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Based on interview and record review, the facility failed to ensure a consent for surgery or special procedure for Hemodialysis, was signed by the provider, prior to the procedure for one of 30 sampled patients (Patient 27).

This failure had the potential for Patient 27 to not be informed of the risks, benefits, and side effects of hemodialysis and delay patient care.

Findings:

On April 1, 2025, at 12:32 p.m., a record review and concurrent interview with the Director of Inpatient Services (DIS) and the Director of Surgical Services (DSS) was conducted.

A facility document titled, "Consent to Surgery or Special Procedure," dated March 27, 2025, was reviewed. The document indicated, "...attending physician...operation or procedure...Hemodialysis...Date: March 27, 2025...Time...9:45 a.m....Signature...Patient 27..." The document was not signed, dated, or timed by the provider.

On April 1, 2025, at 12:35 p.m., an interview with the DIS was conducted. The DIS stated the provider does not have to sign the consent if they document the risk and benefits in the patients' chart. The DIS further stated she reviewed the patients electronic medical record and did not see any documentation of the risk and benefits in the chart.

On April 1, 2025, at 12:37 p.m., a record review was conducted with the DIS. A facility document titled "History and Physical," dated March 26, 2025, was reviewed. The document indicated Patient 27 was admitted for altered mental status, and a history of End Stage Renal Disease (ESRD, kidneys are no longer working) and a history of dialysis (procedures that filters and cleans the blood).

A facility undated document titled, "Order Inquiry" was reviewed. The document indicated, "...hemodialysis...Description...Dialysis Duration 3 hours...Start 3/27/25 [March 27, 2025]...stop 3/27/25 [March 27, 2025]...once...Routine..."

A facility document titled, "Hemodialysis Treatment Flow sheet," dated March 27, 2025, was reviewed. The document indicated dialysis started March 27, 2025, at 10:15 a.m., and ended March 27, 2025, at 1:15 p.m.

A facility document titled, "Hemodialysis Treatment Flow sheet," dated April 1, 2025, was reviewed. The document indicated dialysis started April 1, 2025, at 11:30 a.m., and ended April 1, 2025, at 3:30 p.m.

A facility policy and procedure titled, "Informed Consent," dated November 2024, was reviewed. The document indicated, "...the hospital is required to obtain documentation of consent to hospital services and to verify that the physician has obtained informed consent as appropriate..."

Based on interview and record review, the facility failed to implement their policy and procedure for nine of 30 sampled patients (Patients 1, 4, 5, 11, 12, 15, 21, 29, and 30) when:

1. For Patient 21, the critical laboratory results were not reported to the physician;

2. For Patients 1, and 11, pain medications were not provided timely after arriving at the Emergency Department (ED), with complaints of pain;

3. For Patients 4, 12, 15, and 30, no pain medication was provided when the patient stated they had pain; and

4. For Patients 5, and 29, there was no pain reassessment completed after pain medication was administered.

These failures had the potential to cause patient harm, delay timely treatment, and for patient's pain to not be addressed or treated in a timely manner.

Findings:

1. On April 2, 2025, at 1:45 p.m., a review of Patient 21's record was conducted with the Director of Inpatient Services (DIS). An untitled facility document, dated March 27, 2025, at 12:11 p.m., was reviewed and indicated Patient 21 was admitted to the facility on March 27, 2025, for acute hypoxic respiratory failure (a condition where the lungs fail to effectively provide oxygen to the body's tissues).

An untitled facility document dated March 27, 2025, was reviewed. The document indicated, "...Lactic Acid was Collected: 27-Mar [March]- 2025 at 09:25 [9:25 a.m.]...Called: 10:08 [10:08 a.m.] on 3/27/25 [March 27, 2025] by [name of laboratory tech]..."

During an interview, on April 2, 2025, at 1:45 p.m., conducted with the DIS, the DIS stated, the critical lactic acid result was communicated to the nurse by the laboratory staff on March 27, 2025, as per facility policy. There was no documented evidence the nurse notified the physician of Patient 21's critical lactic acid level after the nurse was notified by the lab.

The facility policy and procedure (P&P) titled, "Critical Lab Values and Diagnostic Test Results; Notification," dated May 2024, was reviewed and indicated, "...Purpose: To improve the effectiveness of communication among caregivers...To report critical results of tests and diagnostic procedures...The responsible physician...will be notified as soon as possible, but no later than, 60 minutes...Document responsible physician notification of the critical laboratory or diagnostic test result in the medical record..."

2a. On April 2, 2025, at 11 a.m., Patient 1's medical record was reviewed with the Interim Emergency Room/Intensive Care Unit Director (I-ED/ICU Director). Patient 1 was seen in the ED after a fall at home.

The facility document titled, "[Name of the facility] Triage Report," dated March 17, 2025, at 8:36 p.m., was reviewed. The document indicated Patient 1 was triaged (sorting of patients (as in an emergency room) according to the urgency of their need for care) at 8:29 p.m., and reported pain of 10/10 (pain scale from 0-10 with 0 being no pain and 10 being worst pain ever). The document further indicated Patient 1 had a blood pressure of 205/98 (normal blood pressure 120/80). There was no documented evidence Patient 1 received any medication for the high blood pressure.

The facility document titled, "ED Provider Notes", dated March 17, 2025, at 9:05 p.m., was reviewed. It indicated Patient 1 was seen by the provider at 9:05 p.m. The document further indicated Patient 1 presented to the ED on March 17, 2025, with a chief complaint of left-sided headache, left neck pain, left chest pain, left hip pain, low back pain, left knee pain, and left shoulder pain after a fall at home.

