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Based on document review and interview, it was determined that for 1 of 2 records reviewed (Pt. #23) for non-violent restraints, the Hospital failed to ensure that a physician's order for restraints was obtained, as required.

Findings include:

1. The Hospital's policy titled, "Restraint Policy" (revised 1/2019), was reviewed on 7/22/19 and required, "...For restraints applied for non-violent or non-self-destructive behavior... Physician's order. A verbal/telephone or CPOE [computerized physician order entry] order from a physician or LIP [licensed independent practitioner] must be obtained and entered into the patient's medical record as soon as possible but not more than 12 hours after the initiation of non-violent, non-self-destructive restraint..."

2. The clinical record of Pt. #23 was reviewed on 7/22/19. Pt. #23 was a 83 year old male, admitted on 7/17/19, with the diagnoses of sepsis (an infection of the blood stream) and UTI (urinary tract infection). Restraint flowsheets indicated that soft wrist restraints were initiated on 7/18/19 at 8:00 PM. A physician's order for medical (non-violent), soft wrist restraints was not placed until 7/19/19 at 10:17 AM (14 hours and 17 minutes after initiation).

3. An interview was conducted with the Manager of the Critical Care Unit (E#14) on 7/24/19, at approximately 3:15 PM. E#14 stated that if a nurse initiates medical restraints, a physician's order must be obtained as soon as possible, or at least within 12 hours of initiation.

Based on document review and interview, it was determined that for 1 of 2 records reviewed (Pt. #23) for non-violent restraints, the Hospital failed to ensure that restraints were not used on an as needed basis.

Findings include:

1. The Hospital's policy titled, "Restraint Policy" (revised 1/2019), was reviewed on 7/22/19 and required, "...For restraints applied for non-violent or non-self-destructive behavior... 2. When the restraint is no longer needed, it may be discontinued at the direction of a physician, LIP [licensed independent practitioner], or trained RN [Registered Nurse] or physician assistant. 3. New orders for restraint shall be obtained only if the restraint is discontinued and needs to be reapplied. PRN [as needed] and standing orders for restraint are not used."

2. The clinical record of Pt. #23 was reviewed on 7/22/19. Pt. #23 was a 83 year old male, admitted on 7/17/19, with the diagnoses of sepsis (an infection of the blood stream) and UTI (urinary tract infection). A physician's order for medical (non-violent) restraints was placed on 7/19/19 at 10:17 AM. Restraint flowsheets indicated:

- On 7/20/19 at 8:00 PM: soft wrist restraints were initiated.
- On 7/19/19 at 12:00 PM: restraints removed due to "family at bedside... trial released at this time."
- On 7/19/19 at 12:00 AM: restraints were reapplied.
- On 7/20/19 at 8:00 AM: "family at bedside restraints removed/trial release."
- On 7/20/19 at 4:00 PM: "restraints remain off, patient cooperating, family at bedside."
- On 7/20/19 at 10:00 PM: restraints were reapplied.
- On 7/21/19 at 8:00 AM: "family at bedside, restraints on trial release."
- The record lacked physician's orders to restart restraints on 7/19/19 at 12:00 AM and 7/20/19 at 10:00 PM.

3. An interview with the Associate Vice President of Nursing (E#11) was conducted on 7/23/19, at approximately 9:16 AM. E#11 stated, "There is no policy for trial release of restraints or else it would be considered PRN..." E#11 stated that new orders for restraints should have been obtained to restart the restraints on Pt. #23.

Based on document review and interview, it was determined that for 1 of 2 records reviewed (Pt. #15) for non-violent restraints, the Hospital failed to ensure that the condition of the patient was monitored every 2 hours while in restraints as required.

Findings include:

1. The Hospital's policy titled, "Restraint Policy" (revised 1/2019), was reviewed on 7/22/19 and required, "...For restraints applied for non-violent or non-self-destructive behavior... The patient shall be monitored at regular intervals, at least every 2 hours, to be determined consistent with physician orders and/or patient condition and will have documented assessments to assure patient is free from adverse events and to determine if restraint shall be continued..."

