/14/23 at 8:00 AM revealed, "Type of Restraint: Bilateral, Wrist/Arm restraint..."

There was no new physician's order written on 7/14/23 at 6:30 AM, which was 24 hours after the initial order, for the continuing use of the restraint as directed per the hospital policy.

An interview was conducted on 11/2/23 at 11:14 AM with Employee Identifier # 6, Director of Nursing, who confirmed the staff failed to ensure orders for restraints were renewed within 24 hours of the initial order per hospital policy.

Based on review of the hospital QAPI (Quality Assessment and Performance Improvement) documentation, hospital policies and interviews, it was determined the facility failed to implement a complete and ongoing QAPI program.

Findings:

Refer to tags A 0273, A 0286, A 0297, A 0308, and A 0309.

Based on review of the hospital QAPI (Quality Assessment and Performance Improvement) documentation, hospital policy and interviews, it was determined the hospital failed to implement a QAPI program to include:

1. All areas of the hospital, including the Nursing Services, Patient Registration, Dietary, Physical Rehabilitation Services, and physical environment department, participated in the QAPI activities.

2. An ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes

3. QAPI monthly meetings to identify opportunities to improve services.

4. The frequency and detail of data collection was specified by the hospital's governing body.

This had the potential to negatively affect all patients served by this hospital.

Findings include:

Hospital Policy: Performance Improvement Program (PIP)
Policy Number: Not documented
Date: Not documented

...continuous quality improvement (CQI) being the objective of the program and the facility...

I. Purpose. The purpose of the PIP is to ensure that the Governing Body...professional service staff demonstrate a consistent endeavor to deliver optimal care in an environment of minimal risk... The hospital wide program... approval from the governing board, has the responsibility for monitoring every aspect of patient care...

II. Assigned Responsibility.

...D. The board of trustees will support and have the final authority and responsibility for the... PIP...

III. Authority for PIP.

a. Performance Improvement Director. The Performance Improvement Director, is responsible for...

1. Monitoring and evaluating the quality and appropriateness of patient care services and resolving identified problems.

...4. Documenting and reporting the findings and conclusions of such monitoring, evaluation, and problem-solving activities.

...Responsible for the integration of all performance improvement functions to include...hospital-wide quality improvement activities.

IV. Objectives.

...B. To coordinate and integrate all quality improvement and quality management activities throughout the facility and ensure participation of all departments and services.

...D. To assure communication and reporting between hospital administration...department managers, hospital staff and the Board of Trustees.

V. Goals.

A. To assure the following:

1. That clinical and administrative staff monitor and evaluate the quality and appropriateness of patient care and clinical performance, resolve identified problems, and report information to the Board of Trustees to assist it in fulfilling its responsibility for the quality of patient care.

...VII. Scope of Activities.

The PIP...shall apply to all hospital services...

E. Ongoing review of the quality of care/service in the following hospital service areas: ...Dietetic Services...Nursing Services...Physical Rehabilitation Services...

IX. Hospital PIP.

Membership. The Total Quality Management Committee membership will be composed of the following:

Medical Staff representative...Chief of Staff...Administrator...Director of Nurses...Director of Quality Management.

Reporting: Department included in the PIP shall report monthly to the Director of the Performance Improvement. The department manager will give written and verbal report to the Performance Improvement Committee quarterly...

Meetings: The committee shall meet monthly.... Review departmental/services Performance Improvement activities in order to integrate activities to identify opportunities to improve services... Written minutes with conclusion, recommendations, actions taken, and the results of actions are maintained.

1. Review of the hospital QAPI program was conducted on 11/2/23 at 8:42 AM with Employee Identifier (EI) # 2, Chief Operating Officer.

Review of the hospital QAPI Program documentation for Quarter 2 (April, May, and June) 2023 revealed no documentation the nursing, registration, physical therapy, and physical environment departments reported data to the hospital QAPI program.

The surveyor asked for the hospital QAPI Program documentation for Quarter 3 (July, August, and September) 2023. EI # 2 verbalized there was no documentation the department data had been entered into the hospital Quarter 3 2023 QAPI program. EI # 2 verified during the interview the hospital was currently in the second month of Quarter 4 2023.

An interview was conducted, during the review, with EI # 2. When asked for the minutes of the Performance Improvement Committee meetings, EI # 2 replied, "since COVID we do not do meetings". EI # 2 verbalized there was no documentation the governing body specified the frequency and detail of the data collection for the hospital QAPI program.

Based on review of the hospital QAPI (Quality Assessment and Performance Improvement) documentation, hospital policy and interviews, it was determined the facility failed to ensure the QAPI program measured, analyzed, and tracked adverse patient occurrences and medical errors.

This had the potential to negatively affect all patients served by this facility.

Findings include:

Hospital Policy: Performance Improvement Program (PIP)
Policy Number: Not documented
Date: Not documented

...continuous quality improvement (CQI) being the objective of the program and the facility...

...IV. Objectives.

...G. To provide for the rapid identification and prevention of adverse patient occurrences, and to facilitate their optimal management through coordination of appropriate services...

1. Review of the hospital QAPI program was conducted on 11/2/23 at 8:42 AM with Employee Identifier (EI) # 2, Chief Operating Officer.

Review of the hospital QAPI Program documentation for Quarter 1 (January, February, and March) and Quarter 2 (April, May, and June) 2023 revealed documentation of the number of medication errors and near misses. There was no documentation of the type of medication errors and near misses, no documentation an analysis was conducted for their causes, and no documentation preventive actions and mechanisms were implemented.

Further review of the hospital QAPI Program documentation for Quarter 1 and Quarter 2 revealed no documentation of other adverse patient occurrences.

During the review, the surveyor asked for the hospital QAPI Program documentation for Quarter 3 (July, August, and September) 2023. EI # 2 verbalized there was no documentation adverse patient occurrences and medical errors had been entered into the hospital Quarter 3 2023 QAPI program. EI # 2 verified during the interview the hospital was currently in the second month of Quarter 4 2023.

During the review, EI # 2 confirmed there was no documentation of the type of medication errors and near misses, no documentation an analysis was conducted for their causes, and no documentation preventive actions and mechanisms were implemented in the hospital QAPI Program. EI # 2 further confirmed medication errors and near misses are the only adverse patient occurrences and medical errors documented in the hospital QAPI Program.

Based on review of the hospital QAPI (Quality Assessment and Performance Improvement) documentation and interview, the facility failed to ensure Performance Improvement Projects were developed, measurable progress was achieved and incorporated into the hospital wide QAPI program.

This had the potential to negatively affect all patients served by this facility.

Findings include:

1. Review of the hospital QAPI program was conducted on 11/2/23 at 8:42 AM with Employee Identifier (EI) # 2, Chief Operating Officer. Review of the hospital QAPI program revealed no documentation of a Performance Improvement Project.

An interview was conducted, during the review, with EI # 2, who confirmed there was no documentation of a Performance Improvement Project and verbalized the hospital did not have a Performance Improvement Project "...to my knowledge" and no documentation the governing body performed an annual evaluation of the hospital's QAPI program.

Based on review of the hospital QAPI (Quality Assessment and Performance Improvement) documentation, hospital policy and interviews, it was determined the hospital governing body failed to ensure the program reflects the complexity of the hospital's organization and services including all hospital departments and services.

This had the potential to negatively affect all patients served by this facility.

Findings include:

Hospital Policy: Performance Improvement Program (PIP)
Policy Number: Not documented
Date: Not documented

...continuous quality improvement (CQI) being the objective of the program and the facility...

I. Purpose. The purpose of the PIP is to ensure that the Governing Body...demonstrate a consistent endeavor to deliver optimal care in an environment of minimal risk... the governing board, has the responsibility for monitoring every aspect of patient care...

