HospitalInspections.org

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Based on interview and review of the hospital's quality program, the hospital failed to create, implement, monitor, and evaluate effective performance improvement action plans for identified deficiencies identified by Root Cause Analysis for 3 of 3 Adverse Events reviewed.

Failure to develop and implement corrective action plans for identified problems and monitor for sustained improvement limits the hospital's ability to provide high quality clinical care and improve patient outcomes.

Findings included:

1. Document review of the hospital's Quality Plan titled, "Sentinel/Adverse Events", policy number 10525436, last reviewed 10/07/21, showed the following:

a. The Root Cause Analysis will be conducted and completed according to the timeline established by this policy.

b. If a corrective action plan is required, it must include:

i. How each finding will be addressed and corrected.

ii. When each correction will be completed.

iii. Who is responsible to make the corrections.

iv. What action will be taken to prevent the adverse health event from reoccurring.

v. A monitoring schedule to assess the effectiveness of the corrective action plan, including who is responsible for the monitoring schedule.

2. On 08/31/22 at 1:53 PM- 4:00 PM, Surveyor #7, the Quality Director (Staff#712) and the Quality manager (Staff #713) reviewed 3 Root Cause Analysis investigations conducted by the hospital.

3. Surveyor #7 found no evidence the hospital created and implemented a corrective action plan with measurable and quantifiable action items for each adverse event consistent with the findings of the root cause analysis reviewed.

4. At the time of the review Staff #712 and Staff #713 verified there was no reassessment process to ensure improvement was attained and sustained.
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Based on document review and interview, the hospital failed to measure and assess data related to medication management or administration related to wrong medication, wrong dose, wrong time, near misses and any other medication errors and incidents as part of its quality improvement program.

Failure to measure and assess data on medication error near misses as part of an overall quality program puts patients at risk of harm or death.

Findings included:

1. Record review of the hospital's quality program documents showed that there was no evidence to indicate that the hospital collected, reviewed, and analyzed patient medication errors and incidents.

2. On 09/01/22 at 1:56 PM, during the Quality meeting Surveyors #7 and #9 interviewed the Director of the Quality Program (Staff #712), who verified there were no dashboards for data collection, aggregation and dissemination, and no collection of data in the Quality Program that she could demonstrate related to medication errors and incidents. Staff #712 stated Pharmacy and Therapeutics reports to the medical executive committee, not Quality.
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Based on interview, document review, and review of hospital policies and procedures, the hospital failed to ensure that nursing staff members provided nursing care in accordance with the patient's health care needs.

Failure to follow hospital policy and procedure and recognized standards of care for nursing oversight for patient assessments, reassessment, evaluation, and treatment puts patients at risk for delayed treatment, inappropriate treatment, poor health care outcomes, or patient harm.

Findings included:

1. Failure to ensure that hospital staff members completed and documented an initial admission assessment.

2. Failure to ensure staff completed and documented a fall risk assessment.

3. Failure to ensure that inpatients receiving care in the location of the Emergency Room received a suicide risk assessment.

4. Failure to implement policies and procedures to ensure patients had a completed head to toe skin assessment with Skin Risk Assessment/Braden Risk Assessment on admission.

5. Failure to ensure admission nutritional screening/risk assessments were completed according to hospital policy.

6. Failure to ensure that staff performed and documented appropriate functional assessments on admission.

7. Failure to follow hospital policy for suicide risk reassessment.

8. Failure to complete and document shift reassessments for patients with changes in status.

9. Failure to ensure that staff performed and documented a complete Triage Assessment for all patient's admitted to the hospital's Emergency Room.

10. Failure to ensure hospital staff implemented and documented appropriate observational monitoring and enhanced precautions for patients assessed at high risk for suicide in the Emergency Center.

Cross Reference A0395

11. Failure to ensure staff members completed and documented pain assessments and reassessments for each pain management intervention.

12. Failure to ensure that medications were kept secure from unauthorized access.

13. Failure to ensure medications were not stored or available for patient use beyond the time they are stable outside packaging.

14. Failure to ensure patient's medications were returned to the patient or destroyed after the patient discharged as directed by hospital policy.

15. Failure to ensure that medications were labeled properly to show the medication name, strength, quantity, and expiration.

Cross Reference A0405

16. Failure to ensure hospital staff members performed transfusion services procedures according to hospital policy and procedure.

Cross Reference A0410

Due to the scope and severity of these deficiencies, the Condition of Participation at 42 CFR 482.23, Nursing Services was NOT MET

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Item #1 Admission Assessments

Based on interview and document review, the hospital failed to ensure that hospital staff members completed and documented an initial admission assessment for 7 of 8 patients reviewed (Patient #502, #503, #504, #505, #506, 507, and #508).

Failure to perform an initial admission assessment of the patient created risk that patients would not receive medical treatment appropriate to their care needs.

Findings included:

1. Document review of the Hospital's policy titled, "Assessment, Plan of Care, and Minimum Charting Standards," policy number 6921661, reviewed 10/07/19, showed the following:

a. Each patient admitted to an inpatient unit at Providence St Peter Hospital (PSPH) is assessed by a qualified individual. This assessment begins at the time of admission and continues throughout the patient's stay at PSPH. Assessment includes the collection and analysis of relevant physiological, psychological, and social/environmental data for each patient. This process is utilized to determine the need for additional information, the patient's care needs, priorities, and the patient's individualized care.

b. The Abbreviated Assessment is performed by a registered nurse (RN) immediately on arrival to the inpatient unit. The assessment includes the reason for admission, a brief physical evaluation, risk for falling, risk for dysphagia or aspiration and safety risk due to impulsive behaviors.

c. The Admission Assessment is completed by the RN within 2 hours of arrival to the unit. The assessment and plan of care will be documented by the RN within the timeframe indicated in the policy titled, "Minimum Charting Standards-Adult Units/Critical Care Unit/Pediatric Unit," and the policy titled, "Minimum Charting Standards-Maternal." The assessment includes, but is not limited to the following:

i. Vital Signs

ii. Allergies

iii. History

iv. Immunizations

v. Medication Reconciliation

vi. Advanced Directives.

vii. Patient Belongings

viii. Pain

ix. Nutrition

x. Swallow screen (Adults only)

xi. Activities of Daily Living Screening

xii. Psychosocial

xiii. Preferred language

xiv. Suicide Risk

xv. Sepsis Screening

xvi. Fall Risk

xvii. Delirium Screening (CAM/CAM-ICU)

xiii. Skin Risk Assessment including the Braden Scale

xix. Patient Profile (Including Substance Abuse and Spiritual and Cultural needs)

xx. Head to Toe Assessment

xxi. Discharge Planning

xxii. Height/Weight

xxiii. Learning Needs.

Document review of the Hospital's policy titled, "Nursing Documentation Guidelines During Contingency and Crisis Operations," policy number 10424415, revised 09/21/21, showed the following:

a. Providence remains committed to maintaining professional standards of practice in its care of patients. There may be times of exceptionally high patient census that requires flexible medical record documentation to enable staff to prioritize direct patient care.

b. The policy guidance is specific to documentation requirements and does not imply altering the frequency or the delivery of patient care activities.

c. Minimum standards for documentation when the Chief Nursing Officer has declared that the hospital or a specific unit is operation on crisis contingency standards include:

i. Admission Assessment (to include but not limited to allergies, fall risk. abuse/neglect, suicide screening, Braden skin risk, language, and pain).

ii. Lines, drains, airways, and wounds are documented upon insertion or presentation. Ongoing assessments and care occur, but only exceptions to care/assessment are documented.

iii. Changes to the patient's condition, communications to other heath care professionals, interventions, and patient response.

iv. Restraints, Suicidal Ideation, and 1:1 sitter must be completed per existing policies.

d. During contingency or crisis operations, other documentation may be minimized or eliminated such as:

i. Purposeful hourly rounding

ii. Comprehensive or focused shift assessments if there is no change to the patient's condition.

iii. Daily risk assessments if there is no change to the patient's condition.

Patient #502

2. On 08/23/22 from 2:45 PM to 3:45 PM, Surveyor #5, the Chief Nursing Officer (Staff #501), the Emergency Room Assistant Manager (Staff #506) and an Emergency Room Registered Nurse (RN) (Staff #505) reviewed the medical record for Patient #502. Patient #502 arrived at the Emergency Department on 08/22/22 at 12:25 PM via ambulance for the treatment of shortness of breath, edema, abdominal distention, and a pleural effusion. The patient had a history of a liver and kidney transplant. The patient was diagnosed in the ED with a Non-STEMI (heart attack). The review showed the following:

a. On 08/22/22 at 2:22 PM, the patient was admitted to the hospital. Although the patient was admitted under inpatient status, a bed was not available in the designated inpatient locations of the hospital, so the patient was receiving care in the location of the Emergency Department as an Inpatient.

b. The patient was receiving Bumex intravenously via a drip (a medication used to treat swelling and high blood pressure. This includes swelling as a result of heart failure, liver failure, or kidney problems).

c. The patient was receiving Dobutamine intravenously via a drip (a medication used in the treatment of cardiogenic shock and severe heart failure).

d. The patient had decreased oxygen levels but was unable to tolerate the BiPAP (a form of non-invasive mechanical pressure support ventilation that uses a time-cycled or flow-cycled change between two different applied levels of positive airway pressure) and Oxygen was increased 3 liters per nasal cannula. His oxygen saturations were 93%.

Surveyor #5 found no evidence a Registered nurse completed an admission assessment after the patient was admitted to the hospital (a period of 24 hours). Surveyor #5 found no evidence in the ED record that the patient was reassessed with any type of nursing assessment.

3. At the time of the review, Staff #505 verified that no Admission Assessment was documented in the medical record.

4. At the time of the review, Staff #506 verified that staff had not completed an Admission Assessment. She stated that the staff in the Emergency Department did not have access to any Inpatient Assessment and Documentation screens in the electronic health record (EHR). Staff #506 verified that Inpatient Standards of Practice and Standards of Care including screening tools and assessments would not be triggered in the EHR as ED staff do not have access to or education related to inpatient documentation.

Patient #503

5. On 08/23/22 at 4:00 PM, Surveyor #5, a Registered Nurse (Staff #507) and the Emergency Room Assistant Manager (Staff #506) reviewed the medical record for Patient #503 who was admitted to/ the hospital on 08/22/22 at 11:42 PM. The patient arrived at the hospital's Emergency room on 08/22/22 at 8:52 PM after a fall at home. The patient took blood thinning medication and had a history of a seizure disorder and a prior stroke. The patient was diagnosed in the Emergency Room with a fractured hip and a urinary tract infection. Although the patient was admitted under inpatient status, a bed was not available in the designated inpatient locations of the hospital, so the patient was receiving care in the location of the Emergency Department as an Inpatient.

Surveyor #5 found no evidence staff competed an initial assessment of the patient after the inpatient admission.

6. At the time of the finding, Staff #506 and #507 verified that the admission assessment was not completed. Staff #507 stated that there would be no inpatient assessments documented in any of the medical records for inpatients receiving care by Emergency Room nurses as the ED staff do not have access to complete in patient assessments.

