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Based on observation, interview, and record review, the hospital failed to ensure the patient's personal privacy was maintained for one nonsampled patient (Patient A) and the ICU developed the written guidelines for the use of a camera in the patient rooms. These failures had the potential for the patients' personal privacy to not be protected.

Findings:

On 12/26/24 at 0904 hours, the ICU was toured with the Director of ICU.

One computer monitor with video surveillance of nine patient rooms was observed at the nursing station. Three patients including Patients 3 and A were observed on the monitor. Patient A was observed to be topless on the computer screen monitor. When asked, the Director of ICU stated Patient A had high temperature.

When asked, the Director of ICU stated the cameras were not recording and the privacy curtain in the patient's room would be closed when providing personal hygiene.

When asked, the Director of ICU stated staff who did not provide direct patient care, had access to view the monitor since it was located at the nursing station.

When Patient 3's room was toured, the camera and signage (for your safety, closed circuit cameras are in used in this area) was observed on the upper right-hand corner of the ceiling. When asked, Patient 3 stated Patient 3 was not sure what the camera was for, and no staff had talked about it.

On 12/26/24 at 1340 hours, a follow-up interview was conducted with the Director of ICU. When requested, the Director of ICU stated the hospital did not have any written guidelines for the use of cameras in the patient rooms.

Based on interview and record review, the hospital failed to ensure the patients received care in a safe environment as evidenced by:

1. The known issue of the documented unavailable supply on 7/14/24, by MD 2 was not investigated until 12/31/24.

2. There was no OPPE for the physicians as per the Medical Staff Bylaws.

3. The reappointment and privileges were granted when the qualifications were not met for two physicians (Neurosurgeons 1 and 2).

These failures created the risk of substandard healthcare outcomes to the patients in the hospital.

Findings:

1. On 12/27/24, Patient 8's closed medical record was reviewed. Patient 8's medical record showed Patient 8 was admitted to the hospital on 7/14/24.

Review of the ED Provider Aware Note dated 7/14/24 at 1231 hours, showed MD 1 discussed with MD 2 regarding Patient 8's medical condition. The ED Provider Aware Note showed MD 2 would take care of it later today as MD 2 needed to find a vendor that was able to come in with supplies.

Review of the Progress Note dated 7/14/24 at 1555 hours, showed MD 2 called back and stated MD 2 was waiting for the vendor to give him supplies required for surgery that the hospital did not have it available.

On 12/31/24 at 1033 hours, the Director of Imaging Services was interviewed in the presence of the Director of Quality. When asked, the Director of Quality stated the above documentation was well known due to the previous survey in 7/16/24. When asked, the Director of Imaging Services stated there was no issue for MD 2 to perform the surgery. There were enough supplies and staff. The Director of Imaging Services also stated the supplies that would be used during the surgery, would be approved by the hospital's department. MD 2 could not just bring the supplies and performed the surgery. When asked, the Director of Imaging Services stated she was not known what type of supply the MD needed.

The Director of Imaging Services and Director of Quality verified the known issues were not investigated until 12/31/24.

2. Review of the hospital's Medical Staff Bylaws dated 11/22/21, showed under 6.3.2 Ongoing Performance Practice Evaluation (OPPE), all members are subject to ongoing evaluation based on medical staff peer review criteria. Evaluation results are used in privileging, system improvement, and when warranted, corrective action. Department shall develop and routinely update peer review criteria based on current practices and standards of care. At a minimum, departments shall, where relevant, collect and evaluate department members' data pertaining to:

* Operative and other clinical procedure(s) performed and their outcomes
* Pattern of blood and medication usage
* Morbidity and mortality
* Documentation (timeliness, clinical pertinence)

Data shall be collected no less frequently than semi-annually on each member. Department Chair analysis shall be conducted and reported monthly to the Medical Executive Committee. Members are kept apprised of reviews of their performance.

On 12/31/24 starting at 0921 hours, the credential files of Neurosurgeon 1, Neurosurgeon 2, MD 1, MD 2, and MD 4 were reviewed with the Medical Staff Director.

When asked, the Medical Staff Director stated there was no OPPE program. The Medical Staff Director verified the above findings.

3. Review of the hospital's Department of Surgery Rules and Regulations dated March 2023 showed for Neurosurgery Trauma, voluntary panel unless there is an insufficient number of surgeons to adequately cover the panel as determined by the Director of Neurosurgical Services. The Director will review and reassess coverage needs annually. Members providing coverage will be required to:

* Document 16 hours annually of verifiable, external trauma- related CME.
* Be regularly involved in the care of head and spinal injury patients by documentation of 20 head cases and 10 spinal cases in the past two years.
* Attend 50 % of Trauma Operations Committee and Trauma M&M meetings.

On 12/31/24 starting at 0921 hours, Neurosurgeons 1 and 2's credential files were reviewed with the Medical Staff Director. When asked, the Medical Staff Director stated Neurosurgeon 1 was on the call panel for the neurosurgery trauma.

a. Review of Neurosurgeon 2's credential file showed Neurosurgeon 2 was reappointed on 12/1/2023 and the reappointment would be expiring on 11/30/2025.