...XIII. Annual Evaluation

...D. The Board of Trustees...will appraise the PIP at least annually... The reappraisal will identify components of the PIP that need to be instituted, altered, or deleted.

1. Review of the hospital QAPI program was conducted on 11/2/23 at 8:42 AM with Employee Identifier (EI) # 2, Chief Operating Officer.

Review of the hospital QAPI Program documentation for Quarter 2 (April, May, and June) 2023 revealed no documentation the Nursing Services, Patient Registration, Dietary, Physical Rehabilitation Services, and physical environment department reported data into the hospital QAPI program.

The surveyor asked for the hospital QAPI Program documentation for Quarter 3 (July, August, and September) 2023, EI # 2 verbalized there was no documentation the department data had been entered into the hospital Quarter 3 2023 QAPI program. EI # 2 verified during the interview the hospital was currently in the second month of Quarter 4 2023.

An interview was conducted, during the review, with EI # 2. EI # 2 verbalized there was no documentation of communication with the governing body to ensure the program reflects the complexity of the hospital's organization and services including all hospital departments and services and no documentation the governing body performed an annual evaluation of the hospital's PIP.

Based on review of hospital policy, hospital QAPI (Quality Assessment and Performance Improvement) program and staff interviews it was determined the governing body failed to ensure:

1. The hospital QAPI included indicators to identify and reduce medical errors.

2. The number of distinct improvement projects to be conducted annually was determined.

3. Approve the improvement projects to include in the QAPI program.

This had the potential to negatively affect all patients served by this facility.

Findings include:

Hospital Policy: Performance Improvement Program (PIP)
Policy Number: Not documented
Date: Not documented

...continuous quality improvement (CQI) being the objective of the program and the facility...

...IV. Objectives.

...G. To provide for the rapid identification and prevention of adverse patient occurrences, and to facilitate their optimal management through coordination of appropriate services...

1. Review of the hospital QAPI program was conducted on 11/2/23 at 8:42 AM with Employee Identifier (EI) # 2, Chief Operating Officer.

Review of the hospital QAPI program revealed no documentation of a Performance Improvement Project.

Review of the hospital QAPI Program documentation for Quarter 1 (January, February, and March) and Quarter 2 (April, May, and June) 2023 revealed documentation of the number of medication errors and near misses. There was no documentation of the type of medication errors and near misses, no documentation an analysis was conducted for their causes, and no documentation preventive actions and mechanisms were implemented.

Further review of the hospital QAPI Program documentation for Quarter 1 and Quarter 2 revealed no documentation of other adverse patient occurrences.

During the review, the surveyor asked for the hospital QAPI Program documentation for Quarter 3 (July, August, and September) 2023. EI # 2 verbalized there was no documentation adverse patient occurrences and medical errors had been entered into the hospital Quarter 3 2023 QAPI program. EI # 2 verified during the interview the hospital was currently in the second month of Quarter 4 2023.

EI # 2 confirmed during the review, there was no documentation of the type of medication errors and near misses, no documentation an analysis was conducted for their causes, and no documentation preventive actions and mechanisms were implemented in the hospital QAPI Program. EI # 2 further confirmed medication errors and near misses are the only adverse patient occurrences and medical errors documented in the hospital QAPI Program and no documentation the governing body performed an annual evaluation of the hospital's PIP.

Based on review of medical records (MR), hospital policies and procedure and interviews with staff, it was determined the hospital failed to ensure:

1. Nursing staff documented a pain assessment and follow up assessment after a PRN (as needed) medication was administered for pain.

2. Wound care was performed as ordered by the physician.

3. Nursing staff documented the required wound care and wound assessment per the hospital policy.

This did affect 3 of 20 inpatient records reviewed including Patient Identifier (PI) # 2, PI # 13, PI # 16 and two of two records reviewed with wounds including PI # 2, PI # 17. This had the potential to negatively affect all patients served by this facility.

Findings include:

Hospital Policy: Assessment - Initial Patient Assessment and Reassessment
Policy Number: Not included
Reviewed Date: 7/22

... Assessment

...All patients are assessed upon admission and at least once per shift after they are admitted.

Hospital policy: Assessment and Documentation of Pain
Policy number: Not included
Reviewed: 7/22

Policy:

It is the policy of Evergreen Medical Center to provide for a uniform method of assessing and documenting patient report of pain.

...personnel assessing reports of pain shall request the patient to rate the pain on a scale of 1-10 (one to ten).

Pain should be documented using the 1-10 scale, and the appropriate medication administered based on the pain scale.

...After the administration of pain medication, the patient shall be reassessed within one hour for effectiveness of the medication.

Hospital Policy: Wound Care
Policy number: Not included
Reviewed: 7/22

Policy:

It is the policy of Evergreen Medical Center to evaluate patients with a wound ... and obtain treatment orders from the physician.

Procedure:

1. The following information will be evaluated and documented by the nurse:

a. Location of the wound.
b. Stage if a decubitus ...
c. Dimensions...
d. Presence of undermining or sinus tracts with the dimensions and at what direction in reference to the clock.
e. Exudate/drainage amount, color, and presence/absence of any odor.
f. Wound base status-granulation versus eschar/slough and what color....

1. PI # 2 was admitted to the facility on 10/24/23 with diagnoses including Cellulitis, Rule out Osteomyelitis, Peripheral Vascular Disease and Ulceration.

Review of the Patient Progress Notes dated 10/24/23 at 9:38 PM and 10/25/23 at 5:54 AM revealed, "Patient c/o (complained of) generalized pain all over, PRN Percocet given po (by mouth)". There was no documentation the nurse reassessed the patient's pain within one hour for effectiveness of the PRN medication per the hospital policy.

Review of the MR revealed a physician's order dated 10/24/23 at 2:46 PM, "Wet to dry dressing change bid (twice daily)".

Review of the Physicians History and Physical (H&P) dated 10/25/23 revealed, "...severely infected right foot. The foot was very malodorous. You could smell it all around the office".

Review of the MS (Medical/Surgical) Daily Nursing Assessment dated 10/25/23 at 8:22 AM revealed, "Pressure Ulcer". There was no documentation of drainage, drainage color, presence or absence of odor and wound base per hospital policy.

Further review of the MS Daily Nursing Assessment dated 10/25/23 at 8:22 AM revealed there was no documentation wound care was provided bid as ordered.

Review of the MS Daily Nursing Assessment dated 10/25/23 at 11:08 PM revealed there was no documentation of drainage, drainage color, presence or absence of odor and wound base per hospital policy.

Review of the MS Daily Nursing Assessment dated 10/26/23 at 10:12 AM revealed there was no documentation wound care was provided bid as ordered.

An interview was conducted on 11/2/23 at 11:20 AM with Employee Identifier (EI) # 6, Director of Nursing (DON), who confirmed the staff failed to reassess the patient's pain one hour after a PRN was given for the effectiveness of the medication. EI # 6 also confirmed the staff failed to provide wound care per the physician orders and document wound assessments every shift per hospital policy.


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2. PI # 13 was admitted to the hospital on 10/15/23 with diagnoses including Acute Diverticulitis and Acute Abdominal Pain.

Review of the Patient's Progress Notes dated 10/25/23 at 5:46 PM revealed the patient c/o pain. There was no documentation of the location of the pain or a pain scale. Toradol 15 milligrams (mg) PRN was given per injection. There was no documentation the nurse reassessed the patient's pain within one hour for effectiveness of the PRN medication as directed per the hospital policy.

Review of the Patient's Progress Note dated 10/25/23 at 8:04 PM revealed the patient c/o pain. There was no documentation of the location of the pain or a pain scale. Norco 10 mg PRN given po. There was no documentation the nurse reassessed the patient's pain for effectiveness of the PRN medication as directed per hospital policy.

