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ONE HOSPITAL DRIVE

COLUMBIA, MO 65212

PATIENT RIGHTS

Tag No.: A0115

PATIENT RIGHTS: CARE IN SAFE SETTING

Tag No.: A0144

Based on observation, interview, record review and policy review, the hospital failed to:
- Ensure safe patient monitoring for one patient (#73) of three who received a blood transfusion (to administer blood into a vein);
- Ensure blanket warmers-maintained temperatures in a safe range;
- Secure medications on three units of 26 units observed;
- Ensure sharps (a term used for devices with sharp points or edges that can puncture or cut the skin) were safely stored.

Findings included:

1. Review of the hospital's policy titled, "Blood Product Transfusion," dated 05/09/22, showed: Vital signs (VS, measurements of the body's most basic functions) were to be recorded prior to the transfusion, 15 minutes after the transfusion started and at completion. Staff were to remain with or able to closely observe the patient for the first 15 minutes of the infusion to observe for adverse reactions.
Review of Patient #73's medical record, dated 10/30/24, showed a blood transfusion started at 12:15 PM and VS were recorded at that time. VS were next recorded at 2:26 PM when the transfusion ended.

Observation on 10/30/24, showed Staff ZZZ, Registered Nurse (RN), obtain VS at 12:15 PM and started the blood transfusion for Patient #73 at 12:20 PM. He obtained VS at 12:30 PM, then left the patient's room.

During an interview on 10/31/24 at 2:25 PM, Staff PPPP, Chief Nursing Officer (CNO), stated that she expected patient observation and VS monitoring should follow hospital policy for all patient receiving blood transfusions.

2. Although requested a policy related to blanket warmer temperature monitoring was not provided.

Observation on 10/30/24 at 12:49, in the Cardiovascular Unit, showed the blanket warmer located in the supply room had a temperature of 131 degrees.

Observation on 10/29/24 at 10:15 AM, in the nursery, showed the blanket warmer temperature was 132 degrees.
During an interview on 10/31/24 at 2:24 PM, Staff PPPP, CNO, stated that she expected blanket warmers to be monitored and for there to be a policy to ensure monitoring was completed.

During an interview on 10/30/24 at 2:29 PM, Staff HHHH, Facilities Director, stated that they were not able to monitor the temperatures of blanket warmers remotely and there was no system for monitoring the temperatures at all. Unit staff were expected to check the temperature and report any blanket warmers that were out of range.

During an interview on 10/30/24 at 12:49 PM, Staff BBB, Service Line Specialist, stated that she generally checked the temperature on the blanket warmers periodically but did not have a log to indicate when or how often it was checked. The goal was for the temperature to be under 130 degrees.

During an interview on 10/29/24 at 8:15 AM, Staff CC, Risk and Regulation Manager, stated that the blanket warmers were to be no warmer than 130 degrees Fahrenheit. Staff were expected to assess the blanket warmers temperature every shift, logs were not completed to confirm the temperature.

During an interview on 10/30/24 at 2:29 PM, Staff JJJJ, Maintenance, stated that the newer blanket warmers would not alarm until the temperature reached 136 degrees. The older models would not alarm at all.

During an interview on 10/30/24 at 9:58 AM, Staff FF, Women's Services Manager, stated that the blanket warmers were centrally monitored by clinical engineering.

During an interview on 10/29/24 at 9:55 AM, Staff EE, RN, stated that she did not know who was responsible to assess the warmer temperatures.

3. Review of the hospital's policy titled, "Medication Management - Medication and Quality Assurance - Policy," approved 06/08/21, showed:
- To ensure patient safety and regulatory compliance, it is necessary that unusable medication be unavailable for patient use.
- Medication storage areas will be kept clean, organized, temperature-controlled, secured, and with appropriate light, moisture and ventilation levels.
- Any unusable medication will be removed from active stock.

Observation on 10/29/24 at 11:10 AM, in the Labor and Delivery Unit anesthesia (a state of controlled, temporary loss of sensation or awareness that is induced for medical purposes) work area, showed 12 vials of injectable medication in an unsecured cabinet.

Observation on 10/29/24 at 9:50 AM, in the Pediatric (pertaining to children) Unit, showed one partially used tube of medication in an empty patient room.

Observation on 10/29/24 at 2:45 PM, in Hospital C's medication room, showed one unsecured partially used medication vial and one opened package with one white tablet unsecured in a medicine cup in a patient's medication bin.

During an interview on 10/31/24 at 2:24 PM, Staff PPPP, Chief Nursing Officer, stated that she expected unsecured medications were discarded. She expected all medications to be secured.

4. Review of the hospital's policy titled, "Infection Prevention and Control Program - 2024 Infection Control Manual," approved 11/20/23, showed:
- All health care workers shall take precautions to prevent injuries caused by needles.
- Prepare each injection in a designated clean area where blood and body fluid contamination are unlikely.
- Inspect the syringe and needle package for breaks.
- Discard syringe and needle if the package has been punctured, torn and/or damaged by exposure to moisture.

Observation on 10/29/24 at 11:13 AM, on the Medical/Surgical unit of Hospital B, showed a computer workstation on wheels that was left unattended in the hallway. The workstation contained unlocked drawers with multiple insulin syringes.

Observation on 10/29/24 at 11:13 AM, on the Progressive Care Unit (PCU) unit of Hospital B, showed a new packaged 18-gauge needle that was left on the patient's bedside table.

During an interview on 10/31/24 at 2:24 PM, Staff PPPP, CNO, stated that she would not expect to see sharps anywhere outside of a locked drawer or sharps container.

During an interview on 10/29/24 at 2:55 PM, Staff TTT, Hospital B Director of Nursing, stated that she expected staff members to lock up the insulin syringes when they walked away from their workstations.

46554

48359

49404

50321

PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT

Tag No.: A0145

Based on interview, record review, video review and policy review, the hospital failed to thoroughly investigate an allegation of abuse and neglect related to two patients (#67 and #68). They failed to determine whether abuse had occurred, failed to notify the patient's guardians and failed to provide education to all staff. These failed practices placed all patients admitted to the hospital at increased risk for their safety.

Findings Included:

Review of the hospital's policy titled, "Abuse and Neglect Prevention," dated 03/27/19, showed:
- Employees who observe acts of possible sexual misconduct by a patient or against a patient, should immediately report the incident to the direct supervisor.
- Contact security to have them meet with the patient and set expectations of appropriate behavior, if applicable.
- Document patient's misconduct in the Electronic Medical Record (EMR).
- A trained investigator with Missouri University Health Care (MUHC) Security will initiate a fair, impartial and reliable investigation of the allegations.
- Investigative efforts may include instituting interim remedies for the safety and security of all patients, visitors and employees at MUHC.
- Interview direct witnesses of the alleged conduct and other relevant witnesses, if available.
- Collect relevant evidence; security footage, emails/text messages/photos, documentation of related prior conduct, etc.
- Allow the accused party to tell their side of the story.
- At the completion of the investigation, a summary of the investigation will be submitted to the MUHC Title IX (a federal law that prohibits sex-based discrimination in educational programs and activities that receive federal financial assistance) Coordinator's designee and any necessary stakeholder.
- If the MUHC Title IX Coordinator makes a determination that there was a violation of the Collected Rules & Regulations (CRR) 600.020 Sexual Discrimination, Harassment or Misconduct in Education/Employment Policy, then a committee comprised of the Manager of Regulatory Affairs, the Manager of Risk Management and the MUHC Title IX Coordinator or Deputy Title IX Coordinator, or designee, and other stakeholders as needed, will recommend appropriate sanctions or remedial actions, if applicable.
- If supported by the evidence sanctions may include a Behavioral Intervention Plan which outlines expectations and possible consequences for the patient's failure to adhere to the Behavioral Intervention Plan. Risk Management will only approve and/or recommend a Behavioral Intervention Plan if the evidence supports it.
- Termination of the patient, area specific, or system wide.

Review of the hospital's policy titled, "Discharge Planning & Care Coordination - Guardian Notification of Important Clinical Events," dated 12/08/20, showed that the purpose of the policy was to establish guidelines for contacting guardians after important clinical events, however, the policy does not address the notification of a minor's parent or guardian after any type of verbal, physical or sexual allegation.

Review of the hospital provided document titled, "Incident Number 922494," dated 03/28/24, showed Patient #77 reported to a Mental Health Technician (MHT) she did not want to be in the room she was currently located in. When the MHT asked her why she said that Patient #68 came into the room and had sex with her roommate, Patient #67, while staff were not present. The patient then showed the MHT a bed sheet that she had kept that the "patient had put his semen on". Patient #77 stated that she was waiting for her roommate to be discharged before reporting because she did not want her to get in trouble.

