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Based on interview and record review, the hospital failed to ensure the medical staff was accountable to the Governing Body for quality of care for one of three sampled patients (Patient 3) as evidenced by:

* A physician's progress note was not prepared timely as per the hospital Bylaws.

* There was no documented evidence to show the reason for Patient 3 to be transferred to the other hospital's NICU.

These failures had the potential for substandard level of care.

Findings:

Review of the hospital's Medical Staff Bylaws and General Rules & Regulations dated November 2021 showed pertinent progress notes shall be signed, dated, and timed at the time of each visit. Notes shall be sufficient to permit continuity of care and transferability. Whenever possible each of the patient's clinical problems should be clearly identified in the progress notes and correlated with specific orders as well as results of tests and treatments.

On 7/31/24 at 1335 hours, an interview with concurrent review of Patient 3's medical records was conducted with the Interim CNO and RN 1.

Review of Patient 3's medical record showed Patient 3 was born on 7/15/24 at 2133 hours.

Review of the Admission Note Newborn Nursing dated 7/15/24 at 2245 hours, showed the following:

* Delivery date and time was 7/15/24 at 2133 hours.

* The Estimated Gestational age (EGA) was 36.2 weeks

* The birth type was Cesarean Section.

* The patient's temperature was 97.7 degrees Fahrenheit. The patient's heart rate was 130 bpm. The patient's respiratory rate was 52 breaths per minute.

* The patient's admit weight was 2295 gram.

* The patient's Apgar was eight at one minute and nine at five minutes.

* For the initial exam, there was no abnormalities observed

* The discharge planning section showed the anticipated discharge was to home.

Review of the Process Notes dated 7/16/24 at 0104 hours, showed at 0005 hours, Patient 3 was transferred out to the other hospital's NICU.

Review of the Newborn Admission Note dated 7/31/24 at 0829 hours, showed the General Exam section showing Patient 3 was alert, active non-dysmorphic-appearing infant, and in no acute distress. The Assessment and Plan section showed to continue normal newborn care and follow up with pediatrician in two to three days.

There was no documented evidence to show the physician dictated a note following the delivery of Patient 3 as per the hospital's Bylaws and General Rules & Regulations

There was no physician's note to show the reason for Patient 3 to be transferred out to the other hospital's NICU.

The above findings were verified by the Interim CNO and RN 1.

Based on interview and record review, the hospital failed to ensure MD 1 saw and evaluated one of three sampled patients (Patient 1) in the ICU within six hours of admission. This failure increased the risk for substandard outcome to the patient.

Findings:

Review of the hospital's Medical Staff Bylaws and General Rules & Regulations dated November 2021 showed all patients admitted to the Critical Care Unit shall be seen by a staff physician on staff within six hours or less from the time of admission. Upon the request of the emergency physician, the physician responsible for the care of the patient must respond immediately.

On 8/1/24 at 0901 hours, an interview and concurrent review of Patient 1's medical record was conducted with LVN 1. LVN 1 stated Patient 1 walked into the ED on 7/16/24 for methamphetamine (highly addictive stimulant that affects the central nervous system) overdose and was admitted to the ICU on the same day.

Patient 1's medical record showed Patient 1 visited the ED on 7/16/24 at 1258 hours.

Review of the ED Provider Aware Note dated 7/16/24 at 1340 hours, showed the ED provider, MD 1 spoke with MD 2 at 1406 hours. MD 2 agreed to accept Patient 1 in the ICU as the attending physician. The ED Provider Aware Note showed MD 3 was also consulted on Patient 1's case. The ED Provider Aware Note showed Patient 1 was on a BiPAP.

Review of the location history showed Patient 1 was moved to the ICU on 7/16/24 at 1544 hours.

Review of the Event Note dated 7/16/24 at 1751 hours, showed the RN documented informing MD 3 of Patient 1's respiratory status. The RN received new orders for Patient 1's BiPAP settings. The RN documented Patient 1's respiratory rate was 38 breaths per minute and a temperature of 104.8 degrees Fahrenheit.

Review of the Consult Note dated 7/16/24 at 2119 hours, showed MD 4 from the ED intubated Patient 1 due to severe respiratory distress, as the BiPAP that Patient 1 was on, could no longer maintain Patient 1's oxygenation.

Review of the Consult Note dated 7/16/24 at 2318 hours, showed Patient 1 had a Code Blue response at 2218 hours with cardiac arrest and had a death pronouncement at 2246 hours.

