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Based on observation, record review, and staff interviews, the facility failed to construct, install and maintain the building systems to ensure a physical environment that was safe for patients and staff. The cumulative effects of the environment deficiencies result in the hospital's inability to ensure a safe environment for all patients and staff.

Findings include:

The facility was found to contain the following deficiencies. Refer to the full description at the cited K-tags:

K-0131 - Multiple Occupancies
K-0225 - Stairways And Smokeproof Enclosures
K-0291 - Emergency Lighting
K-0293 - Exit Signage
K-0311 - Vertical Openings - Enclosure
K-0321 - Hazardous Areas - Enclosure
K-0341 - Fire Alarm System - Installation
K-0345 - Fire Alarm System - Testing And Maintenance
K-0351 - Sprinkler System - Installation
K-0353 - Sprinkler System - Maintenance And Testing
K-0361 - Corridors - Areas Open To Corridor
K-0363 - Corridor - Doors
K-0372 - Subdivision of Building Spaces - Smoke Barrier Construction
K-0712 - Fire Drills
K-0908 - Gas and Vacuum Piped Systems - Inspection and Testing Operations
K-0911 - Electrical Systems - Other
K-0914 - Electrical Systems - Maintenance And Testing
K-0923 - Gas Equipment - Cylinder And Container Storage

Based on observation, interview and record review the staff failed to assure availability and proper functioning of essential equipment in 1 of 4 departments (Medical/Surgical) observed.

Findings include:

Per observation on 12/14/2021 at 11:15AM, observed a Bladder Scanner in the clean supply/storage room on the Medical/Surgical unit, biomed tag indicating preventative maintenance (pm) is due by 10/20/2021.

During an interview on 12/14/2021, Medical/Surgical Manager J stated, "Yes, it is over due."

During an interview on 12/16/2021, Facilities Director E stated, "We don't have a specific policy regarding preventative maintenance for the bladder scanner, we follow manufacturer recommendations." Director E stated "I can't find the bladder scanner book."

Based on observation, record review, interview, facility staff failed to ensure the emergency code carts were locked and medications secure on 11 days from 10/1/2021 - 12/14/2021 in a total universe of 1 of 3 (Emergency Department) emergency code carts in the facility.

Record review of the facility's policy titled, "Code Blue Policy" #ES-GEN-002 dated 3/23/2021 revealed the Crash Cart Check log which revealed, "Crash Cart/Defib (defibrillator) check to be done every day and after each time cart is used."

Record review of the Emergency Department "Crash Cart Check" logs from 10/1/2021 through 12/14/2021 revealed 11 days without documented checks of the security of the cart.

On 12/14/2021 at 10:50 AM during interview with Emergency Department Director D when asked about expectation for checking the cart stated, "Of course it should be checked and documented daily. It looks like some days, that were probably busy, it didn't get done."

Based on observation, record review, and interview, facility staff failed to monitor daily temperature, expiration, and PAR levels (Periodic Automatic Replenishment - minimum and maximum quantity) of the fluid warmer holding intravenous fluids during 6 of 6 months in the control log (7/01/2021 through 12/14/2021) in a total universe of 1 of 2 fluid warmers (Emergency Department) observed.

Findings include:

Record review of the facility's policy titled, "Fluid Warmer, [manufacturer name of the unit]" last reviewed 2/20/2018, under Policy B. revealed, "The [fluid warmer] will have daily operation checks of temperature, fluid expiration, and PAR level."

Record review of the "Pedigo Fluid Warmer Temperature Control Log" from 7/1/2021 thru 12/14/2021 revealed 54 days with no documentation of checks for temperature, quantity, or expiration dates on the fluids.

On 12/14/2021 at 11:00 AM during interview with Emergency Department (ED) Director D, Director D stated that it is the responsibility of the ED staff to check the fluid warmer daily for quantity, expiration dates on the fluids, and temperature of the unit and to document on the log. "It is obviously not being done every day as it should be."

Based on observation and staff interviews, the facility failed to construct, install and maintain the building systems to ensure live safety from fire was safe for patients and staff. The cumulative effects of these deficiencies result in the hospital's inability to ensure a safe environment for all patients and staff.