Review of Patient #67's medical record showed:
- She was a 17-year-old female admitted to the adolescent psychiatric (relating to mental illness) unit on 03/22/24.
- Progress Notes dated 03/23/24 through 03/26/24, showed no documentation of any inappropriate sexual behaviors or encounters.
- Nursing Narrative Reviews dated 03/22/24 through 03/26/24, showed no documentation of any inappropriate sexual behaviors or encounters.
- There was no documentation in the EMR of parental notification after the alleged sexual encounter between Patient #67 and Patient #68.
- She was discharged on 03/27/24.

Review of Patient #68's medical record showed:
- He was a 16-year-old male admitted to the adolescent psychiatric unit on 02/15/24.
- Progress Notes, dated 03/23/24 through 03/28/24, showed no documentation of any inappropriate sexual behaviors or encounters.
- Nursing Narrative Reviews, dated 03/22/24 through 03/27/24, showed no documentation of an inappropriate sexual behaviors or encounters.
- A Nursing Narrative Review dated 03/28/24, showed the patient, "keeps asking to go back to 3 South, doesn't want to be on Pediatric Assessment Unit (PAU)."
- A Progress Note dated 03/29/24, showed the patient, "did not like the fact that he was moved from the inpatient unit and wants to go back to the other side. Patient did not mention anything regarding why he was moved yesterday."
-A Social Work Narrative Review dated 03/28/24, showed Staff EEEE, Licensed Master Social Worker (LMSW), received a call from the patient's guardian (the person/ appointed by a judge to manage the property and rights of another person who is considered incapable of doing so themselves) who "mentioned that the patient talked about going into a female's room for two to five minutes." Staff EEEE confirmed to the guardian that the patient was in a female patient's room for about three minutes, but the patient denied doing anything physical or sexual with the other patient.
- He was discharged on 04/01/24.

Review of video surveillance from the West Corridor, West Dining Room and the West Television Room on 03/26/24, showed:
- At 09:06:48 PM, an unidentified MHT was observed sitting at a dining room table with view of the patient hallway.
- At 09:07:02 PM, the MHT was observed walking out of camera view, leaving the patient hallway unmonitored. The hallway was not visible from the nurse's station.
- At 09:07:35 PM, Patient #68 exited the room and proceeded down the hallway to Patient #67's room.
- At 09:07:41 PM, Patient #68 entered Patient #67's room and closed the door.
- At 09:11:21 PM, Patient #68 exited Patient 67's room.

Review of the hospital provided document titled, "Case Report #2024-000428," submitted 04/06/24, showed:
- On 03/28/24 at 8:33 AM, security was dispatched to the Pediatric Psychiatric Unit. Upon arrival, security was informed that Patient #77 reported that Patient #67 and Patient #68 had, what was believed to be, consensual sexual contact on 03/26/24 around 9:00 PM. Patient #77 reported that she was present in the room at the time of the event and witnessed the encounter. She also reported she "still had the sheet the two were on while having sex." The sheet had since been placed in a bag.
- Patient #67 had been discharged on 03/27/24. Patient #68 and Patient #77 were still present on the unit but had been separated from having contact with each other.
- At 8:38 AM, security dispatch was informed that an investigator needed to be assigned for further follow-up as the incident would be considered a Title IX Investigation.

Review of the hospital provided document titled, "Follow-Up 2024-00428," submitted 04/01/24, showed:
- On 03/28/24 at 9:58 AM, Patient #77 was interviewed and reported that it was "around bedtime" when Patient #67 and Patient #68 had sex. Patient #68 entered Patient #67's room between staff room checks and was in the room for approximately five minutes. When asked to describe what she saw Patient #77 only mentioned the two patients undressing. She reported that they did not speak and "they just started fucking." Patient #77 reported that Patient #67, "spit cum on the ground" and then helped Patient #68 "clean up using the sheet", which Patient #77 later provided to staff. Patient #77 stated she did not report the incident sooner as she "didn't want to get anyone in trouble" and that she was afraid Patient #67 and Patient #68 "would do it again."
- On 03/28/24 at 12:40 PM, Patient #68 was interviewed, and he admitted to going into Patient #67's room but said that they were "only talking." He claimed he "could not remember the girl's name nor could he remember what they talked about because it was a long time ago." He denied having any sexual contact with Patient #67. When it was explained to him that there was a bed sheet that allegedly had semen on it, and if he had an explanation, he claimed to not know what semen was.
- Security collected the "bed sheet that was inside a large bag that had been stapled closed across the top." The bag was sealed with evidence tape and locked the bag inside a cabinet.
- Video footage from the evening of 03/26/24 was reviewed. Patient #68 was observed entering Patient #67 and Patient #77's room at 9:07 PM. Patient #68 was in the room for three minutes and 37 seconds. There were no staff in view of the patient rooms when Patient #68 entered.
- After Patient #68's interview a team meeting was held, and "interim remedies" were discussed for the patients. Patient #67 had already been discharged and the decision was made to move Patient #68 to a different unit for closer observation. The topic of patients' guardians came up and staff were advised "to follow their policies and/or standard procedures that covered providing notifications to guardians."
- On 03/28/24, a copy of the report was sent to Staff MMMM, Title IX Coordinator, and Staff CC Risk/Regulatory Affairs Manager for review and further action.
- On 04/02/24 at 3:59 PM, the determination was made that the case was "dismissed pursuant to Title IX policies because the allegations do not describe a possible violation of the Title IX and circumstances prevented the gathering evidence sufficient to reach a determination as to whether the respondent is responsible for a possible policy violation."
- The matter was referred back to Risk & Regulatory Affairs.

Although requested the Risk & Regulatory Affairs department failed to provide evidence that Patient #67 was interviewed, that either patient's parent/guardian were notified or that education was provided to hospital staff after the incident.

During an interview on at 10/30/24 at 10:25 AM, Staff EEEE, LMSW, stated that when there was an allegation, or sexual offense of some kind, a Title IX request and an incident form would be completed. The only role that hospital staff played would be separating the patients, notifying the parent or guardian and making a note regarding the incident in the patient's nursing progress notes.

During an interview on at 10/31/24 at 1:10 PM, Staff MMMM, Title IX Coordinator, stated that if there was an allegation of abuse, security had a team that would investigate. Any abuse or neglect allegation was potentially a Title IX allegation as well. Security would conduct the investigations and report their findings to both the Title IX department and the hospital's Risk/Regulatory department. Title IX standards were different than the hospital's regulatory standards. If an allegation of abuse had a sexual misconduct component the Title IX investigators would investigate and make a determination. "If the determination was made that an allegation did not meet Title IX standards, that would not mean anything as to whether or not there was abuse or neglect related to a hospital patient. The Title IX team would not have the authority to make that determination, which is why the Risk & Regulatory department should be doing their own parallel investigation. This was how the process used to be, but recently there had not been two different parallel decision-making processes."

During an interview on at 10/31/24 at 2:00 PM, Staff IIIII, Hospital Security Captain, stated that the hospital was required to follow Title IX standards as they were a University that accepted federal funds. The hospital had a Title IX Coordinator who oversaw and understood all of the regulations. When there was an allegation, his team would be asked to go and find "the facts". Security would notify the Title IX Coordination as well as Risk and Regulatory and let them know the allegation they received. They would then review video, speak with staff members and patients involved to find all the details of that event. They would then report their findings to the Title IX Coordinator who would make a determination as to whether or not the allegation fell under Title IX standards. If it did not, the investigation would be referred back to Risk and Regulatory. Any further involvement from the security department would only be if Risk and Regulatory requested their assistance. For this particular investigation, Patient #67 was not interviewed as security does not have any authority outside of the organization and the patient had already discharged. The hospital should have policies for investigative processes and notification of parents or guardians and the hospital staff would need to follow those policies.

During an interview on at 10/31/24 at 3:03 PM, Staff CC, Risk/Regulatory Affairs Manager, stated that typically the Risk and Regulatory department started an abuse and neglect investigation regardless of the Title IX investigation/outcome. This allegation was sent to Title IX for investigation and Risk/Regulatory made a behavioral plan for the patient. "After getting it back from Title IX we assumed they would take care of it, so I take full responsibility for this one not getting done." Going forward there would be a new process to ensure that if an allegation did not fall under Title IX, that on the hospital's end there would be a full and complete investigation, including interviewing all parties involved, notifying all parents, and guardian if that applied, and then determining whether the allegation was substantiated or unsubstantiated.

PATIENT RIGHTS: CONFIDENTIALITY OF RECORDS

Tag No.: A0147

Based on observation, interview and policy review, the hospital failed to safeguard the Protected Health Information (PHI, any information about health status, provision of health care, or payment for health care that can be linked to a specific individual) of patients. This failure had the potential to affect the confidentiality of all patients in the hospital.