2. The clinical record of Pt. #15 was reviewed on 7/22/19 with the Charge Nurse (E#3) of the Transitional Care Unit. Pt. #15 was a 75 year old male, admitted on 6/14/19, with a diagnosis of abdominal pain. A physician's order for initiation of medical, non-violent, soft wrist restraints was dated 7/12/19 at 1:45 AM, and was discontinued on 7/17/19 at 5:35 PM. Restraint flowsheets indicated that Pt. #15 was in soft wrist restraints from 7/11/19 at 8:00 PM until 7/17/19 at 12:00 PM. The flowsheets lacked documentation of restraint monitoring assessments on 7/14/19 from 6:00 AM to 8:00 PM (14 hours) and on 7/16/19 from 12:00 PM to 8:00 PM (8 hours).

3. An interview was conducted with the Charge Nurse (E#3) of the Transitional Care Unit on 7/22/19, at approximately 11:55 AM. E#3 stated that for medical/non-violent restraints, assessments should be conducted every 2 hours and documented in the record. E#3 reviewed Pt. #15's medical record and did not find documentation indicating whether the restraints were removed or if the patient was not present on the unit during the periods when restraint monitoring was not documented.

A. Based on document review and interview, it was determined that for 1 of 2 clinical records (Pt #13) reviewed for pain management, on the Labor and Delivery Unit, the Hospital failed to ensure that pain was assessed and addressed upon admission, as required.


Findings include:

1. The Hospital's policy titled, "Admission to Labor and Delivery" (revised 12/2017), was reviewed on 7/22/19 and required, "...All pregnant women presenting to Labor and Delivery will be safely and accurately assessed to allow for optimal care of the woman...4. Assess and record vital signs including pain assessment with pain score..."

2. The Hospital's policy titled, "Assessment and Plan of Nursing Care" (revised 07/2014), was reviewed on 7/22/19 and required, "...3. A pain assessment is completed on all patients at admission and is a component of the shift assessment. 1. The patient's pain goal is obtained during the admission assessment..."

3. The clinical record of Pt #13 was reviewed on 7/22/19. Pt# 13 was a 31 year old female, admitted on 7/20/19 to the Labor and Delivery Unit at 6:21 PM, for SROM (Spontaneous Rupture of Membrane) at 38 weeks (pregnant). Pt # 13's initial vital signs were documented at 6:45 PM, however did not include a pain score. Pt #13's pain score was first documented at 7:00 PM, when patient was rating a pain (level) "10" (indicating severe pain). Pt # 13 did not receive Stadol (pain medication used during Labor) until 7:53 PM (53 minutes after the documented pain score), and at that time, the patient rated pain at "9" (severe pain).

4. On 7/22/19 at 10:47 AM, an interview was conducted with Pt #13. Pt #13 stated, "I came to the hospital in labor at about 3 cm dilated [centimeters-opening of cervix during labor]. I was in so much pain that I was yelling and shaking. I was told that I had to wait to get pain medicine because there was another C-section [cesarean section-surgical procedure to deliver baby] going on. I didn't get pain medicine until I was 6 cm and it was almost too late for me to get the epidural [anesthetic administered via spine]."

5. On 7/23/19 at 12:00 PM, an interview was conducted with the Associate Vice President of Nursing (E# 11). E# 11 stated, "I expect the nurse to give pain medication to the patient as soon as possible. The OB [Obstetrician] Doctor is in charge of pain management, and then the Anesthesiologist once the patient is in active labor. If there is a delay in getting an order for pain medication from the OB Doctor, then the nurse could always call the House Doctor on duty. That was a long time to wait for pain medicine [related to Pt #13]."


B. Based on document review and interview, it was determined that for 1 of 2 clinical records (Pt #14) reviewed for nursing assessments, on the Woman and Infant Services Unit, the Hospital failed to notify the physician of abnormal vital signs, as required.


Findings include:


1. The Hospital's policy titled, "Vital signs" (dated 2/2016), was reviewed on 7/23/19 and required, "...Notify physician of significant variances from patient's normal. Suggested guidelines: A. Blood pressure 90 systolic [top number of blood pressure reading] or below. B. Apical [heart] pulse 50 or below, 110 or above..."