Patient #504

7. On 08/24/22 at 9:30 AM, Surveyor #5, the Emergency Room Assistant Manager (Staff #506), and the Emergency Room Clinical Manager (Staff #508) reviewed the medical record for a Patient #504 who presented to the Emergency Room on 08/12/22 at 5:56 AM for the treatment of Suicidal Thoughts. The patient stated he wanted to die from Diabetic Keto Acidosis (DKA) and had had stopped taking his insulin as an attempt to die. The patient had a history of Type I Diabetes and multiple comorbid conditions including a leg amputation. The patient was held in the Emergency Room from 08/12/22 at 5:56 AM until 08/2022 at 6:01 AM when the patient was admitted under the "Single Bed Certification" status which allows a person to be detained under the mental health criteria of the Involuntary Treatment Act when there are no available certified Evaluation and Treatment (E&T) facility beds. Although the patient was admitted under inpatient status, a bed was not available in the designated inpatient locations of the hospital, so the patient was receiving care in the location of the Emergency Department as an Inpatient.

Surveyor #5 found no evidence staff completed an admission assessment.

8. At the time of the finding, Staff #506 and #508 verified the medical record did not show that an admission assessment of the patient had been completed.

Patient #505

9. On 08/24/22 at 11:11 AM, Surveyor #5, the Emergency Room Assistant Manager (Staff #506), and the Emergency Room Clinical Manager (Staff #508) reviewed the medical record for a Patient #505 who present to the Emergency Department on 08/09/22 at 2:41 PM for the treatment of agitation and homicidal intention. The patient had a history of Alzheimer's Dementia, a stroke, cardiomyopathy with an implanted pacemaker. The patient was admitted to the hospital on 08/11/22 at 8:41 AM. Although the patient was admitted under inpatient status, a bed was not available in the designated inpatient locations of the hospital, so the patient was receiving care in the location of the Emergency Department as an Inpatient.

Surveyor #5 found no evidence staff completed an admission assessment of the patient.

10. At the time of the review, Staff #506 and #508 confirmed that no admission assessment was documented.

Patient #506

11. On 08/25/22 at 3:50 PM, Surveyor #5, the Director of Behavioral Health (Staff #509) and a Registered Nurse (Staff #510) reviewed the medical record for Patient #506 who was admitted to Inpatient Psychiatric on 08/18/22 for the treatment of suicidal ideation with means and intent. On 08/19/22, the patient complained of a sore throat and was diagnosed with Covid-19 infection. The patent has a history of insulin dependent diabetes and was incontinent of urine and used adult briefs. The patient was in isolation at the time of the review. Document review of the admission assessment completed on 08/18/22 at 5:25 PM, showed that the area for documenting a systems assessment (respiratory, cardiovascular, skin, gastrointestinal, genitourinary, neurological, and etc.) was blank.

12. At the time of the review, Staff #510 stated that the nurses do not complete a system assessment for patients admitted for psychiatric care. She stated they only complete a Behavioral Health assessment daily.

Patient #507

13. On 08/30/22 at 10:00 AM, Surveyor #5, the Behavior Health Director (Staff #509), and a Registered Nurse (Staff #511) review the medical record for Patient #507. The patient was admitted to inpatient status on 03/05/22 for Parkinson's Disease Dementia. The patent was transferred to the medical overflow unit on 05/13/22 as a result of unsafe discharge.

Surveyor #5 found no evidence staff completed an admission assessment at the time of admission. On 03/08/22 at 11:19 PM, Surveyor #5 found a partially completed admission assessment. The fields that addressed cardiovascular, respiratory, gastrointestinal, genitourinary, nutrition, skin, and safety were blank. No additional admission assessment was completed on transfer to the overflow unit.

14. At the time of the review, Staff #511 verified the finding and stated the patient was not on their unit for admission.

15. On 08/26/22 at 1:00 PM, Surveyor #5 and a Registered Nurse (Staff #513) reviewed the medical record for Patient #508 who was admitted on 08/15/22 for the treatment of suicidal ideation with means, delusions, and homicidal intentions. The medical record review showed the patient had a history of sleep apnea. The record review showed that on 08/15/22 at 11:08 PM, the nursing assessment was partially completed and did not contain any physical assessment. The fields that addressed cardiovascular, respiratory, gastrointestinal, genitourinary, nutrition, skin, and safety were blank.

16. At the tine of the review, Staff #511 verified the missing documentation and stated that they don't complete the physical assessment.

17. On 08/26/22 at 8:15 AM, the Chief Nursing Officer (Staff #501) stated that on 09/21/21, the hospital had implemented the policy, "Nursing Documentation Guidelines During Contingency and Crisis Operations." The hospital had reviewed the hospital operation plan in 06/21 and the plan remains in effect. She stated that the hospital was not meeting the intent of the policy, which is to allow staff to document by exception and that staff were still required to complete admission assessments, focused assessments, and assessments on admit, and assessments when there is a change in condition.

Item #2 Fall Risk Assessment

Based on interview, record review, and review of policy and procedure, the hospital failed to ensure that patients admitted to the hospital received a Fall Risk Assessment on admission to the hospital for 6 of 6 patients reviewed (Patient #502, #503, #504, #505, #903, and #904).

Failure to perform a fall risk assessment appropriate to a patient's illness created risk that patients would not receive medical treatment appropriate to their care needs.

Findings included:

1. Document review of the Hospital's policy titled, "Assessment, Plan of Care, and Minimum Charting Standards," policy number 6921661, reviewed 10/07/19, showed the following:

a. Each patient admitted to an inpatient unit at Providence St Peter Hospital (PSPH) is assessed by a qualified individual. This assessment begins at the time of admission and continues throughout the patient's stay at PSPH. Assessment includes the collection and analysis of relevant physiological, psychological, and social/environmental data for each patient. This process is utilized to determine the need for additional information, the patient's care needs, priorities, and the patient's individualized care.

b. The Abbreviated Assessment is performed by a registered nurse (RN) immediately on arrival to the inpatient unit. The assessment includes the reason for admission, a brief physical evaluation, risk for falling, risk for dysphagia or aspiration and safety risk due to impulsive behaviors.

c. The Admission Assessment is completed by the RN within 2 hours of arrival to the unit. The assessment and plan of care will be documented by the RN within the timeframe indicated in the policy titled, "Minimum Charting Standards-Adult Units/Critical Care Unit/Pediatric Unit," and the policy titled, "Minimum Charting Standards-Maternal." The assessment includes, but is not limited to the following:

i. Falk Risk Assessment will be completed upon admission and documented within 2 hours, every shift, upon transfer between levels of care, with significant changes in patient condition, and after any procedural sedation or anesthesia administration.

Document review of the Hospital's policy titled, "Standards of Assessment and Care," policy number 5694631, last reviewed 12/14/18, showed the following:

a. As soon as possible, upon arrival, each patient presenting to the triage/advanced treatment area is evaluated by a Registered Nurse (RN) or Provider.

c. Assessments (portions of the assessment are performed once the patient is roomed) include a fall risk assessment for patient greater than or equal to 65 years of age, an altered mental status, decreased bone density and anticoagulation therapy.

Document review of the Hospital's policy titled, "Nursing Documentation Guidelines During Contingency and Crisis Operations," policy number 10424415, revised 09/21/21 showed the following:

a. Providence remains committed to maintaining professional standards of practice in its care of patients. There may be times of exceptionally high patient census that requires flexible medical record documentation to enable staff to prioritize direct patient care.

b. The policy guidance is specific to documentation requirements and does not imply altering the frequency or the delivery of patient care activities.

c. Minimum standards for documentation when the Chief Nursing Officer has declared that the hospital or a specific unit is operation on crisis contingency standards include:

i. Admission Assessment (to include but not limited to allergies, fall risk. abuse/neglect, suicide screening, Braden skin risk, language, and pain).

ii. Restraints, Suicidal Ideation, and 1:1 sitter must be completed per existing policies.

Patient #502

2. On 08/23/22 from 2:45 PM to 3:45 PM, Surveyor #5, the Chief Nursing Officer (Staff #501), the Emergency Room Assistant Manager (Staff #506) and an Emergency Room Registered Nurse (RN) (Staff #505) reviewed the medical record for Patient #502. Patient #502 arrived at the Emergency Department on 08/22/22 at 12:25 PM via ambulance for the treatment of shortness of breath, edema, abdominal distention, and a pleural effusion. The patient had a history of a liver and kidney transplant. The patient was diagnosed in the ED with a Non-STEMI (heart attack). The review showed the following:

a. On 08/22/22 at 2:22 PM, the patient was admitted to the hospital. Although the patient was admitted under inpatient status, a bed was not available in the designated inpatient locations of the hospital, so the patient was receiving care in the location of the Emergency Department as an Inpatient.

Surveyor #5 found no evidence a Registered nurse completed a Fall Risk Assessment at the time of admission.

3. At the time of the review, Staff #505 verified that no Fall Risk Assessment was documented in the medical record.

4. At the time of the review, Staff #506 verified that staff had not completed an Admission Assessment. She stated that the staff in the Emergency Department did not have access to any Inpatient Assessment and Documentation screens in the electronic health record (EHR). Staff #506 verified that Inpatient Standards of Practice and Standards of Care including screening tools and assessments would not be triggered in the EHR as ED staff do not have access to, or education related to inpatient documentation.

Patient #503

5. On 08/23/22 at 2:00 PM, Surveyor #5, a Registered Nurse (Staff #507) and the Emergency Room Assistant Manager (Staff #506) reviewed the medical record for Patient #503 who was admitted to/ the hospital on 08/22/22 at 11:42 PM. The patient arrived at the hospital's Emergency room on 08/22/22 at 8:52 PM after a fall at home. The patient took blood thinning medication and had a history of a seizure disorder and a prior stroke. The patient was diagnosed in the Emergency Room with a fractured hip and a urinary tract infection. Although the patient was admitted under inpatient status, a bed was not available in the designated inpatient locations of the hospital, so the patient was receiving care in the location of the Emergency Department as an Inpatient.

Surveyor #5 found no evidence staff competed an initial Fall Risk assessment of the patient after the inpatient admission.

6. At the time of the finding, Staff #506 and #507 verified that the admission assessment was not completed. Staff #507 stated that there would be no inpatient assessments documented in any of the medical records for inpatients receiving care by Emergency Room nurses as the ED staff do not have access to complete in patient assessments.

Patient #504

7. On 08/24/22 at 9:30 AM, Surveyor #5, the Emergency Room Assistant Manager (Staff #506), and the Emergency Room Clinical Manager (Staff #508) reviewed the medical record for a Patient #504 who presented to the Emergency Room on 08/12/22 at 5:56 AM for the treatment of Suicidal Thoughts. The patient stated he wanted to die from Diabetic Keto Acidosis (DKA) and had had stopped taking his insulin as an attempt to die. The patient had a history of Type I Diabetes and multiple comorbid conditions including a leg amputation. Although the patient was admitted under inpatient status, a bed was not available in the designated inpatient locations of the hospital, so the patient was receiving care in the location of the Emergency Department as an Inpatient.