Findings included:

Review of the hospital's policy title, "Medical Record Service - Confidentiality of Medical Record Information - Policy," approved 05/14/24, showed patient protected health information (PHI) shall be maintained in a confidential and controlled environment, regardless of whether it is stored in paper or electronic form.

Observation on 10/29/24 at 10:25 AM, on the Progressive Care Unit (PCU) of Hospital B, showed a manila folder, on the ledge of the nurse's station, with papers turned sideways and facing outward. On the paper was the list of room numbers and patient first and last names on that unit. The patient information was visible to anyone that would approach the nurse's station.

Observation on 10/29/24 at 11:13 AM, on the Medical/Surgical Unit of Hospital B, showed a computer workstation on wheels that was left unattended in the hallway. The patient information was visible to anyone walking in the hallway.

During an interview on 10/29/24 at 2:55 PM, Staff TTT, Director of Nursing at Hospital B, stated that she expected staff members to shut down their computer screens when they walked away from their workstations to protect patient's privacy.

During an interview on 10/31/24 at 2:24 PM, Staff PPPP, Chief Nursing Officer (CNO), stated that she expected all staff to protect PHI.

46554

PATIENT RIGHTS: RESTRAINT OR SECLUSION

Tag No.: A0168

Based on interview, record review and policy review, the hospital failed to ensure restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body or head) were ordered by a licensed practitioner (LP) responsible for the care of the patient for five patients (#55, #66, #70, #71 and #79) of six restraint patients reviewed. This failure created an unsafe environment and had the potential to place all patients admitted to the hospital at risk for their safety.

Findings included:

Review of the hospital's policy titled, "Patient Safety - Nonviolent Behavior Restraint Policy," approved 01/17/24, showed an order must be obtained from the LP before a restraint is applied. If emergency application of a restraint is required, a registered nurse (RN) may apply, or delegate application to permissible professionals and then shall request an order immediately.

Review of Patient #55's medical record dated 09/18/24, showed:
- On 09/18/24 at 6:00 PM, nonviolent restraints were applied.
- At 8:00 PM, an order was written for nonviolent restraints, two hours after the restraints were applied.
- On 09/19/24 at 4:00 AM, an order was written to continue nonviolent restraints.
- On 09/22/24 at 4:00 AM, an order was written to continue nonviolent restraints.
- Patient #55 remained in nonviolent restraints on 09/20/24 and 09/21/24 without a restraint order.

Review of Patient #66's medical record dated 10/19/24, showed:
- On 10/20/24 at 6:00 PM, an order was written to initiate nonviolent restraints.
- On 10/22/24 at 4:00 AM, an order was written to continue nonviolent restraints.
- Patient #66 remained in restraints on 10/21/24 without a written restraint order.

Review of Patient #70's medical record dated 09/26/24, showed:
- On 09/27/24 at 8:00 PM, nonviolent restraints were applied.
- On 09/28/24 at 12:00 AM, an order was written for nonviolent restraints, four hours after the restraints were applied.
- On 09/29/24 at 12:00 AM, an order was written to continue nonviolent restraints.
- On 10/01/24 at 12:00 AM, an order was written to continue nonviolent restraints.
- Patient #70 remained in restraints on 09/30/24 without a restraint order.

Review of Patient #71's medical record dated 10/06/24, showed:
On 10/11/24 at 8:00 PM, nonviolent restraints were applied. At 10:00 PM, an order was written for nonviolent restraints, two hours after the restraints were applied.

Review of Patient #79's medical record dated 10/06/24, showed on 04/22/24 at 8:00 PM, violent restraints were applied. At 10:44 PM, an order was written to initiate violent restraints, two hours and 44 minutes after the restraints were applied.

During an interview on 10/31/24 at 2:24 PM, Staff PPPP, Chief Nursing Officer, stated that she expected all restraints had a provider order written within one hour of the restraint application. Delays in obtaining restraint orders did not meet her expectations.

PATIENT RIGHTS: RESTRAINT OR SECLUSION

Tag No.: A0175

Based on interview, record review and policy review, the hospital failed to ensure appropriate monitoring and nursing documentation during the use of restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) for four discharged patients (#55, #66, #70, and #79) of six restraint patients reviewed. This failure created an unsafe environment and had the potential to place all patients admitted to the hospital at risk for their safety.

Findings included:

Review of the hospital's policy titled, "Patient Safety - Nonviolent Behavior Restraint Policy," approved 01/17/24, showed the nurse is to observe and document on the patient at least every two hours.

Review of Patient #55's medical record dated 09/18/24, showed on 09/23/24 at 4:01 AM, a restraint observation was documented. At 8:00 AM, a restraint observation was documented. There were three hours and 59 minutes between restraint observations.

Review of Patient #66's medical record dated 10/19/24, showed on 10/23/24 at 6:00 AM, a restraint observation was documented. At 8:46 AM, a restraint observation was documented. There were two hours and 46 minutes between restraint observations.

Review of Patient #70's medical record dated 09/26/24, showed on 10/03/24 at 6:00 PM, a restraint observation was documented. At 8:58 PM, a restraint observation was documented. There were two hours and 58 minutes between restraint observations.

Review of Patient #79's medical record dated 10/06/24, showed on 04/21/24 at 5:00 AM, a violent restraint observation was documented. At 7:00 AM, a violent restraint observation was documented. There were two hours between violent restraint observations.

During an interview on 10/31/24 at 2:24 PM, Staff PPPP, Chief Nursing Officer, stated that she expected nursing observations were completed and documented as required by the hospital's policy.

NURSING SERVICES

Tag No.: A0385

RN SUPERVISION OF NURSING CARE

Tag No.: A0395

Based on observation, interview, record review and policy review, the hospital failed to:
- Ensure proper insertion of an ultrasound (a test that uses sound waves to create images of structures within the body) guided intravenous (IV, in the vein) catheter for one patient (#78) of one discharged patient reviewed;
- Maintain an effective wound care prevention program that prevented new or worsening wounds from occurring for one patient (#78) of one discharged patient reviewed; and
- Ensure proper hygiene policy was implemented for one (#78) of one discharged patient reviewed.

Findings included:

1. Review of Patient #78's medical record, dated 11/06/23 through 11/18/23, showed:
- On 11/06/23, she was a 90-year-old who was admitted for an obstructed left arteriovenous fistula (AVF, an abnormal connection between an artery and a vein).
- On 11/07/23, a right antecubital (AC, inner elbow) IV was inserted via ultrasound guidance by Staff DDDDD, Registered Nurse (RN).
- On 11/11/23, a nursing note stated that she had reported that her IV was painful. The RN removed the IV and it bled profusely. After 15 minutes of holding pressure at the insertion site, the RN called a physician to the bedside who then consulted vascular surgery (surgery that can be used to treat a wide range of heart and blood flow issues). The vascular team placed a pressure dressing and the bleeding subsided.
- A second nursing note documented that a type and screen (a laboratory test that identifies a person's blood type and screens for unexpected antibodies in the blood that may react with transfused blood products) was obtained in case she needed blood related to the bleeding at the IV insertion site.
- A physician's note documented that they received a page at 4:39 PM after an IV was removed due to pain and continued to bleed. Bleeding was contained while pressure was held but pulsated when released. Vascular surgery was then consulted. A computed tomography angiography (CTA, a combination of x-rays [test that creates pictures of the structures inside the body-particularly bones], computer and intravenous [IV, in the vein] injection of substance to produce detailed images of blood vessels and tissues in the body) was obtained to rule out a thrombus (blood clot formation in a deep vein in an arm or leg). Anticoagulants (drugs used to prevent blood clots) were then held for two days. Informed consent (A process in which patients are given important information, including possible risks and benefits, about a medical procedure or treatment) was obtained in case she required a blood transfusion (to administer blood into a vein).
- A vascular surgery note documented that an IV had been placed in the right brachial artery (the major blood vessel supplying blood to your upper arm, elbow, forearm and hand).
- On 11/12/23, a vascular surgery note documented that she had some associated numbness and tingling. A CTA showed no arterial injury or hematoma (collection of blood below the surface of the skin).

During an interview on 11/04/24 at 4:43 PM, Staff CCCCC, Vascular Surgeon, stated that he had been consulted to assess Patient #78 for a vascular injury after the removal of a line. He stated that typically this would be related to an incorrectly placed arterial line (thin, flexible tube placed into an artery). He was not aware that line was an ultrasound guided peripheral IV.

During an interview on 10/31/24 at 9:11 AM, Staff UUUU, Registered Nurse (RN), stated that she had been called into a room by Patient #78's primary RN. She observed that the patient was bleeding and proceeded to hold pressure so the primary RN could call the physician to the bedside. Vascular surgery was consulted and came to the bedside. She was not aware the IV had been inserted in an artery but did recall that the primary RN had been "squirted in the face" by the blood.