Review of the Patient's Progress Note dated 10/26/23 at 2:00 AM revealed the patient c/o pain. There was no documentation of the location of the pain or a pain scale. Toradol 15 mg PRN given per injection. There was no documentation the nurse reassessed the patient's pain within one hour for effectiveness as directed per hospital policy.

Review of the Patient's Progress Note dated 10/26/23 at 8:42 AM revealed the patient c/o pain. There was no documentation of the location of the pain or a pain scale. Norco 10 mg PRN given po. There was no documentation the nurse reassessed the patient's pain within one hour for effectiveness as directed per hospital policy.

An interview was conducted on 11/2/23 at 10:45 AM with EI # 6 who confirmed the staff failed to document the location of the pain or a pain scale and failed to reassess the patient's pain one hour after a PRN medication was given for the effectiveness of the medication.



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3. PI # 16 was admitted to the hospital on 10/31/23 with a diagnosis of New Onset Atrial Fibrillation with Shock.

Review of the Patient Progress Notes dated 10/31/23 at 7:40 PM revealed, "...c/o pain to left foot...". There was no documentation of a pain level.

An interview was conducted on 11/2/23 at 11:20 AM with EI # 6, who confirmed the staff failed to document the patient's pain level per the hospital policy.

4. PI # 17 was admitted to the hospital on 1/25/23 with diagnoses including Right Middle and Lower Lobe Pneumonia and Recent COVID (Coronavirus) with Severe Physical and Mental Decline with only Gastrostomy Feedings.

Review of the MR revealed a physician's order dated 1/26/23 at 2:32 AM to cleanse coccyx with normal saline, pat dry, and apply duoderm every 72 hours.

Review of the Patient Progress Notes revealed wound care was performed to the coccyx wound on 1/26/23 at 10:50 PM and the next wound care would be due on 1/29/23.

Review of the MS Daily Nursing Assessments dated 1/27/23 revealed no documentation of a wound assessment for the coccyx wound.

Review of the Patient Progress Notes and MS Daily Nursing Assessment from 1/29/23 to 1/31/23 revealed no documentation wound care was performed to the coccyx wound per the physician's order of every 72 hours.

An interview was conducted on 11/2/23 at 11:08 AM with EI # 6, who confirmed the staff failed to document a wound assessment on 1/27/23 and provide wound care per the physician's order of every 72 hours.

Based on review of Medical Records (MR), hospital Code Blue Procedure and interviews it was determined the hospital failed to ensure staff completed the Cardiopulmonary Resuscitation Form for one of one Code Blue records reviewed including Patient Identifier (PI) # 10.
This had the potential to affect all patients served at this hospital who require cardiopulmonary resuscitation.

Findings include:

Hospital Procedure: Code Blue Procedure
Reviewed Date: 01/2022

Procedure: The Code Team
...7. Recorder: Documents everything that goes on during the code...

Charting:
...5. Chart on the Cardiopulmonary Resuscitation (CPR) Form which becomes a part of the medical record.

PI # 10 was admitted on 10/20/23 with a diagnosis of Shortness of Breath and expired on 10/24/23. Review of the MR revealed nursing documentation dated 10/23/23 at 11:35 PM "nursing staff called to room, pt (patient) noted to have no pulse, spoke with pt's spouse about code status, stated he wanted us to save her and to try everything, Code called..."

Further review of the MR revealed nursing documentation CPR continued...Epinephrine 1 ampoule given intravenous...no shock advised....CPR continued...no respiration noted, pupils are fixed...pt remains pulseless...time of death called...12:01 on 10/24/23. The MR did not include the CPR Form. There was no documentation of interventions for airway manaagement, oxygen administration and who participated in the code.

An interview conducted 11/2/23 at 10:35 AM with Employee Identifier # 6, Director of Nursing confirmed the staff failed to document the code on the CPR form as directed by the hospital procedure.

Based on observations, hospital policies, and interviews it was determined the hospital failed to ensure all out of date drugs and biologicals were not available for patient use.

This deficient practice had the potential to affect all patients receiving medications at this hospital.

Findings include:

Hospital Policy: Outdated Supplies and Drugs
Policy Number: Not included
Reviewed Date: 7/22

At the first of the month supply carts, medication room and crash carts are to be checked for outdated supplies and drugs. Outdated drugs are to be returned to the pharmacy and outdated supplies are to be returned to materials management for replacement.

Hospital Policy: Multiple Dose Vials
Policy Number: 7. r.
Date Revised: October 2022

Multiple Dose Vials (MDV) are to be labeled with date opened, expiration date of 28 days post opening or manufacturer's expiration (whichever is earliest), and the initials of the indivdual opening the vial...

1. During a tour of the Medical Surgical (Med/Surg) Unit and Rooms 101 to 105 on 10/31/23 at 9:20 AM with Employee Identifier (EI) # 2, Chief Operating Officer (COO), the following drugs (or items) were identified:

Room 102: one bottle of 0.9 % (percent) Sodium Chloride Irrigation Solution opened and dated 3/2/23 and available for patient use. EI # 2 stated, it (Sodium Chloride solution) should only be stored for 30 days after opening and then discarded.

An interview was conducted on 11/2/23 at 11:22 AM with EI # 6, Director of Nursing, who confirmed the items were opened, expired and available for patient use.

2. A tour of the Respiratory Therapy department was conducted on 11/1/23 at 8:51 AM with EI # 9, Licensed Respiratory Therapist, and the following drugs were expired and available for patient use:

a. Four packs of Sodium Chloride Inhalation Solution 0.9% expired 6/2020.

An interview was conducted with EI # 9 during the tour who confirmed the Sodium Chloride Inhalation Solution was expired and available for patient use.



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3. During a tour of the Emergency Department (ED) on 10/31/23 at 11:05 AM with EI # 5, ED Director, a MDV of Benzoin Compound Tincture 59 milliters (ml) was found opened and available for patient use on top of the Emergency cart with an opened date of 8/20/22 which would have an expiration date of 9/18/22 per hospital policy.

An interview was conducted during the tour with EI # 5 who confirmed the Benzoin was opened, expired and available for patient use.

Based on observations, policy review and interviews it was determined the hospital failed to ensure:

1. Dietary policies were developed, approved and available for staff.

2. Dietary Services were incorporated into the hospital Quality Assessment and Performance Improvement (QAPI) program.

3. The physical environment of the kitchen, equipment and utensils were maintained in a clean, safe and sanitary manner.

This had the potential to affect all persons served by the hospital.

Findings include:

1. A tour of the dietary department was conducted on 10/31/23 at 9:15 AM with Employee Identifier (EI) # 14, Dietary Director. The following observations were made:

Dry Storage Area
Broken floor tiles which prevent proper cleaning, grout dirty.
Plastic tub of sweet potatoes with mold covering multiple potatoes.
Box of potatoe flakes opened with no date.
Honey Mustard salad dressing packs removed from original package and no use by date.
Graham Cracker Crumbs (identified by EI # 14) in a clear plastic bag unlabeled.
Bag of powdered sugar opened and no date.
Corn meal in a plastic bag opened and no date.
Bag of coconut flakes opened and no date.

Freezer
Smoked ham slices opened and no date.
Large box of frozen biscuits with top opened and inside plastic bag opened exposing the biscuits.
Product (identified by EI # 14 as Philly meat) in a clear plastic bag with no label.
Product (identified by EI # 14 as ham hocks) in a clear plastic bag with no label.
Chicken breast, chicken tenders, and Salisbury steak (identified by EI # 14) in small clear plastic bags (not original container) and with no label or date opened.

Refrigerator
Ranch Dressing, gallon size with no opened date, use by date or expiration date.
Clear bag of turkey bacon (identified by EI # 14) with no opened date, use by date or expiration date.

Kitchen
Multiple metal cooking pots with dents and thick, black substance build up on the bottoms.