2. The clinical record of Pt #14 was reviewed on 7/22/19. Pt #14 was admitted on 7/20/19 for labor and delivered a newborn via cesarean section (surgical procedure to deliver baby). Pt #14's orders (dated 7/20/19), included, "...Notify physician if pulse is greater than 110 bpm [beats per minute], continuous order and notify physician if SBP [systolic blood pressure] is less than 80 mmHG [millimeters of mercury] or DBP [diastolic blood pressure-bottom number of blood pressure reading] is less than 50 mmHG (millimeters of mercury), continuous order..."

-Pt #14's initial blood pressure documented on the vital signs flowsheet (dated 7/20/19 at 11:00 AM) was 133/85 mm HG.
-Pt #14's vital signs flowsheet (dated 7/20/19-7/22/19) included the following subsequent vital signs:
- 7/21/19 at 1:34 AM: Heart rate 125 bpm
- 7/21/19 at 1:35 AM: Heart rate 131 bpm
- 7/21/19 at 2:00 AM: Heart rate 131 bpm
- 7/21/19 at 3:00 AM: Heart rate 112 bpm
- 7/21/19 at 2:30 PM: Blood Pressure 89/39 mmHG
- 7/21/19 at 11:28 PM: Blood Pressure 103/48 mmHG
- 7/22/19 at 7:32 AM: Blood Pressure 96/46 mmHG

The clinical record lacked documentation that the physician was notified of Pt #14's abnormal vital signs.

3. On 7/22/19 at 11:25 AM, an interview was conducted with the Woman and Infant Services Educator (E # 10). E #10 stated, "Pt #14's vital signs should have been addressed. The patient's high heart rate could have been an indication of sepsis [infection in blood]."

Based on document review and interview, it was determined that for 2 of 3 (Pt. #7 and Pt. #8) patient records reviewed for nursing care plans on 4 West telemetry, the Hospital failed to ensure that staff included the primary medical diagnoses into the nursing care plan.

Findings include:

1. On 7/22/19, the Hospital's policy titled, "Assessment and Plan of Nursing Care" (revised by the Hospital 07/2014), was reviewed. The policy included, "4. Plan of Care ...2. The plan of care identifies interventions that are prioritized to assist the patient in reaching the optimal level of function."

2. On 7/22/19, Pt. #7's medical record was reviewed. Pt. #7 was a 73 year old female who was admitted to the Hospital on 7/12/19, with the diagnoses of syncope/near syncope (dizziness) and renal (kidney) failure. Pt. #7's nursing care plan lacked documentation of nursing care plan interventions for Pt. #7's renal failure diagnosis.

3. On 7/22/19, Pt. #8's medical record was reviewed. Pt. #8 was a 98 year old female who was admitted to the Hospital on 7/20/19 with the diagnoses of shortness of breath and sepsis (potentially life-threatening condition cause by the body's response to an infection). Pt. #8's nursing care plan lacked documentation of nursing care plan interventions for Pt. #8's sepsis diagnosis.

4. On 7/22/19 at 11:00 AM, an interview with the 4 west (Telemetry) Nurse Manager (E #21) was conducted. E #21 stated that the nursing care plans are recommended for the nurses to initiate based on the patient diagnoses and health information.

Based on document review and interview, it was determined that for 2 of 2 patients (Pt. #1 and Pt #2) receiving pain medication on the 6 West nursing unit, the Hospital failed to ensure a pain reassessment was completed after administration of a pain medication, as required.

Findings include:

1. The Hospital's policy titled, "Pain Management (revised 08/2018)," was reviewed on 7/22/19 and required, "Pain reassessment occurs following a pain intervention as outlined below and will include evaluation and documentation towards pain management goals ... c. Within 1 hour after administration of an oral pain medication."

2. The clinical record of Pt. #1 was reviewed on 7/22/19. Pt. #1 was a 68 year old male admitted on 7/17/19 with a diagnosis of buttock abscess (pocket of pus under the skin that becomes infected). The medication administration record (MAR), dated 7/18/19, included that Tylenol #3 (oral pain medication) was administered at 2:50 PM for a pain score of 7 (scale 1-10, with 10 being the worst). The MAR lacked documentation of a reassessment, within 1 hour, for the effectiveness of the pain medication.