Review of the Progress Note dated 7/18/24 at 0900 hours, showed MD 2 documented Patient 1 was admitted to the ICU and shortly after arriving, the patient was intubated. MD 2 documented Patient 1 became bradycardia, and a Code Blue was called. MD 2 documented Patient 1 passed away on 7/16/24 at 2246 hours (approximately seven hours after the admission to ICU).

On 8/1/24 at 1331 hours, an interview and concurrent review of the hospital's Medical Staff Bylaws and General Rules and Regulations was conducted with the Director of Medical Staff. The Director of Medical Staff stated the attending physician was required to see a patient in the ICU within six hours of admission.

On 8/1/24 at 1500 hours, the above findings were shared with the CEO, ED and ICU Director, Interim CNO, and Quality Manager.

Based on observation, interview, and record review, the hospital failed to maintain the overall hospital environment in such a manner that the safety and well-being of patients were assured as evidenced by:

1. Inoperable equipment stored in Room D.

2. Delivery room light without preventive maintenance.

3. Two janitor's closets: one unlocked with a rusty sink and the other with a rusty drain.

4. Broken supplies stored in the bedside drawer of Room B.

5. A linen hamper filled with soiled linens in an unoccupied patient's bathroom.

6. Inoperable hopper in the dirty utility room.

7. Cleaning log for the ice machine not up to date.

8. Kitchen with rusty areas behind the faucet.

9. Inoperable light above the bed in Room C.

10. No thermostat in the unit's medication room.

11. A storage cart in the nursery's hearing room with a broken drawer.

12. A linen hamper filled with "rejected linens" in the nursery's hearing anteroom.

13. Leaking sink in the CCU and no P&P in place to track and maintain maintenance issues in the facility for the Engineering Department.

14. Two corrugated boxes filled with one- liter bags of Normal Saline were observed stacked directly on the floor of the central supply.

These failures had the potential to compromise patient safety and increase the risk of infections.

Findings:

On 7/31/24 at 0945 hours, a tour of the Labor and L&D unit was conducted with the Interim CNO, Charge Nurse L&D, and Maintenance Supervisor. During the tour the following were observed:

1. During a tour of Room D, two inoperable pediatric and adult ventilators were observed stored in the room. The Charge Nurse L&D stated Room D was set up as a vaginal delivery room overflow. In another interview with the BioMed Technician, he stated the two ventilators were plugged into an outlet in the room waiting to be repaired.

2. In Room E, a delivery light was observed without the preventive maintenance sticker. In an interview the BioMed Technician, he stated the light was a loaner.

3. One janitor closet in the hallway was observed unlocked with brown rusty sink. The second closet had a mop stains and rusty drain sink. The Maintenance Supervisor locked the unlocked closet.

4. Room B which was an unoccupied room, was prepared for a new patient. Broken plastic items and plastic bags were stored in the bedside nightstand. The Charge Nurse L&D responded by disposing the broken items and plastic bags.

5. In Room B, the linen hamper was filled with soiled linens. The Charge Nurse L&D stated the hamper should have been emptied when the room was cleaned.

6. A hopper in the dirty utility room was observed in a disrepair condition. The Maintenance Supervisor stated the Maintenance Supervisor was not aware of the problem with the hopper. When asked, the Maintenance Supervisor stated regarding any repairs or maintenance issues, the nursing unit staff would notify the Engineering Department via an email or a phone call.

7. The cleaning log for the ice machine located in the nutrition room was not up to date. The Charge Nurse L&D stated the EVS cleaned the ice machine daily. The last date on the cleaning log showed 7/17/24.

8. A double sink in the kitchen was observed with rusty areas behind the faucet. The Maintenance Supervisor stated was unaware of the issue.

9. In Room C which was prepared for a new patient admission, a light above the bed was observed in a disrepair condition, the light frame was hanging from the lamp. The Maintenance Supervisor was unaware of the broken lamp.

10. During a tour of the unit's medication room Pyxis machine (automated medication dispensing systems) was observed, an anesthesia cart and several one-liter IV fluid bags were stored in the medication room. No thermostat (a device that controls the temperature) was observed in the room. The Maintenance Supervisor provided a portable thermostat.

11. A storage cart with a broken drawer was observed in the nursery's hearing room. RN 1 stated the infants hearing tests were performed by an outside company, contracted with the hospital, and the individual performing the hearing test was responsible to notify the unit's nursing staff of the broken drawer.

12. A linen hamper in the nursery's hearing room's anti-room was labeled "Rejected Linens". The hamper was filled with dirty linens. RN 1 stated the EVS was responsible for the daily pick up of the dirty linens.

The above findings were verified by the Interim CNO, RN 1, Maintenance Supervisor, and BioMed Technician.