Solid metal colander hanging from pot rack with a split from the rim to approximately three inches toward the middle of the colander.

A stack of oven sheet pans with grease on the bottom of the pans upon inspection.

The counter wall with coffee pot and prepared pitchers of tea had broken subway tile, and broken electrical outlet. The subway tile was installed in a way that created a ledge above the counter top which was covered in dust.

The pot rack hanging directly above the steam service table had visible dust on all surfaces creating a potential for dust to dislodge and fall into prepared food.

Metal storage cabinets in the kitchen were dirty on the inside, some with rust, storage drawers difficult or unable to pull open rendering them unusable.

The stainless steel three compartment sink had build up of a white substance in each sink.

There was a small red bucket with cleaning cloths submerged in liquid sitting by the sink. When asked what was in the container EI # 14 stated it was the cleaning solution with Clorox for disinfecting surfaces. When asked how the staff ensured the solution was mixed properly EI # 14 stated they test it with test strips. There were several loose test strips in a clear plastic bag with a log sheet. The test strips were not in the original container and there was no chart or directions for use of the testing strips. The log indicated the solution was mixed at 6:00 AM, 11:00 AM and 2:00 PM each day with an area to document PPM (parts per million). Every time point was completed with "100" PPM for 10/1/23 to 10/31/23 at 6:00 AM. EI # 14 was asked how the concentration of Clorox to water was verified without a comparison chart. No explanation was provided.

The gas stovetop/oven had grease/grime build up.

The stainless steel food prep sink area was located directly beside the only handwashing sink. There was a small partition attached to the handwashing sink but it was not high enough to prevent water from splashing onto the food prep area when washing hands thereby creating a contamination hazard.

EI # 14, who was present during the tour, confirmed the above findings.

2. An interview was conducted on 10/31/23 at 12:00 PM with EI # 14. The surveyor requested the dietary policy manual. Review of the manual revealed hospital operational policies and no dietary department policies. EI # 14 stated that was the only policies he/she was aware of.

EI # 14 was asked what quality indicators were being monitored and reported to the hospital QAPI committee. EI # 14 stated "I do not know what that is."

3. An interview was conducted on 11/1/23 at 11:30 AM with EI # 17, Registered Dietitian. EI # 17 was asked for the dietary policies and procedures and was unable to locate any policies. EI # 17 stated he/she was not aware there were no policies. EI # 17 confirmed he/she was at the hospital once per month and conducted kitchen inspection and observed food prep. There was no documentation of the monthly inspections.

Based on observations during facility tour with hospital staff by the Life Safety Surveyor and staff interviews, it was determined the facility was not constructed, arranged and maintained to ensure patient safety. This had the potential to negatively affect all patients served by the hospital.

Findings include:

Refer to Life Safety Code violations K 291, K 293, K 324, K 345, K 351, K 353, K 712, K 761, K 907, K 908, K 918, K 927, and health survey citations A 701, and A 724 for findings.

Based on observations, review of policy and procedure, Safety Committee Meeting Minutes, and staff interviews, it was determined the hospital failed to maintain a clean, sanitary, and safe environment.

This had the potential to affect all patients served by this hospital.

Findings include:

Hospital Policy: Infection Control
Policy Number: 4032-047
Effective Date: July 2022

Policy:

The housekeeping departments responsibility is to maintain a clean environment throughout the hospital. Accumulation of dust, soil and microbial contaminants on environmental surfaces is both aesthetically displeasing and a potential source of nosocomial infections. Effective... cleaning methods and schedules are therefore necessary to maintain a clean and healthy environment in health care setting.

Procedure:

Responsibilities:

1. Facility Manager.

A. Supervises all activities in the hospital housekeeping...
G. Supervises activities of hospital housekeeping in their designated areas.
I. Daily monitor their areas... and report any problems to housekeeping...

9. Cleaning.

...C. The key to cleaning and disinfecting of environment surfaces is to use friction (ELBOW GREASE) to remove microorganisms and debris.

1. During a tour of the Medical Surgical (Med/Surg) Unit and Rooms 101 to 105 on 10/31/23 from 9:20 AM to 10:35 AM and 11:00 AM with Employee Identifier (EI) # 2, Chief Operating Officer (COO), the following was observed:

Room 102: Large amounts of a black substance inside and outside the heating and AC (air conditioner) unit. Multiple pieces of old torn tape on the outside of the heating and AC vents.

Room 105: Wallpaper peeling away from the walls in multiple areas and paint peeling under the windowsill. Air vent in ceiling with large amount of dust and cobb webs. Ceiling tile next to air vent with large amount of brown discoloration.

Hallway outside of Room 105: Floor baseboards on both sides of the hall torn away from the walls.

An interview was conducted with EI # 2, during the tour. EI # 2 stated the black substance appeared to be "mold" and confirmed the above findings.


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2. During a tour of the Med/Surg Unit and Rooms 106 to 129 on 10/31/23 at 9:20 AM with EI # 6, Director of Nursing, the following was observed:

Hallway- The floor baseboard was peeling away from the walls in multiple areas.

Room 107- The gray floor baseboard had multiple areas with dark brown grime, the wallpaper was peeling off the walls around the windows, the paint was peeling off the windowsill, the AC vent appeared dusty with small black spots inside the vents, the bathtub had dark brown discolorations inside the tub, the tile grout in the bathroom appeared black, and the perimeter of the floor appeared stained and blackened.

Room 114- Multiple metal cross beams of ceiling tiles had reddish brown stains.

Room 116- The bowl of the sink had a brown discoloration with a black substance circling the drain, the wallpaper was peeling off the walls around the windows and under the AC unit, the paint was peeling on the windowsill, the AC vents appeared dusty and with black spots inside the vents, and the AC vent was taped in multiple areas to prevent vents from moving.

Room 117- The gray floor baseboard had multiple areas with dark brown grime, the paint was peeling on the windowsill, the wallpaper was peeling from walls on each side of the window, the AC vents were dusty and a small amount of a black substance was inside the AC vents.

Room 118- The tile grout in the bathroom appeared black, the toilet seat was stained a brownish color, the wallpaper was peeling off the walls on each side of the window, the bowl of the sink had a brown discoloration with a black substance circling the drain, the electrical plug had a black substance on the top and sides of the plug, the red clean filter light on the AC unit was on.

Room 119- The bowl of the sink had a brown discoloration with a black substance circling the drain, the wallpaper was peeling off the walls under the windows and adjoining walls, the gray floor baseboards had multiple areas with dark brown grime, the AC unit had a small amount of a black substance inside the vents and the red clean filter light was on, and the paint was peeling off the window sill.

Room 120- The bowl of the sink had a brown discoloration with a black substance circling the drain, the wallpaper under the window was peeling off the wall, and the paint was peeling off the window sill.

Room 121- The bowl of the sink had a brown discoloration, the gray floor baseboard had multiple areas with brown grime, the wallpaper under the air conditioner was peeling off the wall approximately seven inches and next to the window approximately one foot long, the light plug had a black substance on the top and sides of plug, and upon moving the hospital bed, there was a used crumbled up paper towel behind the bed, when the room was clean and ready for a patient.

Room 122- The gray floor baseboards had multiple areas with brown grime, the bowl of the sink had a brown discoloration, the wallpaper was peeling under the windowsill, and off the walls around the windows, and the light plug had a black substance on the top and sides of the plug.

Room 123- The bowl of the sink had a brown discoloration.

Room 124- The ceiling tile with a sprinkler head attached had a brown discoloration with tile bubbled up around the sprinkler head.