3. The clinical record of Pt. #2 was reviewed on 7/22/19. Pt. #2 was a 72 year old female admitted on 7/19/19 with a diagnosis of left foot cellulitis (skin infection). The MAR, dated 7/21/19, included that Tramadol (oral pain medication) was administered at 11:07 AM for a pain score of 6. The MAR lacked documentation of a reassessment within 1 hour for the effectiveness of the pain medication.

4. During an interview on 7/22/19 at approximately 10:45 AM, the Clinical Nurse Specialist (E#6) stated, "There should be a post pain assessment documented after each pain medication is given. The route [way] the medication is administered determines the time the reassessment must be completed."

Based on document review and interview, it was determined that for 1 of 1 (Pt. #7) patient reviewed for blood transfusion on the 4 West telemetry unit, the Hospital failed to ensure that blood transfusion documentation was completed, as required.

Findings include:

1. The Hospital's policy titled, "Blood Products Administration" (revised by the Hospital 07/2019), was reviewed on 7/22/19. The policy included, "...2. g. When transfusion is complete, obtain post transfusion vital signs ...3. Transfusion Documentation: complete the Blood Component Transfusion Record to include ...b. vital signs c. date and time transfusion started and stopped d. check box if entire unit was transfused ...e. sign and date next to completed by ..."

2. On 7/22/19, Pt. #7's medical record was reviewed. Pt. #7 was a 73 year old female who was admitted to the Hospital on 7/12/19, with the diagnoses of syncope/near syncope (dizziness) and renal (kidney) failure.

The physician's order, dated 7/12/19, included, "Transfuse RBC's [red blood cells] ...2 units."

-Pt. #7's blood component transfusion record, dated 7/12/19, lacked documentation of the date and time the transfusion was completed. Pt. #7's record also lacked post blood transfusion vital signs.

3. On 7/22/19 at approximately 10:25 AM, an interview with the 4 West (telemetry) Charge Nurse (E #22) was conducted. E #22 stated that the blood component transfusion record should be completed with the stop date and time. E #22 stated that the blood component transfusion record should also include post blood transfusion vital signs.

Based on document review and interview, it was determined that for 1 of 2 clinical records (Pt #14) reviewed, on the Labor and Delivery Unit, the Hospital failed to ensure that a general informed consent was obtained upon admission, as required.


Findings include:


1. The Hospital's policy titled, "Consent for Treatment" (revision date 05/2016), was reviewed on 7/23/19 and required, "...The patient's or their legal representative's consent, written, or verbal, is required for all treatment..."

2. The Hospital's policy titled, "Admission to Labor and Delivery" (revision date 12/2017), was reviewed on 7/22/19 and required, "...11. Obtain signature on consents..."

3. The clinical record of Pt #14 was reviewed on 7/22/19. Pt #14 was a 27 year old female admitted on 7/20/19 for labor, and delivered a newborn via cesarean section (surgical procedure to deliver baby). Pt #14's clinical record lacked a general informed consent upon admission to the Hospital.

4. On 7/22/19 at approximately 11:40 AM, an interview was conducted with the Labor and Delivery Educator (E # 20). E # 20 stated, "There should be an informed consent in the patient's chart with each new admission." E # 20 verified that Pt #14's informed consent was not included in the clinical record.

Based on document review and interview, it was determined that the Hospital's Medical Record Department failed to ensure medical records were completed within 30 days of the patient discharge.

Findings include:

1. On 7/23/19 at 1:00 PM, the Hospital's policy titled, "Medical Record Standards," (revised 11/2018), was reviewed. The policy required, "H. Chart Completion: Charts should be completed within 30 days of discharge."

2. On 7/23/19 at 1:30 PM, the Hospital's letter of attestation, dated 7/23/19, was reviewed. The letter included, the Hospital... "attest[s] that there are currently 621 medical records with a delinquent status..." The letter was signed by the Chief Medical Officer (E #26).