During an interview on 10/29/24 at 11:36 AM, Staff AAAAA, RN, stated that she did not insert this IV, but she was on the vascular access team (VAT) and was qualified to insert such IVs. If an IV had been inserted in an artery she would expect to observe pulsatile blood flow (the rhythmic, intermittent movement of blood through blood vessels) and it would be harder to stop any associated bleeding.

Although requested Staff DDDDD, RN, who placed the IV was not available for interview.

2. Review of the hospital's document titled, "Skin and Wound Care - Skin Impairment Potential for Adolescent/Adult - Clinical Guidelines," dated 03/13/23, showed:
- On admission and each shift a nurse should assess the color and condition of all bony prominences (a part of the body where a bone is close to the skin's surface) and for moisture and incontinence (inability to control urination or bowel movements).
- Mobility was assessed each shift. If the patient was chair bound (unable to get out of a chair), and a moderate or high-risk, sitting time should be limited to no more than one to two hours. Patients who were unable to reposition themselves would receive assistance, and those who were cognitively impaired (the loss of intellectual abilities such as: memory loss and reasoning that interfere with daily living) would receive verbal cues with observation by staff. Bed bound patients would be turned every two hours.
- Interventions was based on a Braden Scale (an assessment tool for predicting the risk of bed sores or pressure ulcers) subscale score. The subcategories were mobility, activity, sensory perception, moisture, friction and shear and nutrition. If a subscale score was below four in mobility, sensory perception or friction and shear they would require a turn schedule or assistive device to prevent injury.

Review of the hospital's undated document titled, "Hospital Acquired Pressure Injury Prevention Bundle," showed:
- The bundle applied to all patients.
- The patient should be turned and repositioned at least every two hours.
- A Braden Scale score should be calculated every shift and as needed for changes with the patient.

Review of the hospital's document titled, "Skin and Wound Care - Four Eyes in Four Hours - Guideline," dated 08/15/23, showed:
- The four eyes in four hours skin assessment was used to identify skin issues within the first four hours of admission.
- Two staff members were to assess a patient's skin for impairments within four hours of arrival to their unit.
- Staff were to look at the patient's skin from head to toe and confirm the assessment and charting were correct.

Review of Patient #78's undated document titled, "Admission Skin Assessment - Four Eyes in Four Hours," showed:
- A skin assessment was verified by a second staff member.
- The sacrum (triangular shaped bone above the tailbone) was assessed and intact.
- Imaging did not reveal tissue injury presence.

Review of Patient #78's medical record, dated 10/01/23 through 10/13/23, showed:
- On 10/01/23, she was admitted for abdominal pain.
- On 10/03/23 at 2:27 AM, a nursing care plan for "skin/wound high risk" was initiated. The outcome was for the patient to remain free of skin breakdown or further impairment. The expectation was noted to be met.
- Her care plan interventions included "turn schedule established" from 10/11/23 at 9:51 AM through 10/13/23 at 9:00 AM; "education regarding pressure injury prevention" from 10/03/23 at 7:54 AM; and "disposable incontinence pad in use" from 10/03/23 at 9:00 PM through 10/13/23 at 9:00 AM.
- Her total Braden Scale score was documented as 18 or below from 10/02/23 at 10:00 PM through 10/13/23 at 8:00 AM.
- There were 35 instances in which no repositioning was charted at the ordered every two-hour interval. There were eight instances where the same position was charted consecutively for four or more hours. There were three instances where a refusal to turn was charted.
- On 10/03/23, 10/09/23, 10/10/23 and 10/12/23, physical therapy notes documented that she required assistance for all bed mobility, transfers and ambulation.
- On 10/06/23 and 10/12/23, a nutrition note documented that skin was noted to be intact per nursing. She had been identified as moderately malnourished with mild muscle wasting and protruding clavicles.
- On 10/13/23 at 3:50 PM, she was discharged to Facility B.

Review of Patient #78's medical record from Facility B, dated 10/13/23, showed:
- On 10/13/23 at 6:22 PM, she was admitted to the facility for rehabilitation (the action of restoring someone to health or normal life through training and therapy).
- Her Braden Scale subcategory total for sensory perception, mobility and friction and shear all scored less than four.
- Her skin assessment showed a Stage two pressure injury (a shallow opening in the skin with red or pink tissue or may present as a fluid filled blister) was present on her intergluteal cleft (the groove that runs between the buttocks, from the sacrum to the perineum) on admission. It measured 2.9 centimeters (cm) by 0.7 cm.

Review of Patient #78's medical record, dated 10/24/23 through 10/31/23, showed:
- On 10/24/23, she was admitted for uncontrolled pain.
- On 10/25/23 at 1:08 AM, a skin team consult was submitted for a pressure injury.
- On 10/25/23 at 5:17 PM, a right gluteal stage three pressure injury was identified. It measured 4.0 cm by 3.0 cm by 0.1 cm.

During an interview on 10/31/24 at 2:24 PM, Staff PPPP, Chief Nursing Officer (CNO), stated that she expected staff to turn patients and complete thorough skin assessments.

During an interview on 10/30/24 at 12:31 PM, Staff ZZZZ, Inpatient Nursing Director, stated that she expected staff to follow protocol and turn patients every two hours. The gaps in repositioning could have contributed to the skin breakdown Patient #78 experienced.

During a telephone interview on 11/04/24 at 10:30 AM, Staff BBBBB, RN, stated that if a patient's Braden Scale total score was 18 or less the expectation was to ensure they were turned every two hours. Patient care technicians shared that responsibility, but ultimately the nurse was responsible. If a patient were to refuse a turn, she had many ways to document that. She felt the expectations on her unit were very high and turns may not have been one of her priorities.

During an interview on 10/30/24 at 2:54 PM, Staff WWWW, RN, stated that she would consider Patient #78 to be at high risk of developing a pressure injury. The wound did not look new when she observed it during her second admission. She would expect nursing staff to thoroughly assess for skin injuries.

During an interview on 10/31/24 at 10:37 AM, Staff SSSS, Hospitalist (physician whose primary professional focus is the general medical care of hospitalized patients), stated that Patient #78 was at a high risk for developing pressure injuries. She would expect staff to implement preventative measures such as frequent turns and thorough skin assessments.

During an interview on 10/31/24 at 12:40 PM, Staff OOOO, Regulatory Affairs, stated that Patient #78 had a Braden Scale subcategory score of less than four for mobility, sensory perception or friction and shear for all total scores of 18 or less. This indicated that nursing staff should have turned her at least every two hours. The document titled, "Admission Skin Assessment - Four Eyes in Four Hours," was the only assessment she could find for Patient #78's first admission and it was completed on 10/01/23.

3. Review of the hospital's document titled, "Skin and Wound Care - Skin Impairment Potential for Adolescent/Adult - Clinical Guidelines," dated 03/13/23, showed elderly and/or patients with fragile skin should receive a daily bath.

Review of Patient #78's medical record, dated 10/01/23 through 10/13/23, showed she was bathed on three of 12 days. There were no documented instances of a refusal to bathe.

Review of Patient #78's medical record, dated 10/24/23 through 10/31/23, showed she was bathed on five of seven days, one of which was noted to have been completed by her family. She refused a bath once.

Review of Patient #78's medical record, dated 11/06/23 through 11/18/23, showed she was bathed on eight of 12 days. She refused a bath on one day.

Review of Patient #78's medical record, dated 11/25/23 through 12/29/23, showed she was bathed on 21 of 34 days. There were no documented instances of a refusal to bathe.

During an interview on 10/30/24 at 12:31 PM, Staff ZZZZ, Inpatient Nursing Director, stated that she expected staff to offer every patient assistance with bathing daily. If a patient were to refuse it should be documented.

50321

ADMINISTRATION OF DRUGS

Tag No.: A0405

Based on interview, record review and policy review, the hospital failed to ensure that staff followed the hospital policies when they failed to perform pain reassessments in a timely manner after pain medication administration for two patients (#78 and #28) of two patients observed.

Findings include:

Review of the hospital's document titled, "Pain Management - Policy," dated 10/09/23, showed:
- Pain would be assessed and managed by screening patients for the presence and absence of pain, assessing and reassessing for pain and measuring pain levels by using standardized tools.
- Pain would be reassessed before and after each as needed pharmacologic intervention. If a pain medication was scheduled routinely a pain assessment would be completed with vital signs (VS, measurements of the body's most basic functions).
- A pain assessment would be documented prior to and after each as needed medication administration. Intravenous (IV, in the vein) medications required an assessment within 30 minutes of administration, and oral or intramuscular (IM, within the muscle) required an assessment within 60 minutes after administration.