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13. Review of the hospital's P&P titled Work Order Reporting, Assignment & Completion, dated August 2023 showed if staff identifies a non-critical corrective issue in their department, staff is to notify the Engineering department by email and/or phone. For critical issues, staff is to notify Engineering immediately by calling during Engineering business hours or Nursing Supervisor after the engineering business hours. Nursing Supervisor will contact Engineering on-call after hours. There was no information about the process engineering would follow to prioritize or address the issue in the policy.

On 7/31/24 at 0945 hours, a tour of the CCU was conducted in CCU with Charge Nurse 1, in the presence of the Quality Nurse. A sink was observed in Room A with a sign "Do not use" taped to the faucet. When asked why there was a sign, Charge Nurse 1 stated there was something wrong with the sink. Charge Nurse 1 turned on the faucet, and water was observed leaking from the pipes underneath the sink onto the floor, and a large rust colored stain was observed. When asked how long the sink had been out of order, Charge Nurse 1 stated possibly a couple of weeks. When asked the process to let the Engineering know about the issue, Charge Nurse 1 stated they called or emailed the Engineering. Charge Nurse 1 stated she did not call Engineering herself, but she thought it had been reported already.

On 7/31/24 at 1320 hours, an interview was conducted with the Maintenance Supervisor and the Admin Assistant, Engineering. The Maintenance Supervisor was asked for a work order regarding the leaking sink in CCU. The Maintenance Supervisor stated the Engineering Department was not made aware of the leaking sink. When asked the process for staff to report an issue to Engineering, the Maintenance Supervisor stated staff would call or email. The Maintenance Supervisor stated there was no other record keeping.

On 7/31/24 at 1421 hours, an interview was conducted with the Quality Manager. The Quality Manager stated there was no system in place for work orders, they were only discussed during the daily huddle meetings.

On 8/1/24 at 1314 hours, an interview was conducted with the Maintenance Director. The Maintenance Director was asked about the process for logging and tracking work orders for the Engineering department. The Maintenance Director stated the staff would call or email the Engineering department, but they did not track the work orders. When asked for a P&P regarding the process for prioritizing and logging work orders, the Maintenance Director stated there was none.

14. According to the CDC, sterile supplies should be stored far enough from the floor (8 to 10 inches), the ceiling (5 inches unless near a sprinkler head [18 inches from sprinkler head]), and the outside walls (2 inches) to allow for adequate air circulation, ease of cleaning, and compliance with local fire codes (e.g., supplies must be at least 18 inches from sprinkler heads). Medical and surgical supplies should not be stored under sinks or in other locations where they can become wet. Sterile items that become wet are considered contaminated because moisture brings with it microorganisms from the air and surfaces.

On 7/31/24 at 1020 hours, a tour of the central supply alternate storage area located within the Physical Therapy department and concurrent interview with the Materials Supervisor, in presence of the Quality Nurse was conducted. Two corrugated boxes filled with one-liter bags of Normal Saline were observed stacked directly on the floor. The Materials Supervisor stated the boxes should be off the floor to avoid contamination.

On 8/1/24 at 0930 hours, an interview was conducted with the Epidemiologist. The Epidemiologist was asked about storing boxes on the floor. The Epidemiologist stated boxes needed to be stored six to seven inches off floor because floor could get wet and items could get contaminated.

Based on observation and interview, the hospital failed to ensure supplies and equipment were updated and stored to ensure an acceptable level of safety and quality as evidenced by:

1. A box of expired suture kit was found available for patient use in Room D/sterile supply room.

2. An IV pump module was found in the ED with a preventive maintenance date of 2/2024.

These failures had the potential to compromise patient safety and increase the risk of infections.

Findings:

1. On 7/31/24 at 0945 hours, a tour of the L&D was conducted with the Interim CNO and Charge Nurse L&D. During the tour of Room D (an OR), Charge Nurse L&D stated the room was used for storing sterile supplies. A box of expired suture kit dated 1/31/24 was found in Room D/sterile supply room available for patient use. The Charge Nurse L&D responded by disposing of the box.

The above finding was verified by the Interim CNO and Charge Nurse L&D.


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2. On 7/31/24 at 0932 hours, a tour of the ED with concurrent interview with the ED and ICU Director was conducted. An IV pump module #9948 was found with a preventative maintenance dated 2/2024. During an interview with the ED and ICU Director, she verified and acknowledge the findings.

On 8/1/24 at 1458 hours, an interview was conducted with the BioMed Technician. The BioMed Technician acknowledged the IV pump module #9948 did not have preventive maintenance completed as scheduled, because it was unable to be found.