Surveyor #5 found no evidence staff completed an initial Fall Risk Assessment on admission to the hospital.

8. At the time of the finding, Staff #506 and #508 verified the medical record did not show that a Fall Risk Assessment had been completed.

Patient #505

9. On 08/24/22 at 11:11 AM, Surveyor #5, the Emergency Room Assistant Manager (Staff #506), and the Emergency Room Clinical Manager (Staff #508) reviewed the medical record for a Patient #505 who present to the Emergency Department on 08/09/22 at 2:41 PM for the treatment of agitation and homicidal intention. The patient had a history of Alzheimer's Dementia, a stroke, cardiomyopathy with an implanted pacemaker. The patient was admitted to the hospital on 08/11/22 at 8:41 AM. Although the patient was admitted under inpatient status, a bed was not available in the designated inpatient locations of the hospital, so the patient was receiving care in the location of the Emergency Department as an Inpatient.

Surveyor #5 found no evidence staff completed an initial Fall Risk Assessment.

10. At the time of the review, Staff #506 and #508 confirmed that no Fall Risk Assessment was documented.

Patient #903

11. On 08/31/22 at 9:05 AM, Surveyor #9 and Clinical Documentation Specialist (Staff #914) and Perianesthesia Manager (Staff #903) reviewed the medical record of Patient #903 who presented on 08/14/22 to the Emergency Center for hip pain. The patient was 75 years old, had a history of hip surgery and was unable to move so called 911 to go to the EC. The review showed that the nursing staff failed to document a fall risk assessment.

12. At the time of the review, Staff #903 verified that there was no fall assessment documented.

Patient #904

13. On 08/31/22 at 10:30 AM, Surveyor #9 and Clinical Documentation Specialist (Staff #914) and Perianesthesia Manager (Staff #903) reviewed the medical record of Patient #904 who presented on 08/26/22 to the Emergency Center for leg pain. The patient was 56 years old, had a history of bilateral hip replacements completed on 07/26/22, and due to leg pain called 911 to go to the EC. The review showed that the nursing staff failed to document a fall risk assessment.

14. At the time of the review, Staff #903 verified that there was no fall assessment documented.

15. On 08/26/22 at 8:15 AM, the Chief Nursing Officer (Staff #501) stated that on 09/21/21, the hospital had implemented the policy, "Nursing Documentation Guidelines During Contingency and Crisis Operations." The hospital had reviewed the hospital operation plan in 06/21 and the plan remains in effect. She stated that the hospital was not meeting the intent of the policy, which is to allow staff to document by exception and that staff were still required to complete admission assessments, focused assessments, and assessments on admit, and assessments when there is a change in condition.

Item #3- Suicide Assessment

Based on interview, record review, and review of policy and procedure, the hospital failed to ensure that inpatients receiving care in the location of the Emergency Room received a suicide risk assessment as directed by hospital policy and procedure for 4 of 4 medical records reviewed (Patient #502, #503, #504, and #505).

Failure to perform a suicide risk assessment, risks that patients would not receive medical treatment appropriate to their care needs.

Findings included:

1. Document review of the Hospital's policy titled, "Assessment, Plan of Care, and Minimum Charting Standards," policy number 6921661, reviewed 10/07/19, showed the following:

a. The Admission Assessment is completed by the RN within 2 hours of arrival to the unit. The assessment and plan of care will be documented by the RN within the timeframe indicated in the policy titled, "Minimum Charting Standards-Adult Units/Critical Care Unit/Pediatric Unit," and the policy titled, "Minimum Charting Standards-Maternal." The assessment includes, but is not limited to the following:

i. Psychosocial assessment and Suicide Risk will be assessed with 2 hours admission and documented within 8 hours of admission.

Document review of the Hospital's policy titled, "Nursing Documentation Guidelines During Contingency and Crisis Operations," policy number 10424415, revised 09/21/21 showed the following:

a. Minimum standards for documentation when the Chief Nursing Officer has declared that the hospital or a specific unit is operation on crisis contingency standards include:

i. Admission Assessment (to include but not limited to allergies, fall risk. abuse/neglect, suicide screening, Braden skin risk, language, and pain).

ii. Restraints, Suicidal Ideation, and 1:1 sitter must be completed per existing policies.

Patient #502

2. On 08/23/22 from 2:45 PM to 3:45 PM, Surveyor #5, the Chief Nursing Officer (Staff #501), the Emergency Room Assistant Manager (Staff #506) and an Emergency Room Registered Nurse (RN) (Staff #505) reviewed the medical record for Patient #502. The review showed the following:

a. On 08/22/22 at 2:22 PM, the patient was admitted to the hospital. Although the patient was admitted under inpatient status, a bed was not available in the designated inpatient locations of the hospital, so the patient was receiving care in the location of the Emergency Department as an Inpatient.

Surveyor #5 found no evidence a Registered nurse completed a Suicide Risk Assessment at the time of admission.

3. At the time of the review, Staff #505 verified that no Suicide Risk Assessment was documented in the medical record.

4. At the time of the review, Staff #506 verified that staff had not completed an Admission Assessment. She stated that the staff in the Emergency Department did not have access to any Inpatient Assessment and Documentation screens in the electronic health record (EHR). Staff #506 verified that Inpatient Standards of Practice and Standards of Care including screening tools and assessments would not be triggered in the EHR as ED staff do not have access to, or education related to inpatient documentation.

Patient #503

5. On 08/23/22 at 2:00 PM, Surveyor #5, a Registered Nurse (Staff #507) and the Emergency Room Assistant Manager (Staff #506) reviewed the medical record for Patient #503 who was admitted to the hospital on 08/22/22 at 11:42 PM. The patient arrived at the hospital's Emergency room on 08/22/22 at 8:52 PM after a fall at home. Although the patient was admitted under inpatient status, a bed was not available in the designated inpatient locations of the hospital, so the patient was receiving care in the location of the Emergency Department as an Inpatient.

Surveyor #5 found no evidence staff competed an initial Suicide Risk assessment after the inpatient admission.

6. At the time of the finding, Staff #506 and #507 verified that the admission assessment including any risk assessments was not completed. Staff #507 stated that there would be no inpatient assessments documented in any of the medical records for inpatients receiving care by Emergency Room nurses as the ED staff do not have access to complete in patient assessments.

Patient #504

7. On 08/24/22 at 9:30 AM, Surveyor #5, the Emergency Room Assistant Manager (Staff #506), and the Emergency Room Clinical Manager (Staff #508) reviewed the medical record for a Patient #504 who presented to the Emergency Room on 08/12/22 at 5:56 AM for the treatment of Suicidal Thoughts. The patient had a history of Type I Diabetes and multiple comorbid conditions including a leg amputation. Although the patient was admitted under inpatient status, a bed was not available in the designated inpatient locations of the hospital, so the patient was receiving care in the location of the Emergency Department as an Inpatient.

Surveyor #5 found no evidence staff completed an initial Suicide Risk Assessment on admission to the hospital.

8. At the time of the finding, Staff #506 and #508 verified the medical record did not show that a Suicide Risk Assessment had been completed.

Patient #505

9. On 08/24/22 at 11:11 AM, Surveyor #5, the Emergency Room Assistant Manager (Staff #506), and the Emergency Room Clinical Manager (Staff #508) reviewed the medical record for a Patient #505 who present to the Emergency Department on 08/09/22 at 2:41 PM for the treatment of agitation and homicidal intention. The patient was admitted to the hospital on 08/11/22 at 8:41 AM. Although the patient was admitted under inpatient status, a bed was not available in the designated inpatient locations of the hospital, so the patient was receiving care in the location of the Emergency Department as an Inpatient.

Surveyor #5 found no evidence staff completed an initial Suicide Risk Assessment.

10. At the time of the review, Staff #506 and #508 confirmed that no Suicide Risk Assessment was documented.

11. On 08/26/22 at 8:15 AM, the Chief Nursing Officer (Staff #501) stated that on 09/21/21, the hospital had implemented the policy, "Nursing Documentation Guidelines During Contingency and Crisis Operations." The hospital had reviewed the hospital operation plan in 06/21 and the plan remains in effect. She stated that the hospital was not meeting the intent of the policy, which is to allow staff to document by exception and that staff were still required to complete admission assessments, focused assessments, and assessments when there is a change in condition.

Item #4 Skin Assessments

Based on interview and document review, the hospital failed to implement its policies and procedures to ensure patients had a completed head to toe skin assessment with Skin Risk Assessment/Braden Risk Assessment on admission for 4 of 4 patients reviewed (Patient #502, #503, #504, and #505).

Failure to complete skin assessments according to policy puts patients at risk for skin breakdown.

Findings included:

1. Document review of the Hospital's policy titled, "Assessment, Plan of Care, and Minimum Charting Standards," policy number 6921661, reviewed 10/07/19, showed the following:

a. The Abbreviated Assessment is performed by a registered nurse (RN) immediately on arrival to the inpatient unit. The assessment includes the reason for admission, a brief physical evaluation, risk for falling, risk for dysphagia or aspiration and safety risk due to impulsive behaviors.

b. The Admission Assessment is completed by the RN within 2 hours of arrival to the unit. The assessment and plan of care will be documented by the RN within the timeframe indicated in the policy titled, "Minimum Charting Standards-Adult Units/Critical Care Unit/Pediatric Unit," and the policy titled, "Minimum Charting Standards-Maternal." The assessment includes, but is not limited to the following:

i. Skin including a Braden Skin Scale will be assessed on admission and documented within 8 hours, every shift, and prior to transfer to another unit.

Document review of the Hospital's policy titled, "Nursing Documentation Guidelines During Contingency and Crisis Operations," policy number 10424415, revised 09/21/21 showed the following:

a. Providence remains committed to maintaining professional standards of practice in its care of patients. There may be times of exceptionally high patient census that requires flexible medical record documentation to enable staff to prioritize direct patient care.

b. The policy guidance is specific to documentation requirements and does not imply altering the frequency or the delivery of patient care activities.

c. Minimum standards for documentation when the Chief Nursing Officer has declared that the hospital or a specific unit is operation on crisis contingency standards include:

i. Admission Assessment (to include but not limited to allergies, fall risk. abuse/neglect, suicide screening, Braden skin risk, language, and pain).

Patient #502

2. On 08/23/22 from 2:45 PM to 3:45 PM, Surveyor #5, the Chief Nursing Officer (Staff #501), the Emergency Room Assistant Manager (Staff #506) and an Emergency

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Item #1 Develop and Implement an Individualized Plan of Care

Based on interview, document review, and review of policies and procedures, the hospital failed to develop and implement an individualized plan of care for 5 of 5 patients reviewed (Patient #502, #503, #504, #505, and #507).

Failure to develop and implement an individualized plan of care can result in the inappropriate, inconsistent, or delayed treatment of patient's needs and may lead to patient harm and lack of appropriate treatment for a medical condition.