Review of Patient #78's medical record, dated 10/01/23 through 10/31/23, showed:
- On 10/01/23, IV pain medications were administered at 9:00 AM and 10:29 AM. A pain scale assessment (pain rating on a scale of zero to ten, zero means no pain and a ten means worst pain possible) was not completed within 30 minutes after administration.
- On 10/02/23, an IV pain medication was administered at 9:17 AM. A pain scale assessment was not completed within 30 minutes after administration.
- On 10/12/23, an IV pain medication was administered at 9:18 PM. A pain scale assessment was not completed within 30 minutes after administration.

Review of Patient #78's medical record, dated 10/24/23 through 10/31/23, showed:
- On 10/25/23, an oral pain medication was administered at 8:53 AM. A pain scale assessment was not completed within 60 minutes after administration. A pain scale assessment score of 0 was recorded before administration of pain medication at 8:53 AM
- On 10/26/23, an oral pain medication was administered at 5:18 PM. A pain scale assessment was not completed within 60 minutes after administration.
- On 10/30/23, an oral pain medication was administered at 11:26 PM. A pain scale assessment was not completed within 60 minutes after administration.

Review of Patient #78's medical record, dated 11/06/23 through 11/18/23, showed:
- On 11/09/23, oral pain medications were administered at 9:57 AM and 8:24 PM. A pain scale assessment was not completed between 3:44 PM and 11/10/23 at 9:00 PM.
- On 11/13/23, an oral pain medication was administered at 1:48 AM. A pain scale assessment was not completed within 60 minutes after administration.
- On 11/15/23, an oral pain medication was administered at 11:01 PM. A pain scale assessment was not completed within 60 minutes after administration.

Review of Patient #78's medical record, dated 11/25/23 through 12/29/23, showed:
- On 11/30/23, an oral pain medication was administered at 1:39 AM. A pain scale assessment was not completed within 60 minutes after administration.
- On 12/02/23, an oral pain medication was administered at 11:52 PM. A pain scale assessment was not completed within 60 minutes after administration.
- On 12/04/23, an oral pain medication was administered at 3:51 AM. A pain scale assessment was not completed within 60 minutes after administration.
- On 12/29/23, oral pain medications were administered at 12:49 AM and 3:33 AM. A pain scale assessment was not completed within 60 minutes after administrations.

Review of Patient #28's medical record, dated 10/27/24, showed on 10/28/24 at 6:49 AM, oral pain medication was administered. A pain scale assessment was not completed within 60 minutes after administration.

During an interview on 10/31/24 at 2:24 PM, Staff PPPP, Chief Nursing Officer (CNO), stated that she expected staff to follow the pain assessment and reassessment policy.

During an interview on 10/29/24 at 11:00 AM, Staff FF, Women's Services Manager, stated that a pain reassessment was required within one hour of oral pain medication administration.

During an interview on 10/31/24 at 9:11 AM, Staff UUUU, Registered Nurse (RN), stated that pain assessments should be completed with vital signs and before administration of pain medication. Vital signs were scheduled every four hours for patients, typically. Pain should be reassessed within 30 minutes if a medication was given IV and within 60 minutes if given orally.

50321

BLOOD TRANSFUSIONS AND IV MEDICATIONS

Tag No.: A0410

Based on observation, interview and policy review, the hospital failed to ensure safe patient monitoring and infusion rate for one patient (#73) of three patients who received a blood transfusion (to administer blood into a vein) reviewed.

Findings included:

Review of the hospital's policy titled, "Blood Product Transfusion," dated 05/09/22, showed:
- Vital signs (VS, measurements of the body's most basic functions) were to be recorded prior to the transfusion, 15 minutes after the transfusion started and at completion.
- Blood transfusions were to start at a rate of approximately 2 milliliters (ml) per minute (120 ml per hour) for the first 15 minutes.
- Staff were to remain with or able to closely observe the patient for the first 15 minutes of the infusion to observe for adverse reactions.

Review of Patient #73's medical record, dated 10/30/24, showed a blood transfusion started at 12:15 PM and VS were recorded at that time. VS were next recorded at 2:26 PM when the transfusion ended.

Observation on 10/30/24 showed Staff ZZZ, Registered Nurse (RN), obtain VS at 12:15 PM and started the blood transfusion for Patient #73 at 12:20 PM. He obtained VS at 12:30 PM, then left the patient's room. The transfusion was initiated at a rate of 175 ml per hour.

During an interview on 10/31/24 at 2:25 PM, Staff PPPP, Chief Nursing Officer (CNO), stated that she expected blood transfusion rates, patient observation and VS monitoring should follow hospital policy for all patient receiving blood transfusions.

INFECTION PREVENTION CONTROL ABX STEWARDSHIP

Tag No.: A0747

INFECTION CONTROL PROGRAM

Tag No.: A0749

Based on observation, interview, and policy review, the hospital failed to:
- Perform hand hygiene (washing hands with soap and water or alcohol-based hand sanitizer) and glove changes when providing care for 15 patients (#3, #4, #5, #6, #27, #28, #35, #36, #40, #47, #52, #62, #63, #72 and #73) of 38 patients observed;
- Label intravenous (IV, in the vein) sites and tubing for nine (#1, #3, #4, #29, #31, #47, #50, #62 and #63) patients of 28 patients observed;
- Follow asepsis technique for a sterile (completely clean and free from germs) procedure for one patient (#27) of one sterile procedure observed;
- Prepare a clean work surface prior to performing patient care for 10 patients (#3, #4, #7, #25, #26, #27, #35, #40, #52 and #72) of 14 patients observed;
- Scrub the rubber stopper of an injectable medication vial for two patients (#3 and #27) of 8 patients observed;
- Remove expired food in five departments of 29 departments observed;
- Remove expired supplies on five units of 26 units observed;
- Remove wet blankets/towels from under the sink/counter in two patient nutrition rooms of 17 patient nutrition rooms observed;
- Discard one used disposable gown and three dirty towels in the decontamination room of Sterile Processing;
- Laminate paper hung on walls in patient care areas to create a cleanable surface on six units of six units observed;
- Clean a microwave and refrigerator in two patient nutrition rooms of 17 patient nutrition rooms observed;
- Remove a staff members personal item from a food dry storage area in one kitchen of three kitchens observed; and
- Follow their Infection Prevention Plan to maintain a sanitary environment.

Findings included:

1. Review of the hospital's policy titled, "Infection Prevention and Control Program - 2024 Infection Control Manual," approved 11/20/23, directed staff to:
- Perform hand hygiene before and after any patient contact, prior to applying gloves and after glove use and after touching beds or bedside objects (patient equipment, computers, handrails, nightstands, phones, etc.);
- Perform hand hygiene before performing a clean or invasive procedure, after handling body fluid, after touching the patient, environment, or objects involved in the patients' care, after removing gloves and between glove changes.
- Perform frequent hand hygiene.
- Gloves shall be worn as an additional measure, not as substitute for hand hygiene.
- Wear non-sterile, disposable, single-use gloves for direct contact with patient's mucous membranes, blood, body fluids, moist body substances and non- intact skin.
- Wear gloves for handling potentially infectious materials or in contact with contaminated items and/or surfaces.
- Standard precautions are used for all patient care. Provides a consistent approach to managing patient body substances to protect healthcare providers from infection and prevention to prevent the spread of infection from patient to patient.

Review of the hospital's document titled, "Hand Hygiene Compliance," dated 08/04/24 through 10/26/24, showed hand hygiene compliance ranged from 88.6 percent to 91.2 percent.

Observation on 10/28/24 at 2:00 PM, of the Medical Intensive Care Unit (ICU, a unit where critically ill patients are cared for), showed Staff C, RN, failed to perform hand hygiene between glove changes in Patient #5's room. Staff C failed to change gloves and perform hand hygiene when she touched the patient then touched the IV tubing, bag and pump and then administered an IV medication.

Observation on 10/28/24 at 2:10 PM, of the Surgical unit, showed Staff F, RN, failed to perform hand hygiene prior to entering Patient #3's room and between glove changes. Staff F failed to change gloves and perform hand hygiene when she touched the patient then touched the keyboard and then administered a subcutaneous (under the skin) medication.

Observation on 10/28/24 at 2:29 PM, of the ICU, showed Staff D, RN, failed to perform hand hygiene between glove changes in Patient #6's room. Staff D failed to perform hand hygiene when she donned three pairs of clean gloves layered over each other to provide personal care following a bowel movement, she then removed each layer of gloves with each patient touch. She then failed to perform hand hygiene prior to reaching into the clean glove box and donning additional clean gloves and completing personal care to the patient. She touched the patient with gloved hands and entered a clean drawer with clean supplies without removing the gloves or performing hand hygiene.