3. On 7/24/19 at 1:30 PM, an interview was conducted with the Medical Records Office Coordinator (E #35). E #35 stated that delinquent medical records should be less than 2% of the total number of medical records and 621 delinquent medical records was "probably not" below 2%.

A. Based on document review, observation and interview, it was determined that the Hospital failed to ensure that the Food and Nutrition Department staff labeled opened food product and discarded expired food. This potentially affected the average 785 daily trays served to patients daily.

Findings include:

1. The Hospital's policy titled, "Food Supply Storage Procedures" (revised 01/12), was reviewed on 7/23/19 and required, "... Date and rotate items. Discard food past the use by or expiration date ... The day of opening counts as day one."

2. During a tour of the Food and Nutrition area on 7/23/19, from 10:30 AM to 11:30 AM, the following was observed:
-Main Freezer - A bag of chicken breasts, a bag of chicken wings, a box of hamburger patties and a box of frozen biscuits were all open; however, the food items were not labeled with the date that they were opened.
-Produce cooler - A tray of sliced tomatoes that expired on 7/21/19 (per written label on tray) and two bags of colored peppers were opened and not labeled with opened date.
Dry Storage - 4 large bowls of candy wrapped in plastic wrap expired on 5/30/19 (per written label on bowls).

3. During an interview on 7/23/19 at 11:00 AM, the Director of Food and Nutrition Services (E#17) stated that all food must be dated when opened, and an expiration date label must be placed on the food product to indicate when the food is due to expire, after being prepared.

B. Based on document review, observation and interview, it was determined that for 1 of 2 cooks (E#19), the Hospital failed to ensure staff performed hand hygiene between tasks, as required.

Findings include:

1. The Hospital's policy titled, "Hand Hygiene" (revised 01/14), was reviewed on 7/23/19 and required, "In the Food and Nutrition Services Department: All associates associated with the handling of food shall wash hands ... at the following times: ... Before handling food or clean utensils/dishes/equipment ... between handling raw and cooked foods."

2. During a tour of the Food and Nutrition area on 7/23/19 from 10:30 AM to 11:30 AM, the following was observed:
- At approximately 11:05 AM, E#19 (cook) placed a tortilla on the grill with gloved hands, picked up a frying pan; walked over to a refrigerator around the corner; opened the door; took uncooked ingredients out of the refrigerator; and went back to the grill and flipped the tortilla again with the same gloved hands. E#19 did not change gloves or perform hand hygiene between tasks.

3. During an interview on 7/23/19 at 11:10 AM, the Executive Chef (E#18) stated, "E #18 definitely should have changed gloves and washed her hands after leaving the grill area."

Based on observations during the survey walk-through, staff interview, and document review during the Life Safety Code portion of a Full Survey Due to a Complaint conducted on July 22- 25, 2019, the facility failed to provide and maintain a safe environment for patients, staff and visitors.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of the Full Survey Due to a Complaint conducted on July 22- 25, 2019, the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags.

A. Based on observation, document request, and interview, it was determined that for 1 of 10 staff (E #31), the Hospital failed to ensure clean supplies that fell on the floor were not returned to clean storage.

Findings include

1. On 7/24/19 at 9:30 AM, an observational tour was conducted in OR suite # 11. At 11:40 AM, a Physician Assistant (E #31) dropped an alcohol swab package on the floor, picked it up, and returned to the clean supply drawer in the prep stand, potentially contaminating the clean supplies.

2. On 7/25/19 at 9:30 AM, the Hospital's policy regarding what to do with clean supplies that fall on the floor was requested.

3. On 7/25/19 at 9:40 AM, an interview was conducted with the Associate Vice President of Nursing (E #11). E #11 stated that there is no policy regarding what to do with clean supplies that fall on the floor, but if an alcohol swab package fell on the floor, it would be thrown away and not returned to clean supply.


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B. Based on document review, observation, and interview, it was determined that for 9 of 9 staff (E#4, E #28, E #30 E#31 E #36-#40) observed, the Hospital failed to ensure that hand hygiene was performed after removing gloves and when exiting a patient's room.