Findings included:

1. Document review of the Hospital's policy titled, "Assessment, Plan of Care, and Minimum Charting Standards," policy number 6921661, reviewed 10/07/19, showed the following:

a. Each patient admitted to an inpatient unit at Providence St Peter Hospital (PSPH) is assessed by a qualified individual. This assessment begins at the time of admission and continues throughout the patient's stay at PSPH. Assessment includes the collection and analysis of relevant physiological, psychological, and social/environmental data for each patient. This process is utilized to determine the need for additional information, the patient's care needs, priorities, and the patient's individualized care.

b. The RN develops and implements an individualized plan of care utilizing information obtained from the admission assessment. Individualization includes but is not limited to the following:

1. Patient need, expectations, and goals.

ii. Age specific concerns.

iii. Safety issues or concerns.

iv. Language preference and use of interpretive services.

v. Discharge Plan.

vi. Interventions by all disciplines involved in care.

c. based on assessment of needs, consult with the provider or ancillary service referrals (e.g., Physical Therapy, Occupational Therapy, Speech, Wound/Ostomy Care, Spiritual Care, Care Coordination, Interpretive Services, and Pharmacy.

d. All patient data collected is documented and available to all disciplines involved to provide the mores comprehensive plan of care.

Document review of the Hospital's policy titled, "Nursing Documentation Guidelines During Contingency and Crisis Operations," policy number 10424415, revised 09/21/21 showed the following:

a. Providence remains committed to maintaining professional standards of practice in its care of patients. There may be times of exceptionally high patient census that requires flexible medical record documentation to enable staff to prioritize direct patient care.

b. The policy guidance is specific to documentation requirements and does not imply altering the frequency or the delivery of patient care activities.

c. Minimum standards for documentation when the Chief Nursing Officer has declared that the hospital or a specific unit is operation on crisis contingency standards include:

i. Changes to the patient's condition, communication to other health care professionals, interventions, and patient response.

ii. Planned/expected outcomes as measurable goals as part of the collaborative plan of care.

d. During contingency or crisis operations, other documentation may be minimized or eliminated such as:

i. Purposeful hourly rounding

ii. Comprehensive or focused shift assessments if there is no change to the patient's condition.

iii. Daily risk assessments if there is no change to the patient's condition.

Patient #502

2. On 08/23/22 from 2:45 PM to 3:45 PM, Surveyor #5, the Chief Nursing Officer (Staff #501), the Emergency Room Assistant Manager (Staff #506) and an Emergency Room Registered Nurse (RN) (Staff #505) reviewed the medical record for Patient #502. Patient #502 arrived at the Emergency Department on 08/22/22 at 12:25 PM via ambulance for the treatment of shortness of breath, edema, abdominal distention, and a pleural effusion. The patient had a history of a liver and kidney transplant. The patient was diagnosed in the ED with a Non-STEMI (heart attack). The review showed the following:

a. On 08/22/22 at 2:22 PM, the patient was admitted to the hospital. Although the patient was admitted under inpatient status, a bed was not available in the designated inpatient locations of the hospital, so the patient was receiving care in the location of the Emergency Department as an Inpatient.

b. The patient was receiving Bumex intravenously via a drip (a medication used to treat swelling and high blood pressure. This includes swelling as a result of heart failure, liver failure, or kidney problems).

c. The patient was receiving Dobutamine intravenously via a drip (a medication used in the treatment of cardiogenic shock and severe heart failure).

d. The patient had decreased oxygen levels but was unable to tolerate the BiPAP (a form of non-invasive mechanical pressure support ventilation that uses a time-cycled or flow-cycled change between two different applied levels of positive airway pressure) and Oxygen was increased 3 liters per nasal cannula. His oxygen saturations were 93%.

Surveyor #5 found no evidence a Registered nurse developed or implement an individualized Plan of Care.

3. At the time of the review, Staff #505 verified that no Plan of Care was documented in the medical record.

4. At the time of the review, Staff #506 verified that staff had not completed a Plan of Care. She stated that the staff in the Emergency Department did not have access to any Inpatient Assessment and Documentation screens in the electronic health record (EHR). Staff #506 verified that Inpatient Standards of Practice and Standards of Care including screening tools and assessments would not be triggered in the EHR as ED staff do not have access to, or education related to inpatient documentation.

Patient #503

5. On 08/23/22 at 2:00 PM, Surveyor #5, a Registered Nurse (Staff #507) and the Emergency Room Assistant Manager (Staff #506) reviewed the medical record for Patient #503 who was admitted to/ the hospital on 08/22/22 at 11:42 PM. The patient arrived at the hospital's Emergency room on 08/22/22 at 8:52 PM after a fall at home. The patient took blood thinning medication and had a history of a seizure disorder and a prior stroke. The patient was diagnosed in the Emergency Room with a fractured hip and a urinary tract infection. Although the patient was admitted under inpatient status, a bed was not available in the designated inpatient locations of the hospital, so the patient was receiving care in the location of the Emergency Department as an Inpatient.

Surveyor #5 found no evidence staff completed a Plan of Care for the patient after the inpatient admission.

6. At the time of the finding, Staff #506 and #507 verified that a Care Plan was not completed. Staff #507 stated that there would be no inpatient documentation documented in any of the medical records for inpatients receiving care by Emergency Room nurses as the ED staff do not have access to complete inpatient assessments.

Patient #504

7. On 08/24/22 at 9:30 AM, Surveyor #5, the Emergency Room Assistant Manager (Staff #506), and the Emergency Room Clinical Manager (Staff #508) reviewed the medical record for a Patient #504 who presented to the Emergency Room on 08/12/22 at 5:56 AM for the treatment of Suicidal Thoughts. The patient stated he wanted to die from Diabetic Keto Acidosis (DKA) and had had stopped taking his insulin as an attempt to die. The patient had a history of Type I Diabetes and multiple comorbid conditions including a leg amputation. The patient was held in the Emergency Room from 08/12/22 at 5:56 AM until 08/20/22 at 6:01 AM when the patient was admitted under the "Single Bed Certification" status (this allows a person to be detained under the mental health criteria of the Involuntary Treatment Act when there are no available certified Evaluation and Treatment (E&T) facility beds. Although the patient was admitted under inpatient status, a bed was not available in the designated inpatient locations of the hospital, so the patient was receiving care in the location of the Emergency Department as an Inpatient.

Surveyor #5 found no evidence staff completed a Plan of Care

8. At the time of the finding, Staff #506 and #508 verified the medical record did not show that a Plan of Care had been completed.

Patient #505

9. On 08/24/22 at 11:11 AM, Surveyor #5, the Emergency Room Assistant Manager (Staff #506), and the Emergency Room Clinical Manager (Staff #508) reviewed the medical record for a Patient #505 who presented to the Emergency Department on 08/09/22 at 2:41 PM for the treatment of agitation and homicidal intention. The patient had a history of Alzheimer's Dementia, a stroke, cardiomyopathy with an implanted pacemaker. The patient was admitted to the hospital on 08/11/22 at 8:41 AM. Although the patient was admitted under inpatient status, a bed was not available in the designated inpatient locations of the hospital, so the patient was receiving care in the location of the Emergency Department as an Inpatient.

Surveyor #5 found no evidence staff completed a Plan of Care for the patient.

10. At the time of the review, Staff #506 and #508 confirmed that no Plan of Care had been developed or implemented.

Patient #507

11. On 08/30/22 at 10:00 AM, Surveyor #5, a Registered Nurse (Staff #511), and a Licensed Practical Nurse (Staff #512), reviewed the medical record for Patient #507. The patient was admitted to inpatient status on 03/05/22 for Parkinson's Disease Dementia. The patent was transferred to the medical overflow unit on 05/13/22 as a result of unsafe discharge. On 03/06/22 the patient was assessed at high risk for falls. On 08/30/22 at 9:55 AM, Surveyor #5 observed the patient #507 crawling out of the bed. Surveyor #5 observed that all 4 of the bed side rails were up. Surveyor #5 observed the patient exit the bed over the bottom foot board of the bed and then use a wheel walker to exit the room.

Surveyor #5 found no evidence that staff developed or implemented a Plan of Care or addresses the patient fall safety concerns

12. At the time of the review, Staff #511 verified that the patient had all 4 side rails up and climbed out the bottom of the bed to exit the bed. Staff #511 verified that the care plan had not been developed.

13. Staff #512 stated that they did not use Care Plans for these patients.

Item #2 Review and Revise the Plan of Care

Based on interview, and document review the hospital failed to ensure staff members reviewed and revised the patient's care plan to reflect changes in the patient condition as demonstrated in 3 of 3 patient records reviewed (Patient #506, #508, and #513).

Failure to develop an individualized nursing care plan and to evaluate and revise the plan as necessary can result in the inappropriate, inconsistent, or delayed treatment of patient's needs.

Findings included:

1. Document review of the Hospital's policy titled, "Assessment, Plan of Care, and Minimum Charting Standards," policy number 6921661, reviewed 10/07/19, showed the following:

a. Each patient admitted to an inpatient unit at Providence St Peter Hospital (PSPH) is assessed by a qualified individual. This assessment begins at the time of admission and continues throughout the patient's stay at PSPH. Assessment includes the collection and analysis of relevant physiological, psychological, and social/environmental data for each patient. This process is utilized to determine the need for additional information, the patient's care needs, priorities, and the patient's individualized care.

b. Any change in patient condition requires an immediate assessment with the changes in the plan of care reflecting the change in condition.

c. The RN updates the plan of care at least once per shift and as indicated by the patient's condition and status.

d. All patient data collected is documented and available to all disciplines involved to provide the mores comprehensive plan of care.

Document review of the Hospital's policy titled, "Nursing Documentation Guidelines During Contingency and Crisis Operations," policy number 10424415, revised 09/21/21 showed the following:

a. Providence remains committed to maintaining professional standards of practice in its care of patients. There may be times of exceptionally high patient census that requires flexible medical record documentation to enable staff to prioritize direct patient care.

b. The policy guidance is specific to documentation requirements and does not imply altering the frequency or the delivery of patient care activities.

c. Minimum standards for documentation when the Chief Nursing Officer has declared that the hospital or a specific unit is operation on crisis contingency standards include:

i. Changes to the patient's condition, communication to other health care professionals, interventions, and patient response.

ii. Planned/expected outcomes as measurable goals as part of the collaborative plan of care.

Patient #506

2. On 08/25/22 at 3:50 PM, Surveyor #5, the Director of Behavioral Health (Staff #509) and a Registered Nurse (Staff #510) reviewed the medical record for Patient #506 who was admitted to Inpatient Psychiatric on 08/18/22 for the treatment of suicidal ideation with means and intent. On 08/19/22, the patient complained of a sore throat and was diagnosed with Covid-19 infection. The patent has a history of insulin dependent diabetes and was incontinent of urine and used adult briefs. The patient was in isolation at the time of the review. Document review showed that the Care Plan was not updated with changes in patient condition and did not include infection with Covid, isolation precautions, shortness of breath or a care related to her incontinence.

3. At the time of the review, Staff #510 verified that the plan of care had not been updated.

Patient #508

4. On 08/26/22 at 1:00 PM, Surveyor #5 and a Registered Nurse (Staff #513) reviewed the medical record for Patient #508 who was admitted on 08/15/22 for the treatment of suicidal ideation with means, delusions, and homicidal intentions. The medical record review showed the patient had a history of sleep apnea. The record review showed that the patient was due for a Treatment Plan update on 08/23/22. Surveyor #5 found no evidence the Treatment Plan was updated at the time of the review. Surveyor #5 found no evidence that the Care plan was updated to include alteration in respiratory.