Observation on 10/28/24 at 2:50 PM, of the Surgical ICU, showed Staff H, RN, failed to perform hand hygiene prior to donning gloves. Staff H failed to change gloves and perform hand hygiene when she picked up trash from the floor then retrieved supplies from a cart and placed a dressing on the Patient #4's injection site.

Observation on 10/29/24 at 10:00 AM, of the Progressive Care Unit (PCU) at Hospital B, showed Staff VV, RN, failed to perform hand hygiene before donning gloves when he provided care to Patient #40.

Observation on 10/29/24 at 10:35 AM, of the nursery unit, showed Staff GG, Pediatric Resident (doctor in training), failed to perform hand hygiene prior to donning and removing gloves when she provided care to Patient #27.

Observation on 10/29/24 at 10:50 AM, of the post-partum unit (hospital unit where healthy mothers and babies are transferred after delivery on an inpatient labor, delivery, and recovery unit where they stay until they are discharged), showed Staff FF, Women's Services Manager, failed to perform hand hygiene prior to entering Patient #28's room.

Observation on 10/29/24 at 10:57 AM, of the Surgical unit at Hospital B, showed Staff XXX, patient care technician (PCT), failed to perform hand hygiene while performing Patient #62's bedside blood glucose (sugar that circulates in the blood and when too high or too low can be detrimental to a person's health) testing. Staff XXX failed to change gloves and perform hand hygiene when she touched the patient to collect the patient's vital signs, then touched the blood glucose tester to insert the testing strip. She then collected the fingertip blood sample.

Observation on 10/29/24 at 11:01 AM, of the Integrated Medicine Unit, showed Staff YY, RN, failed perform hand hygiene before donning gloves, and proceeded to touch the patient scanner without a glove change when she provided care to Patient #36.

Observation on 10/29/24 at 11:09 AM, of the Surgical unit at Hospital B, showed Staff XXX, patient care technician (PCT), failed to perform hand hygiene while performing Patient #63's bedside blood glucose testing. Staff XXX failed to change gloves and perform hand hygiene when she touched the patient to collect the patient's vital signs, then touched the blood glucose tester to insert the testing strip. She then collected the fingertip blood sample.

Observation on 10/29/24 at 11:17 AM, of the Integrated Medicine Unit, showed Staff ZZ, RN, failed to perform hand hygiene before donning gloves when she provided care to Patient #35.

Observation on 10/29/24 at 3:20 PM, of Hospital C, showed Staff MMM, Patient Care Technician, failed to perform hand hygiene prior to entering Patient #52's room and before donning and after removing gloves. Staff LLL, failed to perform hand hygiene prior to entering Patient #52's room.

Observation on 10/29/24 at 12:00 PM, of the Medicine Unit, showed Staff ZZZZ, RN, failed to perform hand hygiene before donning and after removing gloves when performing wound care for Patient #72.

Observation on 10/29/25 at 12:10 PM, of the Medicine Unit, showed Staff ZZZZ, RN, failed to perform hand hygiene before donning gloves and after removing gloves when providing care to Patient #73.

Observation on 10/29/24 at 3:20 PM, of Hospital B, showed Staff GGG, RN, failed to apply gloves prior to priming tubing for a blood transfusion (to administer blood into a vein). Staff GGG also failed to perform hand hygiene between gloves changes four separate times when moving from a dirty area to a clean area when providing care to Patient #47.

During an interview on 10/31/24 at 2:24 PM, Staff PPPP, Chief Nursing Officer (CNO), stated she expected staff to follow the hand hygiene policy. Staff were to change gloves and perform hand hygiene when moving from a dirty area to a clean area.

During an interview on 10/30/24 at 3:30 PM, Staff LLLL, Infection Control Manager, stated she expected staff to perform hand hygiene before entering a patient's room, after touching a patient, when moving from a dirty area to a clean area and between glove changes. The patient environment was considered dirty. She expected clean hands when removing supplies from the patient's supply carts. Triple gloving was not acceptable.

2. Review of the hospital's policy titled, "Vascular Access (IV) - Clinical Guidelines" dated 08/20/24, showed that all IVs and lines should be labeled with the date and time they were changed.

Observation on 10/28/24 at 11:18 AM, of Hospital C, showed Patient #50's IV insertion site was not labeled with a date or time.

Observation on 10/28/24 at 2:05 PM, of the Surgical Unit, showed Patient #1's IV tubing was not labeled with a date or time. The IV tubing was looped and connecting to the side port.

Observation on 10/28/24 at 2:10 PM, of the Surgical Unit, showed Patient #3's IV insertion site was not labeled with a date or time.

Observation on 10/28/24 at 2:50 PM, of the Surgical ICU, showed two of Patient #4's IV tubing were not labeled with a date or time.

Observation on 10/29/24 at 10:35 AM, of Hospital C, showed Patient #47's four different sets of IV tubing were not labeled with a date or time.

Observation on 10/29/24 at 10:57 AM, of the Surgical Unit, showed Patient #62's IV insertion site was not labeled with a date or time.

Observation on 10/29/24 at 11:09 AM, of the Surgical Unit, showed Patient #63's IV insertion site was not labeled with a date or time.

Observation on 10/29/24 at 11:18 AM, of the Labor and Delivery Unit, showed Patient #29's IV insertion site and two IV tubings were not labeled with a date or time.

Observation on 10/29/24 at 1:00 PM, of the Cardiovascular Unit, showed Patient #31's IV insertion site was not labeled with a date or time.

During an interview on 10/31/24 at 2:24 PM, Staff PPPP, CNO, stated she expected IV tubing and sites to be labeled according to the hospital' policy.

During an interview on 10/30/24 at 3:30 PM, Staff LLLL, Infection Control Manager, stated she expected all IV sites and tubing to labeled according to the hospital's policy. She was not surprised the IV tubing and sites were not labeled.

3. Review of the hospital's policy titled, "Infection Prevention and Control Program - 2024 Infection Control Manual," approved 11/20/23, showed:
- Critical items are defined as items which enter sterile tissue, or the vascular system, and must be sterile.
- If sterility is compromised prior to use, the item must be re-sterilized or discarded if it is a single use item.
- If any patient care item is touched with unclean hands or contaminated gloves, then it should be disinfected as soon as possible.

Observation on 10/29/24 at 10:35 AM, of the Nursery Unit, showed Staff GG, Resident, placed a dirty diaper on the counter next to surgical supplies. She opened and donned sterile gloves next to the dirty diaper prior to performing a circumcision on Patient #27.

Observation on 10/29/24 at 10:40 AM, of the Nursery Unit, showed Staff HH, Physician, placed an unopened instrument package on the sterile field. Staff GG, Pediatric Resident Physician opened the instrument package and failed to perform hand hygiene and a sterile glove change prior to completing a circumcision on Patient #27.

During an interview on 10/29/24 at 10:35 AM, Staff HH, Physician, stated a circumcision was "not the most sterile procedure, but we did our best to keep it sterile."

During an interview on 10/31/24 at 2:24 PM, Staff PPPP, CNO, stated she expected surgical instruments were not dropped on the sterile field in their packages. She expected surgical instruments to be opened using a sterile technique and diapers were to be discarded, not placed on the counter next to patient care supplies.

During an interview on 10/30/24 at 3:30 PM, Staff LLLL, Infection Control Manager, stated a circumcision was a "clean procedure." It was not acceptable to drop a dirty package on the sterile field. She expected a sterile glove change after the instrument package was opened prior to returning to the procedure. Clean and dirty items were to be separated. The dirty diaper was to be discarded, not placed on the counter next to the circumcision procedure supplies.

4. Review of the hospital's policy titled, "Infection Prevention and Control Program - 2024 Infection Control Manual," approved 11/20/23, showed:
- If any patient care item is touched with unclean hands or contaminated gloves, then it should be disinfected as soon as possible.
- Clean and disinfect patient care equipment and environmental surfaces.
- Draw up all medications in a clean medication preparation area.
- Prepare medications in areas physically separated from those with potential blood/body fluids contamination.
- Use barriers to protect surfaces from blood contamination.

Observation on 10/28/24 at 2:10 PM, of the Surgical Unit showed Staff F, RN, failed to provide a clean barrier for medication administration when she placed the medication on Patient #3's counter.

Observation on 10/28/24 at 2:50 PM, of the Surgical ICU, showed Staff H, RN, failed to provide a clean barrier for medication administration when she placed the medication on Patient #4's counter.

Observation on 10/29/24 at 10:35 AM, of the Nursery Unit, showed Staff GG, Resident, failed to provide a clean barrier for medication administration when she placed the medication on the treatment room counter for Patient #27.