Findings include:

1. The Hospital's policy titled, "Hand Hygiene" (revised 1/2019), was reviewed on 7/22/19 and required, "...1. HH [hand hygiene] must be performed before entering and upon exiting any patient room. 2. HH must also be performed during patient care as necessary... Before performing a clean or aseptic procedure... After touching a patient... After removing gloves..."

2. Observational tours of the Hospital included the following:

- On 7/22/19, at approximately 10:00 AM, on the Transitional Care Unit (TCU), a Registered Nurse (RN / E#4) went into a patient's room (#104). E#4 changed gloves twice during patient care and did not perform hand hygiene. Before exiting the room, E#4 touched the mouse of the computer with his bare right hand, then exited the room without performing hand hygiene.

- On 7/22/19, at approximately 1:50 PM, on the Critical Care Unit (CCU), a RN (E#36) performed a blood sugar check on a patient in room #1106. After drawing blood, E#36 changed gloves without performing hand hygiene.

- On 7/23/19, at approximately 10:45 AM, on the CCU, a RN (E#37) performed foley (urinary catheter) care on a patient in room #1121. E#37 changed gloves twice during patient care without performing hand hygiene.

- On 7/23/19, at approximately 11:00 AM, on the CCU, a Respiratory Therapist (E#38) performed ventilator (machine used to provide or assist with respirations) care and administered nebulizer (inhaled) medication for a patient in room #1139. E#38 changed gloves three times during patient care and did not perform hand hygiene.

- On 7/23/19, at approximately 3:00 PM, on the 3 East Surgical Unit, an Environmental Services staff (E#39) finished cleaning room #3135. E#39 removed gloves upon exiting the room and did not perform hand hygiene. E#39 then went to the clean linen room to grab a pair of pillowcases.

- On 7/24/19, at approximately 10:50 AM, in the Endoscopy (nonsurgical procedure used to examine a person's digestive tract) Department, a Surgical Technician (E#40) changed gloves twice after washing contaminated endoscopes (an instrument introduced into the body to view internal parts of the intestine) and did not perform hand hygiene.

At 10:45 AM, a Patient Care Technician (E #30), assisted with patient positioning, removed her gloves, but did not disinfect her hands, handed the Scrub Technician a surgical instrument, and then left the OR suite.

- At 10:55 AM, a Registered Nurse (E #28) completed a Foley insertion (artificial urinary tube into the bladder), removed her gloves, but did not disinfect her hands, put on new gloves, and then cleaned the Foley bag.

- At 11:25 AM, a Physician Assistant (E #31) completed assisting with patient positioning on the OR (Operating Room) table, removed his gloves, but did not disinfect his hands, retied his scrub pants cord, and then left the room.

3. On 7/24/19 at 11:30 AM, an interview was conducted with the OR Educator (E #27). E #27 stated that hands should be disinfected after removing gloves.

4. An interview was conducted with the Charge Nurse (E#3) of the TCU on 7/22/19 at approximately 11:55 PM. E#3 stated that hand hygiene should be performed before going into a patient room, each time gloves are removed, and before exiting a patient room.

5. An interview was conducted with an Infection Preventionist (E#41) on 7/24/19, at approximately 1:30 PM. E#41 stated that infection control audits for hand hygiene are performed monthly. E#41 stated that the audits of hand hygiene only focus on observations of staff when entering and exiting patient care areas/rooms. E#41 stated that a process to capture hand hygiene practices inside patient care areas is still being developed.



C. Based on document review, observation, and interview, it was determined that for 1 of 2 staff (E#13) and 2 of 2 visitors on the Critical Care Unit, the Hospital failed to ensure that gloves were worn in contact isolation rooms.

Findings include:

1. The Hospital's policy titled, "Isolation Precautions" (revised 10/2018), was reviewed on 7/22/19 and required, "...Contact Precautions used for patients that are infected or colonized with organisms or infections that is spread by direct (skin-to-skin) or indirect (via environment or equipment) contact. Gloves and gown are required to enter the patient room... Gloves shall be worn whenever touching the patient's intact skin or surfaces and articles in close proximity to the patient...