5. At the time of the review, Staff #511 verified the missing documentation and stated that she would follow up on the treatment team meeting to update the Treatment Plan.

Patient #513

6. On 08/30/22 at 11:09 AM, Surveyor #5 and a Registered Nurse (Staff #511) reviewed the medical record for Patient #513 who was admitted to the medical overflow department for the treatment of a MRSA wound infection in the hand. The review showed the patient had a surgical debridement and a provider was changing the dressings.

Surveyor #5 found no evidence that the care plan was updated to address the patient's wound, wound infection, or care and treatment.

7. At the time of the review, Staff #513 verified that the care plan did not include the patients wound.
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Item #1 Assess and Monitoring of Patients receiving Pain Medication

Based on interview, record review, and review of policy and procedure, the hospital failed to ensure staff members completed and documented pain assessments and reassessments for each pain management intervention for 5 of 8 patient records reviewed (Patient #901, #902, #903, #904, and Patient #911).

Failure to assess and reassess a patient's pain risks inconsistent, inadequate, or delayed relief of pain and risks patient harm related to delayed recognition of adverse effects of pain medication.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Assessment, Plan of Care, and Minimum Charting Standards," policy number 6921661, last reviewed 10/19, showed that pain assessment is to be assessed and documented before and after pain interventions.

Document review of the hospital's policy and procedure titled, "Pain Management," policy number 5588032, last reviewed 11/18, shows the following:

a. The patient's self-report is the single most reliable indicator of pain.

b. Implement appropriate interventions when pain is identified, and an intervention deemed necessary.

c. Perform assessments to identify effectiveness of interventions. Assessment is done and a pain rating documented within an appropriate timeframe.

Document review of the hospital's policy and procedure titled, "Standards of Assessment and Care," policy number 5694631, last reviewed 12/18, shows the following:

a. Before administration of pain medication, pain status and vital signs shall be documented.

b. A reassessment post administration of pain medications including vital signs and pain score shall be documented within 2 hours of administration.

2. On 08/23/22 at 2:30 PM, Surveyor #5, the Chief Nursing Officer (Staff #501), the Emergency Room Director (Staff #502) and an Emergency Room Registered Nurse (RN) (Staff #504) reviewed the medical record for Patient #501, a 67-year-old patient who arrived at the Emergency Room on 08/23/22 at 10:37 AM, via ambulance after falling backward off a curb in his wheelchair and suffering a rib injury. On 08/23/22 1:21 PM, the patient received 2 mg of hydromorphone (an opioid used to treat moderate to severe pain). Surveyor #5 found no evidence that a pain assessment was completed prior to pain medication administration.

At the time of the review, Staff #504 verified the medical record did not contain a pain assessment and stated that the nurse should have documented a pain assessment prior to medicating the patient.

3. On 08/24/22 at 11:00 AM, Surveyor #9 and Quality Improvement Registered Nurse (Staff #904 and Assistant Nurse Manager (Staff #913) reviewed the medical record of Patient #901 who was admitted for an endarterectomy (removal of the inner lining of an artery). The review showed the following:

a. On 08/22/22 at 10:08 PM, the patient received Hydrocodone-acetaminophen (a narcotic pain medication) 5-325 milligrams orally. At that time, there was no pain score documented.

b. On 08/22/22 at 11:08 PM, there is documentation of "pain reduction" and no pain score.

c. On 08/22/22 at 11:53 PM, the patient received Morphine (a narcotic pain medication) 1 milligram intravenously for a pain score of 8. No pain reassessment is documented.

d. On 08/23/22 at 2:11 AM, the patient received Morphine 2 milligrams intravenously for a pain score of 8. At 2:51 AM, there is documentation of "pain reduction" and no pain score.

e. On 08/23/22 at 4:45 AM, the patient received Morphine 2 milligrams intravenously for a pain score of 9. At 5:23 AM, there is documentation of "pain reduction" and no pain score.

4. At the time of the review, Staff #913 verified the documentation in the medical record.

5. On 08/24/22 at 11:00 AM, Surveyor #9 and Quality Improvement Registered Nurse (Staff #904) and Assistant Nurse Manager (Staff #913) reviewed the medical record of Patient #902 who was admitted for treatment of hypertension high blood pressure) and pelvic pain. The review showed the following:

a. On 08/23/22 at 5:10 PM, the patient received Oxycodone (a narcotic pain medication) 5 milligrams orally for a pain score of 9. A pain score of 7 is documented at 7:17 PM.

b. On 08/23/22 at 11:12 PM, the patient received Oxycodone 5 milligrams orally for a pain score of 7. There is no documentation of a reassessment.

c. On 08/24/22 at 7:45 AM, the patient received Oxycodone 5 milligrams orally. There is no documentation of a pain assessment prior to administration. There is documentation of a pain score of 6 at 8:45 AM.

6. At the time of the review, Staff #913 verified the documentation in the medical record.

7. On 08/25/22 at 2:30 PM, Surveyor #9 and Clinical Manager (Staff #916) reviewed the medical record of Patient #911 who was admitted for treatment of Diverticulitis (an infection of inflammation in the digestive tract). The review showed the following:

a. On 08/22/22 at 10:03 AM, the patient received Oxycodone (a narcotic pain medication) 5 milligrams orally. There is no documentation of a pain assessment prior to administration.

b. On 08/23/22 at 6:44 AM, the patient received Oxycodone 5 milligrams orally. There is no documentation of a pain assessment prior to administration.

c. On 08/23/22 at 11:07 AM, the patient received Oxycodone 5 milligrams orally. There is no documentation of a pain assessment prior to administration.

8. At the time of the review, Staff #916 verified the documentation in the medical record.

9. On 08/31/22 at 9:05 AM, Surveyor #9 and Clinical Documentation Specialist (Staff #914) and Perianesthesia Manager (Staff #903) reviewed the medical record of Patient #903 who was seen in the Emergency Center for hip pain. The review showed on 08/14/22 at 9:39 PM, the patient received Oxycodone (a narcotic pain medication) 5 milligrams orally. There is no pain assessment documented prior to administration. There was no pain reassessment documented.

10. At the time of the review, Staff #903 verified the documentation in the medical record.

11. On 08/31/22 at 10:30 AM, Surveyor #9 and Clinical Documentation Specialist (Staff #914) and Perianesthesia Manager (Staff #903) reviewed the medical record of Patient #904 who was seen in the Emergency Center for leg pain. The record showed the following:

a. On 08/26/22 at 7:25 PM, the patient received Hydrocodone-acetaminophen (a narcotic pain medication) 5-325 milligrams 2 tablets orally for a pain score of 7. There is no documentation of a reassessment.

b. On 08/27/22 at 1:10 AM, the patient received Morphine (a narcotic pain medication) 4 milligrams intravenously. There is no documentation of a pain assessment prior to administration.

12. At the time of the review, Staff #903 verified the documentation in the medical record.

Item #2 Un-secure medications

Based on observation, interview, and review of hospital policy and procedures, the hospital failed to ensure that medications were kept secure from unauthorized access.

Failure to secure medications risks potential diversion, medication errors, and patient safety.

Findings included:

1. Document review of the hospital's policy titled "Storage and Security of Medications," policy number 10633907, last reviewed 04/06/22 shows the following:

a. Secure medication areas include clean utilities, storage rooms, procedural rooms, surgical suits, and other areas approved by the Pharmacy Director for storage of medications.

b. When the area is not in active use, the area is not considered secure unless all medications are locked.

2. On 08/25/22 at 10:08 AM, Surveyor #7 and a Quality Specialist (Staff #701) toured the Outpatient Infusion area. Surveyor #7 observed an Armstrong medication cart that was unlocked and contained the following medications:

a. 1 vial of 1% Xylocaine 20 mg/2 ml.

b. 1 vial of 1% Lidocaine 50 mg/5 ml.

c. 4 vials of Sterile water 20 ml.

d. 1 vial of Sterile water 10 ml.

3. Surveyor #7 interviewed a Registered Nurse (Staff #702), who stated the cart should be locked but that the lock was broken and there were no parts available to fix it.

4. At the time of the observation Staff #701 and #702 verified the medications were unsecured and should be locked.

5. On 08/25/22 at 2:02 PM, Surveyor #7, Staff #701, and a Quality Specialist (Staff #703), toured the Clinical Observation Unit Emergency (COU EMG) in the Emily Gamlin Pavilion. Surveyor #7 observed a partial bag of Unasyn, an antibiotic, draining in the public sink outside the medication room.

6. Surveyor #7 interviewed a Registered Nurse (Staff #704) who stated that is where they empty partial bags since there is no sink in the medication room.

7. At the time of the observation Staff #701, #703 and #704 verified there was unsecured medication draining from the bag into the public area sink.

Item #3 Expired Medications

Based on observation, interview, and document review, the hospital failed to ensure medications were not stored or available for patient use beyond the time they are stable outside packaging.

Failure to ensure medication storage areas are devoid of outdated, or otherwise unusable medications, places patients at risk for receiving medications with compromised sterility, integrity, stability, or efficacy.

Findings included:

1. Document review of the hospital's policy titled, "PYXIS System for Medications," policy number 10790779, revised 01/14/22 showed that on a monthly basis, outdated (expired) or short-dated medications shall be removed from the Medication station using the Outdated Inventory Report and Outdate Icon in Pyxis (automated medication dispensing system) that tracks expiraton dates for medications in PYXIS. Additionally, as a quality check, monthly random checks for outdates shall be made by Pharmacy Technicians or Pharmacy Interns in MedStations.

2. On 08/23/22 at 11:30 AM, Surveyor #5, the Chief Nursing Officer (Staff #501), the Director of the Emergency Department (Staff #502) and a Quality Registered Nurse (RN) (Staff #503) inspected the hospital's Emergency Department. The inspection showed 2 bottles of 4% Lidocaine located in the Difficult Intubation Cart with a manufacturer's expiration date of 08/01/22.

At the time of the finding, Staff #502 and #503 confirmed the expired medication and removed the medication from the patient care area.

3. On 08/23/22 at 11:45 AM, Surveyor #5 and the Emergency Room Director (Staff #502) inspected the Emergency Department AB Pod West medication room. Inspection of the medication refrigerator showed a bottle of "Magic Mouthwash" (a solution of diphenhydramine, lidocaine, aluminum, and magnesium) used to treat mouth sores that result from cancer treatment, oral thrush, viral infections, bacterial infections, and autoimmune disease. The bottle was labeled "expired in 14 days." The bottle showed that the medication was prepared by pharmacy on 06/23/22 and expired on 07/07/22.

4. At the time of the finding, Staff #502 verified the expiration date and removed the medication from the patient care area.

5. On 08/25/22 at 11:00 AM, Surveyor #7, the Manager of the Continuous Observation Unit (COU) (Staff #709) and an assistant Nurse manager (Staff #710) toured the COU. Observation showed 7 - 125 mg syringes of Vancomycin oral solution in the Pyxis for use that had expired on 08/24/22.

