HospitalInspections.org

Based on personnel file review,and interview, it was determined the facility failed to ensure criminal background checks were completed for two (#1 and #2) of ten ( #1-#10) Patient Care Technicians (PCT) reviewed who worked in the Emergency Department (ED). This failed practice did not ensure the facility hired individuals without a history of abusive behavior. The failed practice had the liklihood to affect all patients seen in the ED. The findings follow:

A. Review of the facility Policy titled, "Recruiting, Onboarding and Offboarding," showed "Human Resources (HR) will ensure the employee receives consent to do a background check. All job candidates will sign a background consent form that is sent through ADP to the candidates email before hiring. All background checks are conducted by ADP Screening and Selection Services [named state] State Police Website for Criminal Background Investigation and comply with applicable federal, state, and local laws including Fair Credit Reporting Act. For a candidate continued employment, it is contingent upon the satisfactory results of the background check."
B. PCT #1 had a date of hire of 02/21/22. On 10/18/23 at 3:00 PM, PCT #1's employee personnel file was reviewed. There was no evidence of a criminal record check on file.
C. PCT #2 had a date of hire of 03/07/22. On 10/18/23 at 3:05 PM, PCT #2's employee personnel file was reviewed. There was no evidence of a criminal record check on file.
D. On 03/18/23 at 2:45 PM, the Human Resources Director was interviewed and asked to provide the criminal background checks for PC T #1 and #2. The Human Resources Director stated, "I don't have them. I will send off for them today."
E. On 03/19/23 at 3:10 PM, the Human Resources Director provided documentation of an ADP screening and selection services receipt for requested background checks for Patient Care Technician #1 and #2.



44854

Based on observation and interview, it was determined the patients bathrooms, patients rooms, dirty linen, and intensive care unit was not safe and maintained in a state of cleanliness in that the exhaust fans were dirty and/or nonfunctioning, and leaks were present in the light fixtures. The failed practice promoted the spread of infection and had the likelihood to affect all patients and staff. Findings follow.

A. Observation of patient bathroom in Room 1307 at 2:46 PM on 10/16/23 showed to have dirty and nonfunctional exhaust fans.
B. Observation of patient Room 233 at 2:33 PM on 10/16/2023 showed to have a water leak in the light fixture.
C. Observation of the dirty linen closet in the ICU showed there to be a non working exhaust fan on 10/16/2023
D. The findings in A-C were verified in an interview with the Chief Nursing Officer on 10/19/2023 at 12:00 PM.


Based on observation and interview, it was determined the Psychiatric Unit and the Labor and Delivery Unit and Ednoscopy Area was not maintained in an safe environment and state of good repair. The failed practice did not ensure the patients were safe from self-harm and from fire. The failed practice had the likelihood to affect all patients admitted to the Psychiatric Unit and Labor and Delivery. Findings follow:

A. Observation during the above ceiling inspection throughout the facility on 10/16/2023 show to have multiple penetrations in fire barriers and fire walls such as in the Labor and Delivery Unit and the hallway in the endoscopy area.
B. Observation of the Psychiatric unit on 10/19/2023 at 10:30 am showed the patient beds were regular patient beds and not bolted to the floor and could be used to create a sustainable attachment point such as a cord, rope, or other material for the purpose of hanging or strangulation due to the fact that they were electric beds that could be raised 6 inches from the floor. There was no mitigation plan provided and patients were not being monitored by staff 24/7.
C. These findings were verified during an interview with the Director of Maintenance on 10/19/2023 at 12:00 PM.