Review of the Clinical Privileges for Neurosurgeon 2 showed Neurosurgeon 2's privileges status was Class I, meaning unrestricted privilege and the following:

* Maintenance of privileges at reappointment for Level 2 - spinal, peripheral nerve & extracranial vascular privileges required three cases of carotid endarterectomy.

* Maintenance of privileges at reappointment for Level 3 - functional and stereotactic radiosurgery privileges required six cases of endoscopic third ventriculostomy.

There were no recorded cases performed for carotid endarterectomy and endoscopic ventriculostomy for Neurosurgeon 2.

b. Review of Neurosurgeon 1's credential file showed Neurosurgeon 1 was reappointed on 8/1/23 and the reappointment would be expiring on 7/31/25. Further review of the Neurosurgeons 1's credential file showed the following:

* There was no evidence of 16 hours annually of verifiable, external trauma related CME for Neurosurgeon 1.

* No attendance record of Trauma Operations committee and Trauma M&M meetings for Neurosurgeon 1.

The Medical Staff Director verified the above findings.

Based on observation, interview, and record review, the hospital failed to ensure the electronic medical record was secured for two of 12 sampled patients (Patients 3 and 7). This failure had the potential for unauthorized individuals to access and view the patients' electronic medical records and violating the patients' rights.

Findings:

Review of the hospital's P&P titled Patient Rights, Responsibilities, and Ethics dated September 2024 showed the patient has the rights to the confidential treatments of all communications and records pertaining to the care and stay in the hospital.

On 12/26/24, the ICU was toured with the Director of ICU.

1. At 0915 hours, Patient 4's electronic medical record was observed on the computer screen. Patient 4's electronic medical record was opened and unattended.

2. At 0925 hours, Patient 7's electronic medical record was observed on the computer screen. Patient 7's electronic medical record was opened and unattended.

The Director of ICU verified the above findings.

Based on observation, interview, and record review, the hospital failed to ensure the nursing staff developed the care plan for camera monitoring for one of 12 sampled patients (Patient 3). This failure created the risk of not providing necessary care and services to meet the care needs for the patients.

Findings:

On 12/26/24 at 0904 hours, the ICU was toured with the Director of ICU. One computer monitor with video surveillance of nine patient rooms was observed at the nursing station. Patient 3 was observed on the monitor. When Patient 3's room was toured, the camera and signage (for your safety, closed circuit cameras are in used in this area) was observed on the upper right-hand corner of the ceiling. When asked, Patient 3 stated Patient 3 was not sure what the camera was for, and no staff had talked about it.

On 12/26/24 at 1228 hours, Patient 3's medical record was reviewed with the Director of ICU. Patient 3's medical record showed Patient 3 was admitted to the hospital on 12/25/24. Patient 3's medical record did not show a care plan for camera monitoring.

The Director of ICU verified the above findings.

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

1. The medications were administered as per the hospital's P&P for one of 12 sampled patients (Patient 2).

2. The medications were not left unattended.

These failures created the risk of medication errors and poor health outcomes to the patients.

Findings:

Review of the hospital's P&P titled Storage & Security of Medications dated June 2024 showed the medications are not permitted to be stored at the patient's bedside.

Review of the hospital's P&P titled Tube Feeding, Protocol for Enteral Nutrition (Adult) dated April 2022 showed the following:

* Administer each medication separately.

* Prior to administering medication, stop the feeding and flush the tube with at least 15 ml water.

* Flush tube with at least 15 ml water between medication administrations.

1. On 12/26/24 at 0920 hours, RN 3 was observed administering the medications to Patient 2 with the Director of ICU. Patient 2 was observed receiving the enteral tube feeding. RN 3 was observed crushing all four medications (Vitamin C [a supplement], amiodarone [an antiarrhythmic, a medication used to treat abnormal heart rhythm], lisinopril [a medication used to treat high blood pressure], and carvedilol [a medication used to treat high blood pressure and heart disorder]) in a medication bag. RN 3 left the crushed medications at bedside unattended and then returned with sterile water. RN 3 mixed the crushed medications with sterile water. RN 3 checked the placement of feeding tube by auscultating and injecting air with a syringe into the feeding tube. RN 3 administered all the mixed medications via the enteral tube without flushing the tube with at least 15 ml of water.

2. On 12/26/24 at 0925 hours, during a tour of the ICU with the Director of ICU, a computer in WOW was observed on the hallway. Beside the WOW, two bags of D5 in water (Dextrose 5%, a type of IV solution) and sodium bicarbonate (electrolytes) 8.4% 50 ml and two bottles of sodium polystyrene sulfonate (a medication used to treat high levels of potassium in the blood [a mineral]) 15 g/60 ml were observed unattended.

The Director of ICU verified the above findings.