6. At the time of the observation staff #709 and #710 verified the medication was expired and should not be in the Pyxis ready for use.

Item #4 Patient own Medications.

Based on observation, interview and document review, the hospital failed to ensure patient's medications were returned to the patient or destroyed after the patient discharged.

Failure to ensure medications are returned to the patient or destroyed after discharge increases medical cost to patients and risks potential diversion.

Findings included:

1. Document review of the hospital policy titled "Patients Own Medication," policy number 5623112, last reviewed 05/09/19, showed:

a. Patients own medications should be destroyed once the patient has left the facility and reasonable attempts have been made to contact the patient or the patient's representative to return the medications have failed.

b. Nursing will appropriately dispose of all medications stored beyond 90 days from the date of patients discharge.

2. On 08/23/22 at 1:55 PM, Surveyor #7, a Quality Specialist (Staff #701) and the Manager of the Intensive Care unit (ICU) (Staff #705), toured the 2nd floor ICU. Surveyor #7 observed 3 different sealed packs of patient own medications in a locked cabinet. Identified as follows:

a. The first package was labeled with a sticker for Patient #702, an inventory slip that identified the medications as Oxycodone, Trazadone and Tizanidine, and a note that read, "Called, left message on 10/18/21."

b. The second package was labeled with a sticker for Patient #703 and a note that read, "Pick up 10/19/21."

c. The third package was labeled with a sticker for Patent #704 and a note that read, "Called 01/04/22."

3. At the time of the observation Staff #701 and #705 verified the 3 different packages of patient medications should have been returned or disposed of by this time.

Item #5 Medication Labeling

Based on observation, interview and document review, the hospital failed to ensure that medications were labeled properly to show the medication name, strength, quantity and expiration.

Failure to ensure that medication management quality processes for medication preparation and management are implemented places patients at risk for serious harm or death.

Findings included:

1. Document review of the hospital's policy titled "Medication Labeling," policy number 9085404, last reviewed 02/22, shows the following:

a. All medications that are removed from their original container and are not administered immediately or will be used over the course of a procedure or surgery must be labeled at the time the medication is transferred.

b. The medication must be labeled with the following:

i. Medication name, strength, and amount.

ii. Expiration date when not used within 24 hours.

iii. Expiration time when the expiration occurs in less than 24 hours.

2. Document review of the hospital's policy titled "Abbreviations-Dangerous Abbreviations and Symbols, policy number 8769853, last reviewed 12/20, shows the following:

a. The list of dangerous abbreviations and symbols will be reviewed and posted at least annually.

b. "U" or "u" is an unacceptable abbreviation as it is frequently mistaken for the number zero or the number four.

c. Write out the word "unit."

2. On 08/23/22 at 3:45 PM, Surveyor #9 and Quality Improvement Manager (Staff #902) and Cardiac Catheterization Lab Manager (Staff #910) inspected the Cardiac Catheterization Lab. In a procedure room, Surveyor #9 observed one 1000 milliliter bag of intravenous 0.9 Sodium Chloride solution with an orange medication label with "H 2000" written in black marker.

3. At the time of the observation, Surveyor #9 interviewed Staff #910 regarding the medication label. Staff #910 verified the writing "H 2000" on the label and stated that the medication is Heparin and is used during the procedure.

4. In another procedure room, Surveyor #9 observed two 1000 milliliter bags of intravenous 0.9 Sodium Chloride solution with an orange medication label with "Hep 2000U 8/22 1617" written on the label.

5. At the time of the observation, Staff #910 verified the writing on the medication label.
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Based on interview and document review, hospital staff failed to follow its policy and procedure for blood product transfusions for 2 of 3 patient records reviewed (Patient #509, #510, and #511).

Failure to follow blood transfusion procedures according to acceptable standards of practice places patients at risk for transfusion reactions and complications.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Blood and Blood Components," policy number 11691228, revised 05/05/22, showed the following:

a. The transfusionist must verify with another qualified individual that all the information on the Transfusion Report (bag tag) are in complete agreement with the product label and the patent identification band.

b. Dual signoff may not be available in Epic for the Anesthesia providers and verification is documented in the notes section of the Anesthesia Navigator.

c. Obtain baseline vital signs, then check vital signs at 15 minutes after the start of the transfusion, at the discretion of the Registered Nurse (RN) and at the completion of the transfusion.

d. Upon completion of the transfusion the nurse is to complete the documentation in EPIC.

Patient #509

2. On 08/30/22 at 3:00 PM, Surveyor #5 and a Quality RN (Staff #514), reviewed the medical record for Patient #509. Who received 2 units of red blood cells on 05/23/22 and 1 unit of red blood cells on 05/24/22. The review showed the following:

a. Unit #1: The unit completed transfusion at 8:44 PM. The section of the transfusion record to document a suspected transfusion reaction or no reaction was blank.

b. Unit #2: The vital signs taken at completion of the transfusion on 05/24/22 at 12:50 AM, were incomplete and did not include a temperature.

c. Unit #3: No final vital signs were documented when the transfusion was completed. The section of the transfusion record to document a suspected transfusion reaction or no reaction was blank.

3. At the time of the review, Staff #514 confirmed the finding and stated that it was hospital policy to complete vital signs and document in the reaction section of the transfusion record.

Patient #510

4. On 08/31/22 at 9:20 AM, Surveyor #5 and a Quality Registered Nurse (RN) (Staff #514), reviewed the medical record for Patient #510 who received 2 Units of red blood cells and 1 Unit of Plasma on 05/19/22. The review showed the following:

a. On 05/19/22 at 3:11 PM, the first unit of red blood cells was started in the operating room.

Surveyor #5 found no evidence that bedside verification of the patient and the blood product was completed prior to transfusion. The Anesthesia Navigator section of the medical record was blank.

b. On 05/19/22 at 6:53 PM the second unit of red cells was started.

Surveyor #5 found no evidence that bedside verification of the patient and the blood product was completed prior to transfusion. The Anesthesia Navigator section of the medical record was blank.

c. On 05/19/22 at 10:37 PM, a unit of Plasma was started. The transfusion ended on 05/20/22 at 1:15 AM.

Surveyor #5 found no evidence staff documented vital signs 15 minutes after the transfusion was started or at the completion of the transfusion.

5. At the time of the review, Staff #514 stated that staff should document vital signs at 15 minutes and the completion of the transfusion. She stated she was not familiar with the Anesthesiology documentation and called to have Anesthesiology assist with the review.

6. At 10:50 AM, an Anesthesiologist (Staff #515) came to assist with the review. Staff #515 verified that the medical record did not reflect the units were verified by 2 licensed staff prior to administration. Staff #515 verified that Anesthesia Navigator was blank and stated that this was the section of the medical record where blood transfusions should be documented.

Patient #511

7. On 08/31/22 at 9:20 AM, Surveyor #5 and a Quality Registered Nurse (RN) (Staff #514) reviewed the medical record for Patient #511 who received 2 Units of Platelets on 02/11/22. The review showed the following:

a. Unit #2 was started on 02/11/22 at 3:10 PM. The transfusion was stopped on 02/11/22 at 5:30 PM when the patient developed a suspected transfusion reaction.

b. On 02/11/22 at 3:10 PM, the patient's respiratory rate was 22 breaths per minute. At 3:19 PM, the patient's respiratory rate was 36. At 5:30 PM the patient's respiratory rate was 44.

Surveyor #5 found no evidence staff obtained a temperature 15 minutes after the transfusion was started. Surveyor #5 found no evidence staff obtained a temperature or an oxygen saturation level when the transfusion was stopped, and a transfusion reaction was suspected.

8. At the time of the review, Staff #514 verified the medical record did not reflect complete transfusion documentation.
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Based on interview and document review, facilities staff failed to properly maintain medical equipment and laboratory equipment by failing to properly implement an alternate equipment maintenance program, conduct preventative maintenance at required intervals, and certify laboratory hoods at required frequencies.

Failure to properly manage the physical environment by properly maintaining equipment risks patient or staff injury.

Findings included:

1. The hospital failed to properly implement and manage its alternate equipment maintenance program for medical equipment by failing to evaluate the effectiveness of the program.

Cross Reference: A0724

2. The hospital failed to ensure that items placed on an alternate equipment maintenance program had maintenance activities conducted at specified intervals.

Cross Reference: A0724

3. The hospital failed to ensure that items not eligible for an alternate equipment maintenance were not placed on the program.

Cross Reference: A0724

4. The hospital failed to ensure that laboratory hoods were certified at required intervals.

Cross Reference: A0724

5. The hospital failed to ensure that all equipment was inventoried and had documentation of electrical checks before being placed into service.

Cross Reference: A0724

6. The hospital failed to ensure that patient care supplies were maintained to ensure an acceptable level of safety and quality by ensuring expired items were not available for use.

Cross Reference: A0724

7. Failure to develop and implement a process to ensure that positive air pressure respirators (PAPR's) were maintained according to manufacturer's instructions for use.

Cross Reference: A0724

Due to the scope and severity of deficiencies cited under §42 CFR 482.41, the Condition of Participation for Physical Environment was NOT MET.


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Item #1 Alternate Equipment Maintenance Program Management and Evaluation

Based on observation, interview, and document review, the hospital failed to ensure that it properly managed biomedical equipment placed on an alternate equipment maintenance (AEM) schedule based on policy and standards of practice.

Failure to ensure that an alternate equipment maintenance program is properly implemented risks an ineffective program and biomedical equipment that might not properly function leading to patient or staff injury or death.

Findings included:

1. Record review of the hospital document titled, "2022 Medical Equipment Management Plan, Southwest Washington Service Area," reviewed 01/22, showed the following:

a. The hospital identifies all equipment and associated activities and maintenance frequencies. The activities will either be based on manufacturer's instructions for use or an AEM program. The AEM program must be based on an acceptable standard of practice. The policy mentions an example of an acceptable standard (the American National Standards Institute/Association for the Advancement of Medical Instrumentation ANSI/AAMI EQ56: 2013, Recommended Practice for a Medical Equipment Management Program) but did not formally mention which standard is utilized.

b. All equipment on an AEM program must have 100% completion as determined by the program frequencies.

c. All high-risk equipment as well as radiation producing, ultrasound, last, and new types of equipment which have no service history within or outside the hospital is completed as recommended by the manufacturer. Non-high-risk equipment can be reassessed after one year for inclusion in the AEM program.

d. Maintenance history includes records provided by contractors, information made public by nationally recognized sources, or records of the hospital's experience over time.

e. A qualified individual uses written criteria, such as how the equipment is used, consequences of equipment failures, availability of backup equipment, incident history of identical or similar equipment, and equipment maintenance requirements to determine if equipment can be maintained in an alternative manner.

f. The Medical Equipment Management Plan does not provide any criteria for evaluating the AEM program to ensure that it is functioning properly, and that equipment placed on an AEM schedule is functioning properly and is not in need of being placed on manufacturer's recommended maintenance frequencies. The plan does indicate that records from the hospital's experience over time should be used for evaluating maintenance history.