2. An observational tour of the Critical Care Unit was conducted on 7/22/19, at approximately 1:15 PM. At approximately 1:37 PM, a visitor in Pt. #23's room (#1132) was not wearing gloves. At approximately 1:38 PM, a Patient Care Technician (E#42) entered the patient's room and exited at approximately 1:41 PM without instructing the visitor to wear gloves. At approximately 2:04 PM, another visitor was present in Pt. #23's room without gloves on and was touching Pt. #23. At approximately 3:12 PM, a Registered Nurse (E#13) was in Pt. #23's room opening drawers with his bare hands while the two visitors were still present in the room and not wearing gloves. At approximately 3:13 PM, E#13 touched Pt. #23's bare arm without wearing gloves. Pt. #23 was on contact isolation precautions for a history of MDRO (multi-drug resistant organism) infection.

3. An interview was conducted with the Manager of the CCU (E#14) on 7/22/19, at approximately 3:16 PM. E#14 stated that gloves are required when entering a contact isolation room. E#14 stated that gloves should be worn when touching the patient or any surfaces in the room. E#14 stated that bedside nursing is responsible for educating and reminding visitors to follow contact precautions.



D. Based on document review, observation, and interview, it was determined that for 2 of 2 staff (E#4 and E#5) on the Transitional Care Unit (TCU), the Hospital failed to ensure that disposable supplies taken into a contact isolation room were not removed from the room.

Findings include:

1. The Hospital's policy titled, "Isolation Precautions" (revised 10/2018), was reviewed on 7/22/19 and required, "...Patient Care Equipment: ... All disposable supplies or items that cannot be cleaned or are left in the room must be discarded upon patient discharge from the room..."

2. An observational tour of the TCU was conducted on 7/22/19, at approximately 9:41 AM.

- At 10:00 AM, a Registered Nurse (E#4) entered Pt. #15's isolation room with 4 syringes of saline (solution used to flush/clear intravenous lines). At 10:15 AM, after performing care on Pt. #15, E#4 used one saline syringe to administer intravenous medications. At 10:21 AM, E#4 exited the room with the 3 remaining saline syringes. Pt. #15 was on contact isolation precautions for a history MRSA (methicillin resistant staphylococcus aureus) infection.

- At 10:36 AM, a Registered Nurse (E#5) entered Pt. #16's isolation room with 4 syringes of saline. E#5 used a saline syringe to flush the patient's IV (intravenous) line after changing a bag of medication. At approximately 10:40 AM, E#5 exited the room with the 3 remaining saline syringes. Pt. #16 was on contact isolation precautions for pseudomonas aeruginosa infection.

3. An interview was conducted with the Charge Nurse (E#3) of the TCU on 7/22/19, at approximately 11:55 PM. E#3 stated that when entering an isolation room, staff are expected to bring in only the supplies that are needed. E#3 stated that once disposable supplies are brought into an isolation room, they must not come out of the room.



E. Based on document review, observation, and interview, it was determined that for 1 of 1 respiratory therapist (E#38), the Hospital failed to ensure that equipment used on a patient were disinfected after use.

Findings include:

1. The Hospital's policy titled, "Cleaning and Disinfection of Non-Critical, Reusable Patient Care Equipment and Workstations on Wheels" (revised 9/2017), was reviewed on 7/23/19 and required, "...All reusable equipment must be cleaned and disinfected immediately if visibly soiled, and immediately after each patient use, using a hospital approved cleaner and/or disinfectant..."

2. During an observational tour of the Critical Care Unit on 7/23/19, at approximately 11:05 AM, a Respiratory Therapist (E#38) was in a patient's room performing ventilator care. E#38 used a stethoscope on the patient twice during care and placed it back around her (E#38's) neck each time without disinfecting it. E#38 used a pressure monitor on the patient's endotracheal tube (artificial airway) and placed it back on the workstation. At approximately 11:35 AM, E#38 exited the room and placed the workstation with the pressure monitor back into the equipment room without performing disinfection.

3. An interview was conducted with an Infection Preventions (E#41) on 7/24/19, at approximately 1:30 PM. E#41 stated that all equipment used on a patient should be disinfected prior to leaving the patient care area/room.