Observation on 10/29/24 at 10:00 AM, of the Family Medicine Unit, showed Staff VV, RN, failed to provide a clean barrier for medication administration when he prepared an IV medication on Patient #40's computer workstation.

Observation on 10/29/24 at 11:17 AM, of the Integrated Medicine Unit, showed Staff ZZ, RN, failed to provide a clean barrier for medication administration when he placed a medication on Patient #35's counter.

Observation on 10/29/24 at 11:35 AM, of Hospital C, showed Staff K, RN, failed to provide a clean barrier for medication administration when she placed the medication on Patient #7's blanket in his wheelchair.

Observation on 10/29/24 at 3:10 AM, of Hospital C, showed Staff MMM, Patient Care Technician (PCT), failed to provide a clean barrier for blood sugar supplies for Patient #52.

Observation on 10/29/24 at 11:10 AM, of the Post Anesthesia Care Unit (PACU), showed Staff Y, RN, failed to provide a clean barrier for patient supplies when removing an arterial line from Patient #25.

Observation on 10/29/24 at 11:55 AM, of the Emergency Department (ED), showed Staff BB, RN, filed to provide a clean barrier for patient supplies when starting an IV on Patient #26.

Observation on 10/30/24 at 12:00 PM, of the Medicine Unit, showed Staff ZZZZ, RN, failed to provide a clean barrier for patient supplies when providing wound care for Patient #72.

Observation on 10/29/24 at 12:10 PM, of the Medicine Unit, showed Staff ZZZZ, RN, grasped the sterile end of blood tubing with his gloved hand while providing care to Patient #72.

During an interview on 10/31/24 at 2:24 PM, Staff PPPP, CNO, stated she expected a clean surface and/or barrier for patient care supplies and medications.

During an interview on 10/30/24 at 3:30 PM, Staff LLLL, Infection Control Manager, she expected a clean surface and/or barrier was in place for patient care supplies and injectable medication administrations. It was unacceptable to place patient care supplies and/or medications on the patient blanket.

5. Review of the hospital's policy titled, "Infection Prevention and Control Program - 2024 Infection Control Manual," approved 11/20/23, directed staff to disinfect medication vial by rubbing the diaphragm with alcohol.

Observation on 10/29/24 at 10:35 AM, of the Nursery Unit, showed Staff GG, Pediatric Resident Physician, failed to scrub the rubber stopper of an injectable medication vial prior to withdrawing the medication for administration to Patient #27.

Observation on 10/28/24 at 2:50 PM, of the Surgical ICU, showed Staff H, RN, wiped Patient #3's injection site with a used alcohol wipe that was on the patient's blanket.

During an interview on 10/31/24 at 2:24 PM, Staff PPPP, CNO, stated she expected staff to follow the policy for medication administration.

6. Review of the hospital's policy titled, "Dietary Services - Dining & Nutrition - Food Receiving Storage and Labeling - Guideline," dated 12/08/23, showed:
- All items shall be stored in sealed, original containers or in Dining and Nutrition Services (DNS) approved containers with tight covers that have been labeled with content and dated.
- All food items in refrigerators and freezers are properly dated, labeled and covered.
- Canned food items and juices are not stored in open cans. After opening, the food is transferred to non-corrosive containers with tight fitting lids, dated and labeled.

Review of the hospital's policy titled, "Dietary Services - Dining & Nutrition - Floor Stock - Guideline" dated 06/12/23, showed the DNS assigned to an inpatient unit will be responsible for discarding expired food and beverage items.

Observation on 10/28/24 at 2:35 PM, of the Surgical Unit, showed single serving cracker packages without expiration dates.

Observation on 10/28/24 at 2:40 PM, of the Surgical ICU patient nutrition room, showed one bottle of multi-serving instant coffee grounds without an open date.

Observation on 10/29/24 at 9:55 AM, of the Post-Partum Unit patient nutrition room, showed single serving packages of pepper, salt, cheese slices and cheese sticks without expiration dates. A nipple therapy pack, patient care supply, was in the nutrition freezer.

Observation on 10/29/24 at 2:45 PM, of Hospital C's patient nutrition room number one, showed two multi-serving creamer bottles without open dates. Packages of hot cocoa mix, sweetener, creamer, peanut butter, salt, pepper, honey, syrup, jelly, ketchup, cream of wheat, mayonnaise, broth, crackers, cheese sticks, cheese slice and butter without expiration dates.

Observation on 10/29/24 at 3:10 PM, of Hospital C's patient nutrition room number two, showed packages of creamer, tea bags, sweetener, mustard, honey, mayonnaise, ketchup, lemon juice, peanut butter, sugar, syrup, hot cocoa, oatmeal, butter, cheese sticks and cheese slices without expiration dates.

Observation on 10/29/24 at 3:50 PM, of Hospital C's kitchen, showed packages of creamer, jelly, peanut butter, mayonnaise, salad dressing, syrup, hot sauce, ketchup, mustard, croutons, salt, sweetener, pepper, hot cocoa and oatmeal without expiration dates. Single serve containers of granola, brown sugar, cinnamon and oil-vinegar without open or expiration dates.

Observation on 10/29/24 at 4:00 PM, of Hospital C's kitchen, showed one container of seasoning salt with an expiration date of 08/29/24. A second expiration sticker was placed on the container with an expiration date of 08/15/25. One can of vegetable spray, one box of salt, one bottle of soy sauce, one box of corn starch, one bottle of oyster sauce, one bottle of vanilla extract, one bag of seasoned salt, one bag of flour, two bags of brown sugar, one bag of pancake mix, on package of dry pasta, one bag of gravy mix and one bag of potato pearls without open or expiration dates.

Observation on 10/29/24 at 4:00 PM, of Hospital C's kitchen refrigerator, showed one container of whipped topping, six bags of pizza crust, 3 bags of dinner rolls, seven bags of English muffins, one jar of pickles and one bottle of salad dressing without open or expiration dates.

Observation on 10/29/24 at 10:00 AM, of Hospital A's kitchen refrigerator, showed undated grapes, raspberries, tomatoes, lettuce salads, and strawberries.

Observation on 10/29/24 at 10:15 AM, of Hospital A's kitchen freezer, showed an opened, undated bag of sausage links and an undated bag of hamburger patties.

Observation on 10/29/24 at 10:35 AM, of Hospital A's peri-op refrigerator, showed three sandwiches past their expiration dates.

During an interview on 10/31/24 at 2:24 PM, Staff PPPP, CNO, stated she expected all food items to have visible expiration dates. When food items were opened, they were to be marked with open and expiration dates.

During an interview on 10/30/24 at 3:30 PM, Staff LLLL, Infection Control Manager, stated the dietary department stocked and rotated food in the patient nutrition areas. She expected all products to have expiration dates in the patient nutrition rooms and kitchens. Placing a new expiration date on an expired item was unacceptable.

7. Review of the hospital's policy titled, "Infection Prevention and Control Program - 2024 Infection Control Manual," approved 11/20/23, directed staff to conduct period inspections of facilities and equipment which may contribute to infectious hazards.

Observation on 10/28/24 at 2:30 PM, of the Pediatric (pertaining to children) ICU, showed 10 expired needle guide kits.

Observation on 10/29/24 at 9:45 AM, of the PCU, showed 25 expired size six sterile gloves.

Observation on 10/29/24 at 10:00 AM, of the Post-Partum Unit, showed 11 expired tubes of sterile water. One expired specimen swab, seven open cotton tipped vaginal swabs and four packages of expired sterile gloves.

Observation on 10/29/24 at 2:45 PM, of Hospital C's medication room, showed nine oral syringes not in packages and 22 expired needles.

Observation on 10/29/24 at 10:55 AM, of the PACU, showed five expired IV catheters in a cart labeled "Airway Cart," five expired blades used for intubation in a cart labeled "Intubation Cart," and two expired sheaths in a cart labeled "Line Cart."

During an interview on 10/31/24 at 2:24 PM, Staff PPPP, CNO, stated it was every staff members responsibility to ensure expired supplies were not in patient care areas. The distribution team was responsible to rotate supply stock. Oral syringes and vaginal swabs were to be in sealed packages.

During an interview on 10/30/24 at 3:30 PM, Staff LLLL, Infection Control Manager, stated the distribution department was responsible for rotating and evaluating expiration dates for supplies. She was surprised expired supplies were in the patient care areas.

8. Review of the hospital's policy titled, "Infection Prevention and Control Program - 2024 Infection Control Manual," approved 11/20/23, showed:
- Only cleaning products and heavy-duty utility gloves may be stored under any sink within MUHC.
- All soiled linens are to be placed in laundry bags provided by Linen Services while avoiding contact with clothes.
- Soiled linens that are lightly to moderately moist should be folded and/or rolled in such a way as to contain the moist area in the center of soiled linen; and
- Soiled linens that are saturated with moisture should be placed in a plastic bag and tightly secured.