2. Record review of an attachment to the Medical Equipment Management Plan titled, "Biomedical Equipment Risk Assessment," showed that three categories were used to evaluate medical equipment risk and determine maintenance frequencies if placed on an AEM program: Physical Risk, Function, and Failure Rate. The document stated that any items that scored four or fewer points would not need to have preventative maintenance performed. Items with a score of five or more would need to follow an escalating frequency (4-8 points annually, 8-11 points semiannually, >11 points quarterly).

3. Record review of the list of all medical equipment on an AEM program showed that 2056 items out of 2087 scored a total risk score of five or more, which would require them needing annual maintenance according to the current policy. A risk assessment from 2005 was provided that indicated any items that scored more than "7" would need annual preventative maintenance.

4. Record review of the risk assessment for a laryngoscope (asset # KN85874) showed that the approval of the device type for AEM was completed in 02/12/09.

Record review of the risk assessment for an OmniLab continuous positive pressure airway unit (asset # 68727) showed that this item time was placed on an AEM program on 08/09/05.

4. On 08/30/22 at 10:20 AM, Surveyor #8 and Surveyor #17 interviewed the Director of Clinical Technology Services (Staff #1701) about the hospital AEM program. The interview showed the following:

a. Staff #1701 stated that when new medical equipment is inventoried, it is assigned a risk category based on a risk assessment. After the risk assessment is assigned, the device can be placed on an AEM depending on what risk category is assigned.

b. The surveyors asked Staff #1701 if there is a routine review of the AEM program or assessment of quality control data to determine if the program is properly functioning and if items may need to be moved to a different maintenance frequency. Staff #1701 stated they recently took over management of the clinical engineering department and did not think here had been any analysis of the AEM program or collection of quality control data.

c. Staff #1701 stated that the Medical Equipment Management Plan was approved and updated prior to her starting the role and that there was no process to determine if the AEM program needed to be reevaluated when the risk classification changed. Staff #1701 provided an additional risk assessment with different criteria (dated 2005) from the one in the approved management plan.

d. Staff #1701 acknowledged that some items had AEM approvals completed more than a decade ago and was unclear if there was any reevaluation or quality assessment to determine if these approvals should be reevaluated or updated.

5. Record Review of the document titled, "2021 Medical Equipment Management Plan Annual Evaluation," did not show any review of the AEM program or data to indicate that all items on the program received 100% of required maintenance activities as required by policy.

6. Record review of the Environment of Care Committee meeting minutes for 06/04/21, 08/06/21, 10/01/21, 12/03/21, 02/04/22, 04/01/22, and 06/03/22 showed that no preventative maintenance or AEM data was reviewed at any of the meetings. During the 06/04/21 meeting, the committee discussed AEM reporting. The minutes indicate that further discussion would happen, and the committee would "need to get our arms around" the process and "this is a long list and needs to be fully understood going in." No further discussion was mentioned in subsequent minutes.

7. On 08/31/22 at 11:45 AM, Surveyor #8 and Surveyor #17 interviewed the Facilities Manager (Staff #1703) and the Regional Director for Environment of Care (Staff #1704) about the hospital AEM program. The Regional Director stated that the assessment that the AEM program needed to have more evaluation to ensure that it is functioning properly, and it is following policy and industry standards "could be correct". She stated that the discussion in the 06/04/21 minutes was due to some findings at another Providence hospital and that a review was suggested to decern the flow of the program. The Facilities Manager acknowledge that there was room for improvement in the AEM program and that it had fallen out of focus due to changes in leadership in that department.

Item #2 Preventative Maintenance Activities
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Based on record review and interview the hospital failed to ensure that items placed on an Alternate Equipment Maintenance (AEM) schedule were completed as required by hospital policy or the designated interval in the AEM program.

Failure to complete preventative maintenance as required risks ineffective medical equipment that could cause delays in patient care, increased risk of injury, or death.

Findings included:

1. Record review of the hospital policy titled, "Record review of the hospital document titled, "2022 Medical Equipment Management Plan, Southwest Washington Service Area," reviewed 01/22, showed that scheduled maintenance activities for high-risk and non-high-risk medical equipment on an AEM program must have a completion rate of 100% as determined by the program. A risk assessment template attached showed that any item with a score greater than "4" would need to have annual preventative maintenance.

2. Record review of the preventative maintenance (PM) history for an Anesthesia Physiological Multiparameter Monitor (Asset # 61072-18) showed that the item was on a thirty-six-month PM. The AEM criteria indicated that manufacturer's instructions should be followed. Review of the service history showed that the last work order was closed on 02/01/19, with no new maintenance activities documented since then, a period of greater than 36 months.

3. Record review of the preventative maintenance (PM) history for a Laryngoscope (asset KN85874-18) showed that no preventative maintenance had been conducted. The item was scored an "8" on the intake risk assessment.

4. Record review of the preventative maintenance history for an Anesthesia Vaporizer (Asset KN17243H) showed that this item was a life critical item. The AEM risk category states that the item scored "11" and that the PM is conducted with the anesthesia machine maintenance. There was no indication as to which anesthesia machine the vaporizer was attached. Five other vaporizers were on the same AEM program and did not have data indicating what machine to which the vaporizers were attached. Review of the PM records for anesthesia machines in West Surgery (the are where the vaporizers were assigned) showed that the mechanisms were serviced at the defined intervals, but the records did not indicate which vaporizers were attached to each machine. The surveyors could not resolve when the hospital completed preventative maintenance for each specific vaporizer.

4. On 08/30/22 at 10:20 AM, Surveyor #8 and Surveyor #17 interviewed the Director of Clinical Technology Services (Staff #1701) about the hospital AEM program and preventative maintenance. Staff #1701 confirmed that the risk assessment in the Medical Equipment Management Plan was the current approved plan, but also provided an older risk assessment document that had been previously used (revised 2005). This risk assessment indicated that any items with a score over "7" required annual PM. Staff #1701 confirmed that the laryngoscope would be outside of the required PM frequency based on either of the risk assessments.

5. On 08/30/22 at 11:00 AM, Surveyor #8, Surveyor #17, and Staff #1701 reviewed the inventory and maintenance history of biomedical equipment with a Facilities Administrative Assistant (Staff #1702). Staff #1702 accessed the inventory and maintenance history of the above items and confirmed that they had not had PM done per policy. They also confirmed that the anesthesia vaporizers did not have record of the specific machine to which they were attached.

6. At the same time, a clinical engineer (Staff #1705) attempted to find the machines to which the vaporizers were attached. Staff #1705 was able to find this information.

Item #3 Items on Alternate Equipment Maintenance that should be excluded from program

Based on record review and interview, the hospital failed to ensure that items that that should be excluded from alternate equipment maintenance (AEM) programs were not included on the hospital's AEM program.

Failure to ensure that items that are not eligible to be on an AEM risks inadequate function of items that are not maintained as required that could lead to patient or staff injury.

Findings included:

1. Record review of the hospital document titled, "2022 Medical Equipment Management Plan, Southwest Washington Service Area," reviewed 01/22, showed that radiation producing, ultrasound, last, and new types of equipment which have no service history within or outside the hospital is completed as recommended by the manufacture or more stringent requirements. Non-high-risk equipment can be reassessed after one year for inclusion in the AEM program.

2. Record review of the list of items on an AEM program showed that bladder scanners, which are an ultrasound device, were included on the program.

3. On 08/30/22 at 11:00 AM, Surveyor #8, Surveyor #17, and the Director of Clinical Technology Services (Staff #1701) reviewed the list of AEM items with a Facilities Administrative Assistant (Staff #1702). During the review, Staff #1701 and #1702 confirmed that the items on the list were on an AEM program.

4. Record review of the AEM risk assessment for a pulmonary function testing treadmill (asset # SS54385) showed that the risk assessment was conducted on 11/10/18. The placement of the device on an AEM with no PM required was done on 11/19/18. No documentation of any evaluation for the next year for this item to confirm that it could be placed on an AEM was available.

5. On 08/30/22 at 10:20 AM, Surveyor #8 and Surveyor #17 interviewed the Director of Clinical Technology Services (Staff #1701) about the hospital AEM program and preventative maintenance. Surveyors asked Staff #1701 about risk assessments and how it was determined that an item could be placed on an AEM. Staff #1701 stated that the previous manager had made those determinations and that she has not had to determine any new equipment for an AEM since starting the position. Staff #1701 stated that she did not know of any evaluation of the AEM program or its effectiveness for items recently put on an AEM.

Item #4 Laboratory Hood Certification
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Based on observation, document review, and interview, the hospital failed to implement policies and procedures to assure laboratory fume hoods received annual maintenance.

Failure to perform annual maintenance on equipment places staff at increased risk of exposure to airborne emissions from chemicals, biological samples, and analytical processes.

Findings included:

1. Document review of the hospital's document titled, "Equipment Function Checks (Timers, Centrifuges, Analytical Balances, Fume Hoods, & Non-Certified Thermometers) Chemistry Providence St. Peter Hospital Olympia Washington ", document number in lower corner; 3.1.0027, no review date. This document showed that fume hood maintenance will be performed annually.

2. On 08/26/22 between 1:30 PM and 1:45 PM, Inspector #8 toured the hospital laboratory with Laboratory Technician #1 (Staff # 802), Laboratory Technician #2 (Staff # 803), and Quality Improvement Project Manager (Staff #804). During the tour 6 laboratory hoods were inspected and stickers on the hoods contained the below dates showing most recent date tested for hood certification:

Hood Number/Serial Number: 030156772G Date Tested: 06/17/21
Hood Number/Serial Number: 177611122017 Date Tested: 06/17/21
Hood Number/Serial Number: 030256977J Date Tested: 06/17/21
Hood Number/Serial Number: 122604 Date Tested: Not legible
Hood Number/Serial Number: 122522 Date Tested: 06/17/21
Hood Number/Serial Number: 02105415461 Date Tested: 06/17/21

3. On 08/26/22 at 1:50 PM Inspector #8 interviewed Staff #802 and Staff #803 and they confirmed the preventative maintenance annual requirement date for all 6 hoods had been missed and that a testing date for the hoods had been scheduled for September 2022.

Item #5 Equipment Inventory

Based on observation and document review, the hospital failed to ensure that all equipment used in the facility was inventoried into the medical equipment database.

Failure to ensure that all equipment is inventoried risks patient injury from equipment that might be ill functioning or not calibrated per requirements.

Findings included:

1. On 08/23/22 between the hours of 9:30 AM and 11:30 AM, Surveyor #1 and the central sterile technician manager (Staff # 113) observed 1 of 3 enzymatic dispensing pumps in the central sterile department that did not have a facility asset tag. Surveyor #1 requested the preventive maintenance for all 3 enzymatic dispensing pumps.

2. On 08/23/22 between the hours of 3:30 PM and 4:30 PM the surveyor was provided with documentation which indicated 2 of 3 enzymatic pumps were initially checked in 2018 but no documentation on the third enzymatic pump. The document indicated no preventive maintenance required, equipment is placed on an alternate equipment program.
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Item #6 Patient Care Supply Management

Based on interview and observation, the hospital failed to develop and implement a quality control system to prevent the use of patient care supplies that exceeded the manufacturer's expiration date.