Room 125- The ceiling tile with sprinkler head had a brown circular stain surrounding the sprinkler head, the bowl of the sink had a brown discoloration with a black substance circling the drain, the wallpaper was peeling off the wall around the sink area, the wallpaper under the AC was peeling off the wall, the wallpaper was peeling off the walls around the windows, the paint was peeling off the windowsill in several areas, the perimeter of the gray floor baseboard had multiple areas with dark brown grime, the AC unit had small amounts of a black substance inside the vents and the red clean filter light was on, the plaster wall behind the head of the bed had a large hole in it, the gray floor baseboard was peeling away from the wall for approximately 12 inches in front of the patient bed, the foot of the recliner had a large hole in it, and the electrical plug had a black substance along the top and sides of the plug.

Room 126- The bowl of the sink had a brown discoloration and a black substance circled the sink drain, the gray floor baseboard was peeling at the foot of the bed and bubbled up beside the bed, and the paint was peeled off of the windowsill in several locations.

Room 128- The gray floor baseboards had multiple areas with brown grime.

An interview was conducted during the tour with EI # 6, who confirmed the above findings.

Review of the safety committee meeting minutes dated 1/12/23, 4/1/23, 8/15/23 revealed there was no discussion of the safety and environmental rounds.

Review of the safety committee minutes dated 10/5/23 revealed there was no discussion regarding the safety and environmental rounds. Further review revealed a recommendation to remind EI # 17, Maintaince Technician, the environmental rounds need to be completed and the results brought to the safety meeting.

An interview with EI # 17 was conducted on 11/1/23 at 8:28 AM. EI # 17 verbalized there was no log of the routine and preventive maintenance schedules. EI # 17 further verbalized there was no documentation of environmental rounds.

Based on review of hospital policy, observations and staff interview, it was determined the facility failed to ensure:

1. Supplies available for patient use were not expired.

2. Patients were provided with a method of alerting staff for needs while being treated in the Emergency Department (ED).

Findings include:

Hospital Policy: Outdated Supplies and Drugs
Policy Number: None
Date reviewed: 7/22

At the first of every month, supply carts, medication room and crash carts are to be checked for outdated supplies and drugs. Outdated drugs are to be returned to the pharmacy and outdated supplies are to be returned to materials management for replacement.

1. During a tour of the Medication Room on the Medical Surgical floor on 10/31/2023 at 9:19 AM, with Employee Identifier (EI) # 6, Director of Nursing, the following items were found to be expired and available for patient use.

a. Seven yellow/gold top lab blood collection tubes expired 9/30/23.
b. Forty one 14 gauge (g) x (times) two inches Intravenous (IV) Introcan safety IV catheters expired 3/1/23.
c. Two blue top lab blood collection tubes expired 8/31/23.
d. Two Bectin Dickinson (BD) vacutainer Safety-Lok (brand of vacutainer) blood collection sets expired 7/31/23.

An interview was conducted during the tour with EI #6, who confirmed these items were expired and available for patient use.



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2. During a tour of the Medical Surgical (Med/Surg) Unit and Rooms 101 to 105 on 10/31/23 at 9:20 AM with Employee Identifier (EI) # 2, Chief Operating Officer (COO), the following supplies was identified:

Pediatric Crash Cart: three packs of Lubricating Jelly expired 9/23 and available for patient use.

An interview was conducted on 11/2/23 at 11:22 AM with EI # 6 who confirmed the supplies were expired and available for patient use.


40119

3. A tour of the ED was conducted on 10/31/23 at 10:52 AM with EI # 5, ED Registered Nurse.

The surveyor observed five treatment beds within the ED and two overflow treatment beds located in the hallway leading to the ED with a door or curtain to close for privacy.

Beds 1, 2, and 5 inside the ED and the two overflow treatment beds were not visible from the nurses' station and contained no call lights or other method of alerting the staff for needs while a patient was being treated.

An interview was conducted on 11/2/23 at 11:36 AM with EI # 6, who confirmed there was no call lights or other methods of alerting the staff for needs while a patient was being treated.

Based on observations, review of hospital policy, CDC (Centers for Disease Control and Prevention) Hand Hygiene in Healthcare Setting - Hand Hygiene Guidance, CDC: Guidelines for the Prevention of IV (Intravenous) Catheter-Related Infections, CDC Medication Preparation Questions, CDC) and Prevention National Healthcare Safety Network (NHSN) Overview, and interviews, it was determined the hospital failed to ensure all requirements were met for the Infection Control program, and failed to ensure staff followed policies and procedures.

This had the potential to affect all patients served by the hospital.

Findings:

Refer to tags A 0748, A 0749, A 0750, A 0751, A 0761, A 0770, A 0773, A 0776, and A 0781.

Based on staff interview it was determined the hospital governing body failed to document the appointment of the Infection Preventionist to lead the Infection Control (IC) program.

This had the potential to affect all patients admitted to this hospital.

Findings include:

1. Review of the hospital IC program was conducted on 11/2/23 at 8:19 AM with Employee Identifier (EI) # 2, Chief Operations Officer. EI # 2 verbalized he/she was the Infection Preventionist for the hospital.

During the review, EI # 2 verbalized there was no documentation he/she was appointed by the governing body as the Infection Preventionist for the hospital.

Based on observations, review of hospital policy, CDC (Centers for Disease Control and Prevention) Hand Hygiene in Healthcare Setting - Hand Hygiene Guidance, CDC: Guidelines for the Prevention of IV (Intravenous) Catheter-Related Infections, CDC Medication Preparation Questions, and interviews, it was determined the facility failed to ensure the staff:

1. Performed hand hygiene per hospital policy and CDC guidance.

2. Scrubbed IV access ports with an antiseptic prior to administrating IV medications per CDC guidelines.

3. Maintained aseptic technique when preparing medication for administration, including disinfection of the medication rubber septum, and maintaining clean environment prior to administration.

This did affect six of ten patient care observations conducted including Patient Identifier (PI) # 31, PI # 21, unsampled patient (UP) # 1, UP # 2, and UP # 3.

This had the potential to negatively affect all patients served by this hospital.

Findings include:

Hospital Policy: Infection Control
Policy Number: 8260-001
Effective Date: 7/15

...The single best method to prevent the spread of infections is to wash your hands:

...Wash your hands...:

4. Between patient contact.
5. After handling contaminated objects...

CDC: Hand Hygiene in Healthcare Setting - Hand Hygiene Guidance
Date reviewed: 1/30/2020

...Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications:

Immediately before touching a patient.
...After touching a patient or the patient's immediate environment.
After contact with...contaminated surfaces.
Immediately after glove removal.

CDC: Guidelines for the Prevention of IV Catheter-Related Infections
Date: 2011

...Needleless IV Catheter Systems.

Recommendations:

...4. Minimize contamination risk by scrubbing the access port with an appropriate antiseptic (chlorhexidine, povidone iodine, an iodophor, or 70 % alcohol) and accessing the port only with sterile devices...

CDC: Medication Preparation Questions.
Date reviewed: 6/20/19

...Medication should be drawn up in a designated clean medication preparation area that is not adjacent to potential sources of contamination... to ensure that staff can adhere to aseptic technique... Parenteral medication should be accessed in an aseptic manner... Proper hand hygiene should be performed before handling medications and the rubber septum should be disinfected with alcohol prior to piercing it.

1. An observation was conducted on 10/31/23 at 10:36 AM with Employee Identifier (EI) # 11, Licensed Practical Nurse (LPN) and EI # 12, Registered Nurse (RN), to prepare and administer Venofer IV to PI # 31.

EI # 11 started the IV, removed his/her gloves, then retrieved extra supplies lying on the chairside table prior to performing hand hygiene. EI # 11 failed to perform hand hygiene immediately after removing gloves per CDC guidance.

EI # 12 then began preparing the IV Venofer. Wearing gloves, EI # 12 cleaned the septum of the IV Venofer and removed his/her gloves and re-applied gloves without performing hand hygiene.