Observation on 10/29/24 at 12:30 PM, of the Integrated Medicine Unit, showed a portable fan under a sink in the patient nutrition room.

Observation on 10/29/24 at 12:49 PM, of the Cardiovascular Unit, showed a plastic basin holding a water filter under the sink in the patient nutrition room.

Observation on 10/29/24 at 2:45 PM, of Hospital C's patient nutrition room number one, showed a metal tank in a cabinet under the counter with blankets wrapped around the base of the tank. Three cases of soda were next to the tank and blankets.

During an interview on 10/31/24 at 2:24 PM, Staff PPPP, CNO, stated she expected leaks to be repaired to ensure blankets and buckets were not under the counters collecting leaking water/condensation. Soda was not to be stored next to wet blankets.

During an interview on 10/30/24 at 3:30 PM, Staff LLLL, Infection Control Manager, stated only cleaning supplies were to be stored under the sinks. It was "not good" that soda cans were in a cabinet with blankets wrapped around a tank to collect condensation.

During an interview on 10/30/24 at 2:29 PM, Staff HHHH, Facilities Director, stated it was unacceptable for blankets to be in a cabinet wrapped around a tank to collect condensation. She expected the unit staff members to clean the microwaves and refrigerators.

During an interview on 10/29/24 at 12:30 PM, Staff AAA, Service Line Specialist, stated it was her expectation for the area under the sink to remain clear.

During an interview on 10/29/24 at 12:49 PM, Staff AAA, Service Line Specialist, stated the plastic bin had been placed in case the filter leaked.

9. Review of the hospital's policy titled, "Infection Prevention and Control Program - 2024 Infection Control Manual," approved 11/20/23, showed after use, remove gown promptly and discard. All soiled linens are to be placed in laundry bags provided by Linen Services while avoiding contact with clothes.

Observation on 10/29/24 at 11:45 AM, of Sterile Processing, showed one used disposable gown placed on the decontamination sink, one dirty washcloth laying on the floor and two dirty washcloths on the shelf above the decontamination sink.

During an interview on 10/31/24 at 2:24 PM, Staff PPPP, CNO, stated she expected disposable gowns to be discarded when removed, not left on the decontamination sink.

During an interview on 10/30/24 at 3:30 PM, Staff LLLL, Infection Control Manager, stated disposable gowns used in the Sterile Processing Department were to be discarded when removed, not placed on the decontamination sinks.

10. Review of the undated Center for Disease Control and Prevention Best Practices for Environmental Cleaning in Healthcare Facilities Version Two showed wall surfaces should be washable.

Observation on 10/29/24 at 9:55 AM, in the Post-Partum Unit, showed paper taped to the wall in the nutrition room, hallways and supply room.

Observation on 10/29/24 at 10:15 AM, of the Nursery Unit, showed paper taped to the walls in the nurses' station, treatment room and soiled utility room.

Observation on 10/29/24 at 11:10 AM, of the Labor and Delivery Unit, showed paper taped to the wall in the anesthesia work area and nurses' station.

Observation on 10/29/24 at 11:30 AM, of the Neonatal Intensive Care Unit (NICU, unit for premature and ill newborns) showed paper taped to the hallway walls.

Observation on 10/29/24 at 2:45 PM, of Hospital C showed paper taped to the hallway walls, two medication rooms and nutrition room number two walls.

Observation on 10/29/24 at 3:50 PM, of Hospital C's kitchen, showed paper taped to the walls.

During an interview on 10/30/24 at 3:30 PM, Staff LLLL, Infection Control Manager, stated unlaminated paper was to be limited in patient care areas. Paper hanging on the walls was an infection prevention concern. Unlaminated paper and tape residue should not be in the areas of terminal cleaning.

11. Review of the hospital's policy titled, "Infection Prevention and Control Program - 2024 Infection Control Manual," approved 11/20/23, showed items that are routinely shared shall be cleaned and disinfected. Procedures shall be established for assigning responsibility and accountability for routine cleaning.

Review of the hospital's policy titled, "Dietary Services - Dining & Nutrition - Floor Stock - Guideline" dated 06/12/23, showed the DNS assigned to an inpatient unit will be responsible for cleaning the refrigerator.

Observation on 10/28/24 at 2:00 PM, of the Medical Specialties Unit, showed the refrigerators in the patient nutrition rooms on both the east and west end were dirty and appeared to have has a spill in both refrigerators that had dried. Popcorn, crackers, and visible grime were seen below the microwave on the west end.

Observation on 10/29/24 at 2:45 PM, of Hospital C's patient nutrition room number one, showed the microwave had a sticky red substance scattered on the inside.

During an interview on 10/28/24 at 2:00 PM, Staff OO, RN Manager, stated he was responsible to ensure the patient nutrition rooms were clean, and he expected unit staff to clean all spills immediately.

During an interview on 10/30/24 at 3:30 PM, Staff LLLL, Infection Control Manager, stated the unit staff were responsible for cleaning the unit refrigerators and microwaves. She expected them to be clean. Environmental services cleaned the patient nutrition rooms every day.

12. Review of the hospital's policy titled, "Dietary Services - Dining and Nutrition - Food Receiving Storage and Labeling - Guideline," approved 12/08/23 showed:
- Holding of food at optimal conditions to minimize bacterial growth until food is prepared for consumption.
- Foods are stored in a manner to prevent contamination.
- The storeroom is without contamination.

Observation on 10/29/24 at 3:55 PM, of Hospital C's kitchen, showed an ear pod case sitting on the shelf with spices and cooking sprays.

During an interview on 10/31/24 at 2:24 PM, Staff PPPP, CNO, stated ear pods were not to be stored near patient food.

13. Review of the hospital's policy titled, "Infection Prevention and Control Program - 2024 Infection Control Manual," approved 11/20/23, showed:
- All soiled linens are to be placed in laundry bags provided by Linen Services while avoiding contact with clothes;
- Do not shake or place linen directly on the floor;
- Soiled linens that are lightly to moderately moist should be folded and/or rolled in such a way as to contain the moist area in the center of soiled linen; and
- Soiled linens that are saturated with moisture should be placed in a plastic bag and tightly secured.

Observation on 10/28/24 at 2:29 PM, of the ICU, showed the foam repositioning pillow was on the floor in Patient #6's room. Staff D, RN picked the pillow up from the floor and placed it on the ledge of the window to perform patient care. After completing care, she returned the pillow to Patient #6's bed.

Observation on 10/29/24 at 12:49 PM, of the Cardiovascular Unit, showed one bloody hand towel and one large towel on the floor under a sink in Patient #32's room. The patient stated the towel had been present since the night before.

Observation on 10/28/24 at 3:08 PM, of the Medical Specialties Unit, showed 1 sterile sponge and three sterile dressings had been stored on a ledge in the patient supply room.

Observation on 10/29/24 at 9:45 AM, of the PCU, showed 26 abdominal pad dressings in a box and one purple disinfectant container stored on a vent in a patient supply room.

During an interview on 10/31/24 at 2:24 PM, Staff PPPP, CNO, stated she expected staff to ensure towels and bloody items were picked up.

During an interview on 10/30/24 at 3:30 PM, Staff LLLL, Infection Control Manager, stated she would expect nursing staff to remove dirty or bloody linens and they should not be kept on the floor. Supplies should not be store on vents or ledges.

During an interview on 10/29/24 at 9:45 AM, Staff TT, RN Manager, stated supplies should not be stored on ledges, vents, or counters.

14. Review of the hospital's policy titled, "Environmental Services - Operating Room Terminal Clean - Guideline" dated 09/24/21, showed to completely clean and disinfect all ceilings, external wall vents, all walls, horizontal/vertical surfaces (including doors) as per wall washing instructions.

Observation on 10/29/24 at 9:15 AM, of Hospital B's Surgical Area showed Operating Rooms (OR) #5, #6, Obstetrics OR room and the surgical transport patient hallway had exposed sheet rock, paint peeling off the walls, multiple areas with adhesive residue from tape, paper logs taped on to the OR door, ceiling air vents were visibly dirty and the IV poles had visible rust present on the casters and legs.

Observation on 10/29/24 at 2:00 PM, of Hospital B's sterile processing area showed the autoclave (a strong heated container used for chemical reactions and other processes using high pressures and temperatures, e.g. steam sterilization) had discoloration and mineral build up.

During an interview on 10/29/24 at 2:55 PM, Staff SSS, Infection Control Personal, stated there should not be peeling paint or exposed sheet rock in any area that is terminally cleaned and the autoclave should be cleaned regularly. He would not expect to see rust in an OR environment and the Autoclave should be cleaned to manufacture's recommendation.
During a

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