Findings include:

The facility was found to contain the following deficiencies. Refer to the full description at the cited K-tags:

K-0131 - Multiple Occupancies
K-0225 - Stairways And Smokeproof Enclosures
K-0291 - Emergency Lighting
K-0293 - Exit Signage
K-0311 - Vertical Openings - Enclosure
K-0321 - Hazardous Areas - Enclosure
K-0341 - Fire Alarm System - Installation
K-0345 - Fire Alarm System - Testing And Maintenance
K-0351 - Sprinkler System - Installation
K-0353 - Sprinkler System - Maintenance And Testing
K-0361 - Corridors - Areas Open To Corridor
K-0363 - Corridor - Doors
K-0372 - Subdivision of Building Spaces - Smoke Barrier Construction
K-0712 - Fire Drills
K-0908 - Gas and Vacuum Piped Systems - Inspection and Testing Operations
K-0911 - Electrical Systems - Other
K-0914 - Electrical Systems - Maintenance And Testing
K-0923 - Gas Equipment - Cylinder And Container Storage

Based on record review and interview, the facility staff failed to order restraints for Non-Violent patients and reassess the patient per facility policy and procedure in 1of 3 (Pt #16) patients who required the use of restraints out of a total universe of 20 medical records reviewed.

Findings:

The facility policy, titled "Restraint Policy" #HSNG-GEN-005, dated 8/27/2020, revealed: "I. Purpose: The decision to apply restraints is a collaborative process reflecting assessment and intervention on the part of the medical staff and nursing staff. IV. Policy: C. Providers and Nursing staff will assess and monitor a patient's condition on an ongoing basis to ensure that the patient is released from restraint at the earliest possible time....See SCMRC (St. Croix Medical Regional Center) Restraint procedure for assessment and monitoring."

The facility document, titled "Restraints Procedure" #HSNG-GEN-005.01, dated 8/27/2020, revealed: "IV. Procedure: A. Restraint initiation: 1. Application of restraints should always be done in a manner to: c. Ensure safety of the environment. 2. Acute medical restraint (non-violent) Excellian order #205835. c. Renewal orders and Face-to-Face reevaluation are to be done every 24 hours. e. RN assessment and documentation for non-violent restraints will be completed every 2 hours and as needed. 3. PRN OR STANDING ORDERS ARE NOT ALLOWED FOR ANY RESTRAINTS. 5. The nurse is responsible for completing the restraint flow sheet. The events leading up to restraint are documented in the medical record, including: e. Date, time, type of restraint applied. f. Monitoring g. Reassessment h. Plan of care."

Record review of Patient #16's medical record revealed restraint usage from 11/25/2021-12/2/2021. Review of the "Restraint Flowsheet" revealed missing restraint documentation without assessments on 11/25/2021 from 8:39 AM to 3:00 PM. Review of Patient #16's physician orders revealed no restraint orders on 11/26/2021, 11/28/2021 and 11/30/2021. The lack of orders and lack of every 2 hour documentation was confirmed by Nursing Supervisor GG on 12/15/2021 at 3:30 PM.

During an interview on 12/15/2021 at 3:30 PM, Nursing Supervisor GG stated, "There are no orders for restraints on 11/26/2021, 11/28/2021 and 11/30/2021 and the restraints were used."

Based on record review, interview and observation, the facility staff failed to follow their policies and procedures to ensure inpatient nutritional needs are met by failing to complete a registered dietitian assessment of 2 of 20 inpatients (Patient #1 & #18) in a total of 20 medical records reviewed and failed to ensure patients receive safe quality food by failing to ensure food was not expired in 1 of 1 kitchens observed.

Findings include:

The facility policy, titled "Nutrition Screening: Inpatient & Outpatient Nutrition Screening, Dietitian Coverage" dated 5/19, revealed: "II. Policy: A. Inpatient Nutritional Screening via Nursing: All inpatients are screened on admission via Nursing Admission Assessment using the malnutrition screening tool (MST)....III. Procedure: 1. "The patient's nutritional status is screened by nursing within 24 hours of the patient's admission." 2. Nutritional Screening Indications: a. Adult iii. Malnutrition screening score--score of 2 or more the patient is at risk of malnutrition and requires a Nursing Consult to Dietitian....C. The dietitian receives release via phone and/or Excellian system. The dietitian assesses and documents within 3 days or less."

The facility policy, titled "Admission and Assessment of Patients Policy" #HS-GEN-031, dated 2/17/2021, revealed: "IV. Policy: A. Based on this initial history and assessment, an interdisciplinary plan of care will be initiated on all patients following admission. Following the assessment, nursing may make appropriate referrals to the Dietitian, Rehab Services, Social Services or Respiratory Care. The referral will be completed and documented within 48 hours."

A review of Patient #1's medical record revealed Patient #1 was a 79-year-old admitted to the Medical Surgical Unit on 9/04/2021 with the chief complaint of failure to thrive. Patient #1 expired 9/10/2021. There was no malnutrition screening tool (MST), dietary referral or registered dietitian assessment completed.