An interview was conducted on 11/2/23 at 11:22 AM with EI # 6, Director of Nursing (DON), who confirmed the staff should perform hand hygiene after removing gloves.

2. An observation was conducted on 10/31/23 at 1:12 PM with EI # 5, Emergency Department (ED) RN, for the placement of an IV catheter on PI # 21.

EI # 5 removed gloves used for the placement of the IV catheter, exited then returned to the exam room without performing hand hygiene prior to exit or upon return, documented on a label for the laboratory tubes then applied gloves without performing hand hygiene.

An interview was conducted on 11/2/23 at 11:34 PM with EI # 6 who confirmed the staff failed to perform hand hygiene after removing gloves.

3. An observation was conducted on 10/31/23 at 3:14 PM with EI # 5, for the placement of a foley catheter on PI # 21.

EI # 5 removed gloves after opening the sterile field between the patient's legs, then donned sterile gloves without performing hand hygiene after removing gloves.

An interview was conducted on 11/2/23 at 11:36 PM with EI # 6 who confirmed the staff failed to perform hand hygiene after removing gloves.

4. An observation was conducted on 11/1/23 at 8:07 AM with EI # 4, RN, to observe oral and IV medication administration for UP # 1.

EI # 4 entered the medication room, verified medications on the computer then proceeded to withdraw medication from the pyxis without performing hand hygiene prior to handling medications.

After the patient's armband was scanned, EI # 4 removed gloves then donned gloves without performing hand hygiene after the removal of gloves.

EI # 4 removed cover of septum on Protonix medication vial, then punctured septum of without disinfecting the septum with alcohol.

An interview was conducted on 11/2/23 at 11:33 AM with EI # 6 who confirmed the staff failed to perform hand hygiene prior to preparing medications and after removing gloves. EI # 6 also confirmed the staff failed to disinfect septum of medication vial with alcohol prior to puncturing the septum.

5. An observation was conducted on 11/1/23 at 8:15 AM with EI # 13, RN, to observe oral medication administration and flushing of an IV Normal Saline (NS) Lock catheter to UP # 3 in room 107.

EI # 13 applied gloves, scanned the medications into the computer system, and removed his/her gloves and reapplied gloves without performing hand hygiene.

Lastly, EI # 13, obtained the NS flush syringe, applied gloves and flushed the IV catheter without scrubbing the access port with an antiseptic per CDC guidelines.

An interview was conducted on 11/2/23 at 11:22 AM with EI # 6 who confirmed the staff should perform hand hygiene after removing gloves. EI # 6 also stated the staff should clean the IV access port with alcohol prior to flushing the IV catheter.

6. An observation was conducted on 11/1/23 at 8:32 AM with EI # 3, RN, to observe oral medication administration, IV medication administration and a blood transfusion for UP # 2.

After obtaining medication and supplies from the medication room, EI # 3 placed the IV tubing package and Normal Saline 250 ml bag in the left pocket of uniform failing to maintain aseptic environment of the IV tubing package and Normal Saline bag.

EI # 3 entered the patient's room 114, then used signature pad of the computer, located on the computer shelf, for the caregiver and EI # 3 to sign for consent of blood administration. EI # 3 then donned gloves and proceeded to obtain the patient's vital signs without performing hand hygiene prior to direct contact with the patient.

EI # 3 removed and disposed of used blood bag and tubing then tied garbage bag closed, removed gloves, obtained clean pair of gloves and placed the clean pair of gloves in the right uniform pocket. EI # 3 failed to perform hand hygiene after removing gloves and obtaining clean supplies.

After starting the blood infusion, EI # 3 removed gloves, documented on the computer, then obtained Protonix medication vial from the computer drawer. EI # 3 failed to perform hand hygiene after removing gloves and prior to medication preparation.

EI # 3 then proceeded to don gloves without hand hygiene, administered oral medication, removed cover of septum on Protonix medication vial, and punctured the septum without disinfecting the septum with alcohol.

An interview was conducted on 11/2/23 at 11:30 AM with EI # 6 who confirmed the staff failed to perform hand hygiene prior to direct contact with the patient, prior to preparing medications and after removing gloves. EI # 6 also confirmed the staff failed to disinfect septum of medication vial with alcohol prior to puncturing the septum.

Based on the review of the hospital Infection Control (IC) program, hospital laboratory culture results, hospital policy and staff interviews the hospital failed to:

1. Observe, evaluate, and analyze infection control practices.

2. Perform surveillance, prevention, and control of all HAIs (healthcare-associated infections), to include non-catheter associated urinary tract infections, respiratory infections, non-MRSA (Methicillin-resistant Staphylococcus Aureus) blood infections, ENT (ear, nose, and throat) infections, eye infections, Gastrointestinal (GI) infections, wound infections, and skin infections.

This had the potential to negatively affect all patients admitted to the hospital.

Findings include:

Hospital Policy: Infection Control
Policy Number: 8260-001
Effective Date: 7/15

I. Goals. The goals of the Infection Control Program are to:

a. Decrease the risk of infections to patients...
b. Monitor for occurrence of infection and implement appropriate control measures.
c. Identify and correct problems relating to infection control practices.
d. Ensure compliance with state and federal regulations relating to infection control.

II. Scope of the Infection Control Program.

The major activities of the program are:

A. Surveillance of infections...There is on-going monitoring for infections among patients...and...subsequent documentation of infections that occur.

...IV. Reporting mechanisms for infection control.

...c. Compliance with Infection Control Practices is monitored and documented by:
1. Staff evaluation.
2. Observation of practices.

Infection Control Surveillance

Purpose: To conduct surveillance of HAIs to guide prevention activities.

Policy: The Infection Control Practitioner (ICP) conducts surveillance of infections among patients...

I. The ICP conducts surveillance of HAIs through:
a. Review of culture reports and other pertinent lab data.
b. Nurse consultation and referral.
c. Chart review.
d. Follow up on communicable disease exposure...
f. Physician consultation...

The following information contains...definitions of HAIs....

Symptomatic Urinary Tract Infection...Pneumonia... Laboratory- Confirmed Blood stream infection... Clinical Sepsis... Conjunctivitis... Eye, other than Conjunctivitis... Ear, Mastoid, Oral Cavity (mouth, tongue, or gums)... Sinusitis...Upper Respiratory Tract..., Gastroenteritis, GI Tract..., Hepatitis... Lower Respiratory Tract...Skin...Soft tissue...Decubitus Ulcer...Burn...

1. Review of the hospital IC program was conducted on 11/2/23 at 8:19 AM with Employee Identifier (EI) # 2, Chief Operations Officer.

The surveyor asked for the hospital IC staff observation documentation. EI # 2 verbalized the hospital has not performed any IC staff observations for 2023.

Review of the Safety Committee Meeting minutes, which included the IC program meetings, dated 1/12/23, 4/11/23, 8/15/23, and 10/5/23 revealed no documentation of infections reported for the hospital.

Review of the hospital QAPI (Quality Assessment and Performance Improvement) documentation for Quarter 1 and Quarter 2 revealed EI # 2 provided the "nosocomial rates" and "c-diff (Clostridioides Difficile) nosocomial rate" as zero. There was no documentation of infections reported for the hospital for Quarter 1 and Quarter 2.

There was no documentation of the infections reported, nosocomial or c-diff nosocomial rate for Quarter 3.

During the review, EI # 2 verbalized as the ICP for the hospital he/she provided surveillance of patient infections for CAUTI (catheter associated urinary tract infections), MRSA in the blood, and C-diff. EI # 2 confirmed no other infections were monitored through the hospital IC Program. EI # 2 verbalized she/he provided surveillance of patient CAUTI, MRSA in the blood, and C-diff infections, when informed by case management or nursing via email there was a positive culture or central line to determine if the information was HAI or community acquired. EI # 2 verbalized the case management did look at each culture results to ensure the correct antibiotic was used but there was no further surveillance of them, and they were not reported to her/him as the ICP.