F. Based on document review, observation, and interview, it was determined that for 1 of 1 staff (E#15) in the laboratory, the Hospital failed to ensure that gloves were worn when handling blood specimens.

Findings include:

1. The Hospital's Laboratory Department policy titled, "Personal Protective Equipment (PPE) Requirements" (undated), was reviewed on 7/23/19 and required, "...Gloves are worn for: ... d. Obtaining, handling, and manipulating specimen[s]. Work area with instrumentation including computers and phones where biohazardous substances are handled, processed, or tested carry a risk for exposure. Gloves are to be worn at all times in these areas..."

2. During an observational tour of the Laboratory Services Department on 7/23/19, at approximately 9:25 AM, a Medical Technologist (E#15) was observed handling blood specimens in tubes and operating blood testing equipment without wearing gloves. E#15 also used a piece of gauze to wipe a pipette (small hollow tube) of blood with bare, ungloved hands.

3. An interview was conducted with the Associate Vice President of Laboratory Services (E#16) on 7/23/19, at approximately 9:55 AM. E#16 stated that gloves are required when working in the laboratory and handling specimens. E#16 stated that E#15 "definitely should have been wearing gloves."

A. Based on document review, observation, and interview, it was determined that the Hospital failed to ensure tape residue was removed from equipment and surfaces in the Operating Room (OR) to permit thorough disinfection prior to surgical procedures, potentially creating a higher level infection control risk for 2 patients having surgical procedures in OR suite #11 on 7/24/19.

Findings include

1. On 7/24/19 at 2:00 PM, the Hospital's policy titled, "Cleaning the Operating Room (OR) Between Cases," (revised 7/2019), was reviewed. The policy required, "Cleaning Between Cases (Turn-Over)... E. Room Wipe Down and Cleaning... 4. Furniture and horizontal surfaces are wiped... Cleaning 'Non-Critical' Shared Patient Equipment: 1. Non-Critical patient equipment is wiped with a hospital approved disinfectant when visibly soiled, and after each patient use..."

2. On 7/24/19 at 9:30 AM, an observational tour was conducted in OR suite #11. At 9:40 AM, a surgical procedure had ended, the Patient was removed, and 2 environmental service employees entered OR suite 11 to begin the turn-over cleaning. Turn-over cleaning ended at 10:00 AM, but there was still visible tape residue on 1 of 2 intravenous (IV) poles, 1 of 3 supply cabinets, 1 of 1 "prep" table, and 1 of 1 suction machine. Tape residue has the potential to prohibit thorough disinfection of equipment and surfaces.

3. On 7/24/19 at 11:30 AM, an interview was conducted with the OR Educator (E #27). E #27 stated that hands should be disinfected after removing gloves.

5. On 7/24/19 at 11:30 AM, an interview was conducted with the OR Educator (E #27). E #27 stated that tape residue should be removed from OR equipment and surfaces during cleaning.

B. Based on document review, observation, and interview, it was determined that for 3 of 10 staff (MD #2, E #31, & E #33), the Hospital failed to ensure surgical masks were secure/tied upon entering the Operating Room (OR) when sterile instruments and supplies were open

Findings include

1. On 7/25/19 at 9:15 AM, the Hospital's policy titled, "Surgical Attire," (revised 4/2009), was reviewed. The policy required, "Procedure... 6. Surgical Masks: a. Personnel entering the restricted areas wear a surgical mask when there are open sterile supplies... c. Masks will cover the nose and mouth and secured..."

2. On 7/24/19 at 9:30 AM, an observational tour was conducted in OR suite #11, where sterile instruments were open, and the following was observed:

- At 10:25 AM, an Anesthesiologist (MD #2) entered the room, tying on his mask.

- At 10:52 AM, a Physician Assistant (E #31) entered the room, tying on his mask.

- At 11:15 AM, a Patient Care Attendant (E #33) entered the room, tying on her mask.

3. On 7/24/19 at 11:30 AM, an interview was conducted with the OR Educator (E #27). E #27 stated that masks should be tied before entering the OR room [when sterile supplies are open].