A review of Patient #18's medical record revealed a 50-year-old admitted to the medical-surgical unit on 12/9/2021. Malnutrition screening tool (MST) completed on 12/9/2021 at 10:06 PM indicated a MST score of 3 which triggers a need for a Dietician Assessment. Patient #18 is still an inpatient as of 12/16/2021. A dietary referral was not ordered and a registered dietitian assessment was not completed.

On 12/16/2021 at 9:58 AM during interview with Nursing Supervisor GG, when asked if there was a ablution screening or dietary consult completed during Patient #1's hospitalization, Supervisor GG confirmed "I cannot find one."

On 12/15/2021 at 4:00 PM during interview with Nursing Supervisor GG, regarding Patient #18's malnutrition screening, Supervisor GG stated "There should of been a referral to the Dietician and it is not there"



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The facility policy, titled "Food Storage" dated 6/16, revealed: "J. All stock must be rotated with each new order received. 2. Date all items when shelved."

Observations of the kitchen on 12/15/2021 at 9:30 AM revealed the following:

1. Kitchen items were not labeled with the date opened:
Vanilla, lemon pepper, italian seasoning, onion pepper, thyme leaves, ground pepper, basil, marsala, cinnamon, seasame seeds, chipolte, blackened seasonings, nutmeg, celery seeds, black seasame seeds and tarragon.

2. Spices and herbs were expired:
-Splenda expired 11/7/2019
-baking powder expired 5/22/2020
-cayenne pepper expired 10/2017
-dill expired 9/17/2019

During an interview on 12/15/2021 at 9:30 AM, Dietary Director HH stated, "Staff should label food with the date opened and spices/herbs should be discarded 12 months after being opened."

Based on observation, record review, interview, the facility failed to removed expired supplies in 2 of 4 patient care areas (Surgical Unit and Medical Surgical Unit).

Findings include:

Review of facility policy, "Endoscopes (flexible medical device inserted into the body to look at organs or body cavities)-High Level Disinfection vs Sterilization," effective date 8/19 stated, "After each use, Bronchoscopes (tube to look at the lungs), Colonoscopes (tube to look at the colon), Gastroscopes (tube to look at the stomach) and EBUS(Endobronchial ultrasound scope) (tube used to take an ultrasound of the lung), will be decontaminated using chemical sterilization via the Medivator system....See manufacturer's IFU (Instructions for use) for cleaning prior to high level disinfection.....prior to each use, the bronchoscope and EBUS scopes will be sent through the medivator and high level disinfected."

Review of Advantage Plus Endoscope Reprocessing System quick start guide, stated, "Test Disinfectant Concentration, at the end of the cycle, when prompted, test the minimum recommended concentration (MRC) with a Rapicide PA (peracide acid) test strip of the disinfectant sample taken from the sample port."

Review of facility procedure, " Endoscopes-High level disinfection vs sterilization procedure effective date 9/21 stated, "Manufacturers recommendations for cleaning and disinfecting scopes is followed by all CSR (Central Supply Room)/CST (Certified Surgical Tech) staff or designees."

On 12/15/2021 at 9:30 AM during an observation with RN (Registered Nurse) OR (Operating room) Manager M, observed Certified Surgical Technician U use the medivator to clean an endoscope following a colonoscopy. The open bottle of Rapecide PA strips had an expiration date of 11/22/22, no date was present indicating when the bottle was opened, 2 extra unopened Rapecide strip bottles both expired on 07/14/2021.

On 12/15/2021 at 9:30 AM, during an interview with RN OR manager M, confirmed both Rapecide PA strip bottles were expired and the open bottle had no date to indicate when it had been opened. OR Manager M stated, "Materials stocks the strips, the bottles shouldn't be on the shelf, staff should be dating the bottles when opened, but they are good for 90 days after they are opened. Staff should be checking expiration dates routinely before using." When asked how staff can be sure this bottle hasn't been open for more than 90 days or if staff wouldn't use a bottle from the shelf, OR Manager M stated the open bottle of PA strips "should have a date when opened". OR Manager M stated "I would like to say no, but I can't be sure."

On 12/12/2021 at 10:45 AM during tour/observation of the Medical Surgical Unit with EVS (Environmental Services) Manager O in the housekeeping closet, observed one bottle of hand sanitizer that expired 10/21, and one container of hydrogen peroxide wipes that expired on 3/19/21.

On 12/12/2021 at 10:45 AM, during interview with EVS Manager M, Manager M, confirmed the expiration dates of hand sanitizer and wipes. Manager M stated, "They shouldn't be using those, I guess we will be talking about expiration dates at our next department meeting."