Review of the laboratory inpatient culture results revealed the following:

For January 23 there were four positive wound cultures and one positive non-MRSA blood culture, with no documentation if the infection was a HAI or community acquired infection.

For February 23 there was one positive sputum culture and one positive wound culture, with no documentation if the infection was a HAI or community acquired infection.

For March 23 there was seven positive wound cultures, one positive sputum culture, one positive non-MRSA blood culture, with no documentation if the infection was a HAI or community acquired infection.

For April 23 there was one positive sputum culture and one positive wound culture, with no documentation if the infection was a HAI or community acquired infection.

For May 23 there was three positive wound cultures, two positive non-MRSA blood cultures, and one positive sputum culture, with no documentation if the infection was a HAI or community acquired infection.

For June 23 there was one positive non-MRSA blood culture and three positive wound cultures, with no documentation if the infection was a HAI or community acquired infection.

For July 23 there were two positive non-MRSA blood cultures, with no documentation if the infection was a HAI or community acquired infection.

For August 23 there were three positive wound cultures, one non-MRSA blood culture, and one GI positive culture, with no documentation if the infection was a HAI or community acquired infection.

For September 23 there was one positive skin culture, with no documentation if the infection was a HAI or community acquired infection.

For October 23 there was one positive wound culture, with no documentation if the infection was a HAI or community acquired infection.

An interview was conducted with EI # 2 on 11/2/23 at 11:45 AM who confirmed the above laboratory results were from case management and not entered into the hospital IC program.

Based on review of the hospital policy, Infection Control (IC) program, Centers for Disease Control (CDC) and Prevention National Healthcare Safety Network (NHSN) Overview, and staff interviews the facility failed to implement and maintain an active, organization-wide program for identifying, reporting, investigating, and controlling infections and communicable diseases which reflected the scope and complexity of the hospital services provided.

This had the potential to negatively affect all patients admitted to the hospital, staff, and visitors.

Findings include:

Hospital Policy: Infection Control
Policy Number: 8260-001
Effective Date: 7/15

I. Goals. The goals of the Infection Control Program are to:

a. Decrease the risk of infections to patients and personnel.
b. Monitor for occurrence of infection and implement appropriate control measures.
...d. Ensure compliance with state and federal regulations relating to infection control.

II. Scope of the Infection Control Program.

The major activities of the program are:

A. Surveillance of infections...There is on-going monitoring for infections among patients and personnel and...subsequent documentation of infections that occur.

...III. Division of responsibilities for IC activities.

...A. Responsibility is delegated to the IC Practitioner (ICP) to carry out the daily functions of the IC program...

B. IC Committee...meets on a regular basis and provides input and direction for the IC program... Reports of infections are presented to the committee which recommends actions and control measures when needed.

IV. Reporting mechanisms for infection control.

A. Patient infection cases are monitored by the ICP. The ICP completes the line listing of infections and the monthly report form and reports...to the IC committee...

B. Employee Infections are reported by the employee to the employee's supervisor, to the ICP or Employee Health Director. The ICP/Employee Health Director completes the employee infection report form and reports... To the IC committee...

Infection Control Surveillance

Purpose: To conduct surveillance of HAIs to guide prevention activities.

Policy: The Infection Control Practitioner (ICP) conducts surveillance of infections among patients and employees.

I. The ICP conducts surveillance of HAIs through:
a. Review of culture reports and other pertinent lab data.
b. Nurse consultation and referral.
c. Chart review.
d. Follow up on communicable disease exposure...
f. Physician consultation...

CDC NHSN Overview
Dated: 1/23

...Surveillance Techniques

...the IP (Infection Preventionist) and designees shall seek out infections/conditions by screening a variety of data sources, such as laboratory, pharmacy, admission/discharge/transfer, radiology/imaging...as well as patient charts, including history and physical exam notes, nurses'/physicians' notes, temperature charts...Laboratory-based surveillance should not be used alone, unless all possible criteria for identifying an infection are solely determined by laboratory evidence (for example...MDRO/CDI (Multidrug-Resistant Organism and Clostridium Difficile Infection)...

1. Review of the hospital IC program was conducted on 11/2/23 at 8:19 AM with Employee Identifier (EI) # 2, Chief Operations Officer. During the review, EI # 2 was asked for the documentation of the monthly reports prepared for the hospital IC Committee. EI # 2 verbalized he/she does not prepare monthly reports for the hospital IC committee. EI # 2 verbalized the IC committee meets during the safety committee meetings, where he/she gives a verbal report.

Review of the Safety Committee Meeting minutes, which included the IC program meetings, dated 1/12/23, 4/11/23, 8/15/23, and 10/5/23 revealed no documentation of patient and employee infections reported for the hospital.

Review of the hospital QAPI (Quality Assessment and Performance Improvement) documentation for Quarter 1 and Quarter 2 revealed EI # 2 provided the "nosocomial rates" and "c-diff (Clostridioides Difficile) nosocomial rate" as zero. There was no documentation of patient and employee infections reported for the hospital for Quarter 1 and Quarter 2.

During the review, EI # 2 verbalized as the ICP for the hospital he/she provided surveillance of patient infections for CAUTI (catheter associated urinary tract infections), MRSA in the blood, and C-diff. EI # 2 confirmed no other infections were monitored through the hospital IC Program, including employee infections. EI # 2 verbalized she/he provided surveillance of patient CAUTI, MRSA in the blood, and C-diff infections, when informed by case management or nursing via email there was a positive culture or central line.

Based on review of the hospital Infection Control (IC) and QAPI (Quality Assessment and Performance Improvement) Programs and staff interview the hospital failed to demonstrate coordination for antibiotic use and resistance with the hospital IC and QAPI Programs.

This had the potential to negatively affect all patients admitted to the hospital, staff, and visitors.

Findings include:

1. Review of the hospital IC program was conducted on 11/2/23 at 8:19 AM and hospital QAPI program on 11/2/23 at 8:42 AM with Employee Identifier (EI) # 2, Chief Operations Officer.

Review of the hospital IC and QAPI Programs revealed no documentation of the hospital Antimicrobial Stewardship Program, including antibiotic use and resistance.

An interview was conducted during the reviews with EI # 2 who confirmed there was no documentation of the hospital Antimicrobial Stewardship Program, including antibiotic use and resistance in the IC and QAPI programs.

Based on review of the hospital policy, Infection Control (IC) program, Centers for Disease Control (CDC) and Prevention National Healthcare Safety Network (NHSN) Overview, and staff interviews it was determined the governing body failed to ensure systems were in place and operational for the tracking of all infection surveillance, prevention, and control, and antibiotic use activities, in order to demonstrate the implementation, success, and sustainability of such activities.

This had the potential to negatively affect all patients served by this facility.

Findings include:

Hospital Policy: Infection Control
Policy Number: 8260-001
Effective Date: 7/15

I. Goals. The goals of the Infection Control Program are to:

a. Decrease the risk of infections to patients and personnel.
b. Monitor for occurrence of infection and implement appropriate control measures.
...d. Ensure compliance with state and federal regulations relating to infection control.

II. Scope of the Infection Control Program.

The major activities of the program are:

A. Surveillance of infections...There is on-going monitoring for infections among patients and personnel and...subsequent documentation of infections that occur.

...III. Division of responsibilities for IC activities.

...A. Responsibility is delegated to the IC Practitioner (ICP) to carry out the daily functions of the IC program...

B. IC Committee...meets on a regular basis and provides input and direction for the IC program... Reports of infections are presented to the committee which recommends actions and control measures when needed.