Failure to monitor and establish a systematic process for ensuring patient care supplies do not exceed the manufacturer's expiration date risks deteriorated or potentially contaminated supplies being available for patient care.

Findings included:

1. On 08/26/22 at 08:00 AM, Surveyor #9 interviewed Survey Support Manager (Staff #907) regarding a policy to address expired supplies. Staff #906 stated that there is not a specific policy regarding expired supplies.

2. On 08/23/22 at 10:12 AM, Surveyor #5, the Chief Nursing Officer (Staff #501), the Director of the Emergency Department (Staff #502) and a Quality Registered Nurse (RN) (Staff #503) inspected the hospital's Emergency Department. The inspection showed the following:

Supply Cart in Triage

a. (2) Fisher Collection and Transport Swabs with a manufacturer's expiration date of 10/12/21.

b. (1) Fisher Collection and Transport Swab with a manufacturer's expiration date of 04/03/22.

Supply Cart near Triage Room 5

a. (1) Fisher Collection and Transport Swab with a manufacturer's expiration date of 10/16/20.

b. (1) Fisher Collection and Transport Swab with a manufacturer's expiration date of 10/23/20.

c. (1) 24-gauge intravenous catheter with a manufacturer's expiration date of 03/31/21.

d. (1) 22-gauge intravenous catheter with a manufacturer's expiration date of 05/31/21.

e. (1) 22-gauge intravenous catheter with a manufacturer's expiration date of 05/31/21.

f. (1) 22-gauge intravenous catheter with a manufacturer's expiration date of 06/30/21.

g. (1) Fisher Collection and Transport Swab with a manufacturer's expiration date of 12/31/21.

h. (4) BBL Collection and Transport Swabs with a manufacturer's expiration date of 12/31/21.

i. (1) Arterial Blood Gas Kit with a manufacturer's expiration date of 01/28/22.

Near ED Med Room West

a. (1) Bard Davol Insyte N Autoguard intravenous catheter with a manufacturer's expiration date of 09/30/21.

b. (2) Bard Davol Insyte N Autoguard intravenous catheters with a manufacturer's expiration date of 06/30/22.

Difficult Airway Cart

a. (1) End Flow Oxygen modulator with a manufacturer's expiration date of 12/13/20.

3. At the time of the finding, Staff #502 and #503 confirmed the expired supplies and removed the supplies from the patient care area.

4. On 08/23/22 at 2:00 PM, Surveyor #9 and Post Anesthesia Care Unit (PACU) Manager (Staff #901) and Quality Improvement Project Manager (Staff #902) inspected the PACU. The observation showed 24 Pro-Padz Zoll defibrillator pads with a manufacturer's expiration date of 06/22.

5. At the time of the observation, Staff #901 verified the expired supply and removed it from use.

6. On 08/24/22 at 8:00 AM, Surveyor #9 and Perianesthesia Manager (Staff #903) and Quality Improvement Project Manager (Staff #902) inspected the West PACU. The observation showed the following:

a. One Telfa dressing with a manufacturer's expiration date of 04/17.

b. One Meracel Nasal Dressing with a manufacturer's expiration date of 12/17.

c. Two packages of Godman Surgical Patties with a manufacturer's expiration date of 02/17.

d. One Vaseline Gauze with a manufacturer's expiration date of 02/20.

e. Two Heart sync Zoll defibrillator pads with a manufacturer's expiration date of 06/20 and 05/19.

f. One nasal cannula oxygen tubing with a manufacturer's expiration date of expired 04/22.

7. At the time of the observation, Staff #903 verified the expired supply and removed it from use.

8. On 08/24/22 between 2:30 PM and 4:30 PM, Surveyor #9 and Women and Children's Services Director (Staff #905), Interim Manager (Staff #906), and Quality Improvement Project Manager (Staff #904) inspected the Family Birth Center. The observation showed the following in a supply cart:

a. Three povidone iodine packets with a manufacturer's expiration date of 06/22.

b. Five lavender top vacutainer tubes with a manufacturer's expiration date of 08/21.

c. One lavender top vacutainer tube with a manufacturer's expiration date of 08/20.

d. One lavender top vacutainer tube with a manufacturer's expiration date of 08/19.

e. Three large lavender top vacutainer tubes with a manufacturer's expiration date of 01/22.

f. One large lavender top vacutainer tube with a manufacturer's expiration date of 11/19.

g. One large lavender top vacutainer tube with a manufacturer's expiration date of 05/20.

h. Three blue top vacutainer tubes with a manufacturer's expiration date of 01/19.

i. Five green top vacutainer tubes with a manufacturer's expiration date of 12/21.

j. One green top vacutainer tube with a manufacturer's expiration date of 11/20.

k. Two red top vacutainer tubes with a manufacturer's expiration date of 09/20.

l. Three red top vacutainer tubes with a manufacturer's expiration date of 10/18.

m. Two red top vacutainer tubes with a manufacturer's expiration date of 11/21.

n. Five 22 Gauge Insyte Autoguard intravenous catheters with a manufacturer's expiration date of 07/19.

o. Three 22 Gauge Insyte Autoguard intravenous catheters with a manufacturer's expiration date of 03/21.

p. Six 2 Gauge Insyte Autoguard intravenous catheters with a manufacturer's expiration date of 04/21.

9. At the time of the observation, Staff 905 verified the expired supplies. Staff #905 stated that this supply cart is not used.

10. In a hemorrhage supply cart in the same area, Surveyor #9 observed the following:

a. Three 10 milliliter saline flushes with a manufacturer's expiration date of 04/22.

b. Three 10 milliliter saline flushes with a manufacturer's expiration date of 03/22.

c. Four 22 Gauge Insyte Autoguard intravenous catheters with a manufacturer's expiration date of 02/22.

d. One 18 Gauge Insyte Autoguard intravenous catheters with a manufacturer's expiration date of 12/21.

e. One 20 Gauge Insyte Autoguard intravenous catheters with a manufacturer's expiration date of 03/22.

f. One Red Rubber urinary catheter with a manufacturer's expiration date of 04/22.

g. Two Povidone iodine packets with a manufacturer's expiration date of 03/22.

h. One large plastic disposable speculum with a manufacturer's expiration date of 02/22.

11. At the time of the observation, Staff 905 verified the expired supplies.

12. In Operating Room #2, Surveyor #9 observed the following:

a. One 500 milliliter bag of normal saline intravenous solution with a manufacturer's expiration date of 05/22.

b. Three fetal spiral electrode grounding pads (for internal fetal monitoring) with a manufacturer's expiration date of 10/21.

c. One fetal spiral electrode grounding pad (for internal fetal monitoring) with a manufacturer's expiration date of 10/20.

d. Two packages 0.9 ounce of sterile lubricating gel with a manufacturer's expiration date of 10/19.

e. Two packages 0.9 ounce of sterile lubricating gel with a manufacturer's expiration date of 03/21.

f. Eight packages 0.9 ounce of sterile lubricating gel with a manufacturer's expiration date of 05/22.

13. At the time of the observation, Staff 905 verified the expired supplies.

14. In a hemorrhage cart in the recovery area, Surveyor #9 observed the following:

a. Two 18 Gauge Insyte Autoguard intravenous catheters with a manufacturer's expiration date of 04/22.

b. One blood administration set with a manufacturer's expiration date of 07/22.

c. One Alaris pump infusion set with a manufacturer's expiration date of 04/21.

d. Three blue top vacutainer tubes with a manufacturer's expiration date of 07/22.

e. One BD secondary set with a manufacturer's expiration date of 06/22.

15. At the time of the observation, Staff 905 verified the expired supplies.

16. On 08/25/22 at 9:35 AM, Surveyor #9 and Quality Improvement Specialist (Staff #904), Director of Women's and Children's Services (Staff #905), Manager Family Birth Center (Staff #912) and Interim Manager Family Birth Center (Staff #906) inspected the post-partum area of the Family Birth Center. The observation showed the following in a hemorrhage cart:

a. One large single use disposable speculum with a manufacturer's expiration date of 11/21.

b. One large single use disposable speculum with a manufacturer's expiration date of 06/22.

c. One yellow top urine culture vacutainer with a manufacturer's expiration date of 02/22.

d. One yellow top urinalysis vacutainer tube with a manufacturer's expiration date of 1/22.

17. At the time of the observation, Staff #906 verified the expired supplies.

18. On 08/25/22 at 10:39 AM - 11:58 AM , Surveyor #7, the Manager of the Clinical Observation Unit (COU) (Staff # 709) and the Assistant Manager (Staff #710) toured the COU. Surveyor #7 observed the following:

a. In a clean utility room, an open distilled water with no date or time.

19. At the time of the observation Staff #710 stated the opened distilled water might be used by Respiratory services and that it should have a date and time.

20. In a Patient supplies utility room Surveyor #7 observed the following:

a. 3 Remedy no rinse foams that expired on 05/03/22.

b. 2 Remedy no rinse foams that expired on 08/03/22.

c. 1 Remedy no rinse foams that expired on 08/14/22.

21. At the time of the observation Staff #710 verified the 6 Remedy no rinse foams had expired.

22. In a cabinet at the Nurses station Surveyor #7 observed the following:

a. 4 packs of red dot electrodes that expired on 08/10/22.

b. 1 pack of red dot electrodes that expired on 06/11/22.

c. 1 pack of red dot electrodes that expired on 04/05/22.

23. At the time of the observation Staff #710 verified the 6 packs of red dot electrodes had expired.

Item #7 Positive Air Pressure Respirators (PAPR's) Maintenance

Based on observations, interview and document the facility failed to develop and implement a process to ensure that positive air pressure respirators (PAPR's) were maintained according to manufacturer's instructions for use.

Failure to maintain equipment places patients and staff at risk of potential exposure to pathogens.

Findings included:

1. Document review of manufacturer's instructions for use for the 3M Versaflo 300; 300plus and 600 indicate to store in a clean dry environment away from dust.

2. On 08/25/22 between the hours of 1:00 PM and 2:00 PM Surveyor #1 observed 2 PAPR's covered in dust stored uncovered on the personal protective equipment cart in the breakroom in the psych unit. Surveyor #1 observed a sticker on the PAPR's which indicated initial check only, no preventive maintenance required. Surveyor #1 also observed 1 of the 2 PAPR's tested did not turn on.

3. During the observation, Surveyor #1 interviewed charge nurse (Staff #105) regarding routine checks for the PAPR's. Staff #105 indicated that facility maintenance are required to check the PAPR's. Surveyor #1 requested preventive maintenance for the PAPR's.

4. On 08/26/22 between the hours of 10:00 AM and 11:00 AM Surveyor #1 received documentation stating that the PAPR's were placed on an alternative equipment maintenance program (AEM), no preventive maintenance required.

5. On 08/26/22 between the hours of 11:00 AM and 11:30 AM Surveyor #1 interviewed maintenance staff (Staff #110) which indicated no preventive maintenance was required but indicated that it was the responsibility of the unit to do the routine checks.
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