Based on observation and interview, it was determined the facility failed to provide measures to prevent and control the spread of infection and failed to maintain a clean and sanitary environment in that:
1) In the seclusion room, on the behavioral health unit, there was a brown colored substance under the bed mattress, the headboard and splattered on the walls.
2) In the storage room, on the behavioral health unit, patient belongings were stored with mops, brooms, oxygen concentrator with opened nasal cannula, floor cleaner and wetjet mop heads.
The failed practices had the likelihood to promote the spread of infection and had the likelihood to affect all patients admitted to the behavioral health unit. Findings follow:

A. Observation of the seclusion room on the behavioral health unit on 10/18/2023 at 9:20 AM showed there was a brown colored substance under the bed mattress, the headboard and splattered on the walls. The findings were confirmed in an interview with the Reflections Nurse Manager on 10/18/2023 at 9:20 AM.
B. Observation of the storage room on the behavioral health unit on 10/18/2023 at 9:25 AM showed the following:
1) Patient belongings were stored in bins on a wire shelf.
2) Mop heads, brooms and wetjet mop heads were stored adjacent to the patient belongings.
3) A mop head was hanging on the handle of an oxygen concentrator. An opened nasal cannula was connected to the oxygen concentrator.
4) A bottle of floor cleaner was in a bin of patient belongings.
C. The findings of B were confirmed in an interview with the Reflections Nurse Manager on 10/18/2023 at 9:25 AM.


44854



Based on observation and interview, it was determined the facility failed to maintain a safe environment in that the double Emergency Entrance doors to the outside had a gap at the bottom. The failed practice had the likelihood to allow pest to enter which promoted the spread of infection and had the likelihood to affect all patients seeking care in the Emergency Department and all patient on census. The findings follow:

A. Observation on 10/16/23 at 2:49 PM showed there was a gap at the bottom the of the double Emergency Entrance doors exiting to the outside.
B. During an interview on 10/16/23 at 2:49 PM, the Director of Education, Maternity and Emergency Services confirmed the findings in A at the time of the observation.


48330



Based on review of policy, observation and interviews it was determined the Infection Control Manager failed to ensure infection prevention and control in the Surgical Services Department in that surgical staff did not adhere to hospital issued scrub policy. Failure to perform surveillance activities to assure staff compliance with infection control prevention policies for issued scrubs did not ensure patients and staff would be protected from bloodborne pathogens or other infectious materials. The failed practice had the likelihood to affect all surgical patients and staff. The findings follow:

A. Review of Policy and procedure titled, "Hospital Issued Scrubs" dated July 2016 showed, "Employee, whose home department is surgery or nursery, will be issued 5 sets of scrubs upon employment. The scrubs are not to leave the hospital. At the end of the employee's shift, they are to be put in the women's locker room (located in OR or OB) to be laundered. Under no circumstances are scrubs to be worn home or tattered, they will be replaced by Environmental Services (ES) personnel."
B. Observation in operating room (OR) #1 on 10/18/2023 at 10:45 AM showed the surgical staff entering with different colored scrubs to assist with the surgical procedure.
C. In an interview with Infection Control Manager on 10/18/2023 at 11:00 AM, the Infection Control Manager stated that the Association of PeriOperative Registered Nurses (AORN) guidelines were followed in the Surgical Department.
D. In an interview with the Director of Surgical Services on 10/18/2023 at 11:30 AM, the Director stated that staff laundered their own scrubs.
E. On 10/18/2023 at 11:50 AM, the Director of Surgical Services confirmed the findings A-D.


Based on observation and interview, it was determined the facility failed to assure a sanitary environment in multiple patient care areas( Intensive Care Unit and Emergency Department). The failed practice had the likelihood to promote the spread of infection. The failed practice had the likelihood to affect patients transferred to the Intensive Care Units, and any patient whose care was rendered in Emergency Department. Findings follow.

A. Observation on 10/16/2023 at 2:30 PM, Intensive Care Unit Room #4 showed multiple ripped areas on the back of the recliner with foam exposed, rust areas on the shelving over bed and in the right corner of room on the floor.
B. Observation on 10/16/2023 at 2:45 PM, Intensive Care Unit Room #5 showed multiple ripped areas on back of the recliner with foam exposed, rust areas on the shelving over bed,and cobwebs in left corner of room.
C. Observation on 10/16/2023 at 3:25 PM, Emergency Department showed multiple areas on the wall with chipped paint, floor dirty and stained ceiling tiles above the ambulance entrance door.
D. The findings A-C were confirmed with the Director of Emergency Services on10/16/2023 during the tour.
E. The finding of C were confirmed during a second tour on 10/18/2023 at 09:20 AM with the Infection Control Manager