IV. Reporting mechanisms for infection control.

A. Patient infection cases are monitored by the ICP. The ICP completes the line listing of infections and the monthly report form and reports...to the IC committee...

B. Employee Infections are reported by the employee to the employee's supervisor, to the ICP or Employee Health Director. The ICP/Employee Health Director completes the employee infection report form and reports... To the IC committee...

Infection Control Surveillance

Purpose: To conduct surveillance of HAIs to guide prevention activities.

Policy: The Infection Control Practitioner (ICP) conducts surveillance of infections among patients and employees.

I. The ICP conducts surveillance of HAIs through:
a. Review of culture reports and other pertinent lab data.
b. Nurse consultation and referral.
c. Chart review.
d. Follow up on communicable disease exposure...
f. Physician consultation...

CDC NHSN Overview
Dated: 1/23

...Surveillance Techniques

...the IP (Infection Preventionist) and designees shall seek out infections/conditions by screening a variety of data sources, such as laboratory, pharmacy, admission/discharge/transfer, radiology/imaging...as well as patient charts, including history and physical exam notes, nurses'/physicians' notes, temperature charts...Laboratory-based surveillance should not be used alone, unless all possible criteria for identifying an infection are solely determined by laboratory evidence (for example...MDRO/CDI (Multidrug-Resistant Organism and Clostridium Difficile Infection)...

1. Review of the hospital IC program was conducted on 11/2/23 at 8:19 AM with Employee Identifier (EI) # 2, Chief Operations Officer. During the review, EI # 2 was asked for the documentation of the monthly reports prepared for the hospital IC Committee. EI # 2 verbalized he/she does not prepare monthly reports for the hospital IC committee. EI # 2 verbalized the IC committee meets during the safety committee meetings, where he/she gives a verbal report.

Review of the Safety Committee Meeting minutes, which included the IC program meetings, dated 1/12/23, 4/11/23, 8/15/23, and 10/5/23 revealed no documentation of patient and employee infections reported for the hospital.

Review of the hospital QAPI (Quality Assessment and Performance Improvement) documentation for Quarter 1 and Quarter 2 revealed EI # 2 provided the "nosocomial rates" and "c-diff (Clostridioides Difficile) nosocomial rate" as zero. There was no documentation of patient and employee infections reported for the hospital for Quarter 1 and Quarter 2.

During the review, EI # 2 verbalized as the ICP for the hospital he/she provided surveillance of patient infections for CAUTI (catheter associated urinary tract infections), MRSA in the blood, and C-diff. EI # 2 confirmed no other infections were monitored through the hospital IC Program, including employee infections. EI # 2 verbalized she/he provided surveillance of a patient infections, CAUTI, MRSA in the blood, and C-diff, when informed by case management or nursing via email there was a positive culture or central line.

Based on review of the hospital policy, Infection Control (IC) program, Centers for Disease Control (CDC) and Prevention National Healthcare Safety Network (NHSN) Overview, and staff interview it was determined the Infection Preventionist (IP) failed to document the infection prevention and control program and its surveillance, prevention and control activities.

This had the potential to negatively affect all patients admitted to the hospital, staff, and visitors.

Findings include:

Hospital Policy: Infection Control
Policy Number: 8260-001
Effective Date: 7/15

I. Goals. The goals of the Infection Control Program are to:

a. Decrease the risk of infections to patients and personnel.
b. Monitor for occurrence of infection and implement appropriate control measures.
...d. Ensure compliance with state and federal regulations relating to infection control.

II. Scope of the Infection Control Program.

The major activities of the program are:

A. Surveillance of infections...There is on-going monitoring for infections among patients and personnel and...subsequent documentation of infections that occur.

...III. Division of responsibilities for IC activities.

...A. Responsibility is delegated to the IC Practitioner (ICP) to carry out the daily functions of the IC program...

B. IC Committee...meets on a regular basis and provides input and direction for the IC program... Reports of infections are presented to the committee which recommends actions and control measures when needed.

IV. Reporting mechanisms for infection control.

A. Patient infection cases are monitored by the ICP. The ICP completes the line listing of infections and the monthly report form and reports...to the IC committee...

B. Employee Infections are reported by the employee to the employee's supervisor, to the ICP or Employee Health Director. The ICP/Employee Health Director completes the employee infection report form and reports... To the IC committee...

Infection Control Surveillance

Purpose: To conduct surveillance of HAIs to guide prevention activities.

Policy: The Infection Control Practitioner (ICP) conducts surveillance of infections among patients and employees.

I. The ICP conducts surveillance of HAIs through:
a. Review of culture reports and other pertinent lab data.
b. Nurse consultation and referral.
c. Chart review.
d. Follow up on communicable disease exposure...
f. Physician consultation...

CDC NHSN Overview
Dated: 1/23

...Surveillance Techniques

...the IP (Infection Preventionist) and designees shall seek out infections/conditions by screening a variety of data sources, such as laboratory, pharmacy, admission/discharge/transfer, radiology/imaging...as well as patient charts, including history and physical exam notes, nurses'/physicians' notes, temperature charts...Laboratory-based surveillance should not be used alone, unless all possible criteria for identifying an infection are solely determined by laboratory evidence (for example...MDRO/CDI (Multidrug-Resistant Organism and Clostridium Difficile Infection)...

1. Review of the hospital IC program was conducted on 11/2/23 at 8:19 AM with Employee Identifier (EI) # 2, Chief Operations Officer.

During the review, EI # 2 was asked for the documentation of the monthly reports prepared for the hospital IC Committee. EI # 2 verbalized he/she does not prepare monthly reports for the hospital IC committee. EI # 2 verbalized as the ICP for the hospital he/she documented the surveillance of patient infections for CAUTI (catheter associated urinary tract infections), MRSA in the blood, and C-diff. EI # 2 confirmed no other infections were monitored or documented through the hospital IC Program, including employee infections.

Based on review of the hospital policy and staff interview it was determined the Infection Preventionist (IP) failed to document the hospital personnel were audited for the adherence to infection prevention and control policies and procedures.

This had the potential to negatively affect all patients admitted to the hospital, staff, and visitors.

Findings include:

Hospital Policy: Infection Control
Policy Number: 8260-001
Effective Date: 7/15

I. Goals. The goals of the Infection Control Program are to:

...c. Identify and correct problems relating to infection control practices.
d. Ensure compliance with state and federal regulations relating to infection control.

...IV. Reporting mechanisms for infection control.

...c. Compliance with Infection Control Practices is monitored and documented by:

1. Staff evaluation.
2. Observation of practices.

1. Review of the hospital IC program was conducted on 11/2/23 at 8:19 AM with Employee Identifier (EI) # 2, Chief Operations Officer.

During the review, EI # 2 verbalized there was no documentation the hospital personnel were audited for the adherence to infection prevention and control policies and procedures in 2023.

Based on review of the facility Antibiotic Stewardship Program and staff interview the facility failed to document competency-based training and education of hospital personnel and staff, including medical staff, and, as applicable, personnel providing contracted services in the hospital, on the practical applications of antibiotic stewardship guidelines, policies, and procedures.

This had the potential to negatively affect all patients admitted to the hospital, staff, and visitors.

Findings include:

1. Review of the facility Antibiotic Stewardship Program (ASP) was conducted on 11/2/23 at 8:19 AM with Employee Identifier (EI) # 2, Chief Operations Officer.

During the review, EI # 2 was asked to provide documentation of the competency-based training and education of hospital personnel and staff, including medical staff, and, as applicable, personnel providing contracted services in the hospital, on the practical applications of antibiotic stewardship guidelines, policies, and procedures.

An interview was conducted on 11/2/23 at 11:45 AM with EI # 2 who confirmed there was no documentation the hospital personnel and staff, including medical staff, were provided education on the practical applications of antibiotic stewardship guidelines, policies, and procedures.