The facility document titled, "Vitals Inquiry," dated March 17, 2025, at 8:20 p.m., indicated, "...03/17/2025 [March 17, 2025] 20:29 [8:29 p.m.]...Pain Score 10 Numeric hip, left..." The document further indicated the facility staff did not reassess pain after the initial assessment.

The facility document titled, "Medication Administration Record," dated March 17, 2025, was reviewed. The document indicated, "...Ketorolac - STAT - injectable...[30 MG/ML - unit of measurement]...Dose...15 mg...Start 03/17/2025 [March 17, 2025]...22:52 [10:52 p.m.] admin...23:02 [11:02 p.m.]..." Two hours 33 minutes after indicating Patient 1 had 10/10 pain.

On April 02, 2025, at 11:14 a.m., an interview with the I-ED/ICU Director was conducted. The I-ED/ICU Director stated, when a patient expresses pain, it should be addressed immediately. She further stated Patient 1 should not have waited 2 hours and 33 minutes for pain medication. The I-ED/ICU Director stated the policy was to address pain timely and 2 hours and 33 min would not be timely.

2b. On April 3, 2025, at 12:30 p.m., Patient 11's medical record was reviewed with the I-ED/ICU Director. It indicated Patient 11 was seen in the ED for complaint of bilateral (both) knee pain for three weeks.

The facility document titled, "[Name of the facility] Triage Report," dated April 1, 2025, at 10:23 a.m., was reviewed. The document indicated Patient 11 was triaged at 10:23 a.m., and reported pain of 10/10.

The facility document titled, "CPOE Orders Report," dated April 1, 2025, was reviewed. The document indicated, "...Drug... HYDROCODONE-ACETAMINOPHEN [pain medication]...5-325 MG...Start...04/01/2025 [April 1, 2025] 12:22 [12:22 p.m.]..." Order was placed one hour and 59 minutes after Patient 11 indicated she had 10/10 pain.

The facility document titled, "ED Summary Report", dated April 1, 2025, was reviewed. The document indicated, "...Chief Complaint...Hip Pain...Vital Signs...04/01/2025 [April 1, 2025]...10:45 [10:45 a.m.] pain 10...04/01/2025 [April 1, 2025] 12:36 [12:36 p.m.]...Pain 10...Medication Orders...HYDROCODONE-ACETAMINOPHEN...Route...ORAL...Last Given...04/01/2025 [April 1, 2025] 12:38 [12:38 p.m.]..." This was two hours and 15 minutes after Patient 11 indicated she had 10/10 pain. The document further indicated. "...LIDOCAINE PATCH 5%...1 PATCH...Last given 12:39 [12:39 p.m.]. This was two hours and 16 minutes after Patient 11 indicated she had 10/10 pain.

The facility document titled, "Vitals Inquiry," dated April 1, 2025, at 10:23 a.m., indicated, "...04/01/2025 [April 1, 2025] 10:45 [10:45 a.m.]...Pain Score 10...04/01/2025 [April 1, 2025] 12:36 [12:36 p.m.]...Pain Score 10..."

On April 03, 2025, at 12:55 p.m., an interview with the I-ED/ICU Director was conducted. The I-ED/ICU Director stated, when a patient expresses pain, it should be addressed immediately. She further stated Patient 11 should not have waited 2 hours and 15 minutes for pain medication. The I-ED/ICU Director stated the policy was to address pain timely and 2 hours and 15 min would not be timely.

3a. On April 2, 2025, at 1:30 p.m., Patient 4's medical record was reviewed with the I-ED/ICU Director. It indicated Patient 4 was seen in the ED after a fall.

The facility document titled, "[Name of the facility] Triage Report," dated March 18, 2025, at 1:13 p.m., was reviewed. The document indicated Patient 1 was triaged at 1:18 p.m., and had pain of 6/10.

The facility document titled, "ED Summary Report", dated March 18, 2025, was reviewed. The document indicated, "...Chief Complaint...Mechanical Fall...Problem List...Abdominal pain...Laceration of scalp...Vital Signs...Pain 6..." The document further indicated, "...Medication Orders...NO MEDICATION ORDERS DATA..."

The facility document titled, "EMERGENCY PHYSICIAN RECORD," dated March 18, 2025, at 1:30 p.m., was reviewed and indicated, "...03/18/2025 [March 18, 2025] TIME SEEN...13:30 [1:30 p.m.]...R [right] rib lower tender to palpation...Imaging Results...per radiologist as follows...questionable fx [fracture] of right 8th rib...15:35 [3:35 p.m.]...due to questionable fx of right ribs show on xray & possible lung nodule, further orders were placed for CT chest w/o [without] contrast.

The facility document titled, "CPOE Orders Report," dated March 18, 2025, was reviewed. There was no documented evidence of orders for pain medication.

On April 2, 2025, at 2 p.m., an interview with the I-ED/ICU Director was conducted. The I-ED/ICU Director stated, when a patient expresses pain, it should be addressed immediately. The I-ED/ICU Director stated the policy was to address pain and Patient 4 should have gotten pain medication.

3b. On April 3, 2025, at 2 p.m., Patient 12's medical record was reviewed with the I-ED/ICU Director. It indicated Patient 12 was seen in the ED for chronic back pain.

The facility document titled, "Triage," dated April 1, 2025, at 6:58 a.m., was reviewed. The document indicated Patient 12 was triaged at 6:58 a.m., and reported pain of 8/10 [8 being severe pain].

The facility document titled, "CPOE Orders Report", dated April 1, 2025, was reviewed. The document indicated, "...TRAMADOL...50 MG ORAL...Start Date...04/01/2025 [April 1, 2025] 09:00 [9 a.m.]..." There was no documented evidence Patient 12 received medication for pain of 8/10.

The facility document titled, "Vital Sign Report," dated April 1, 2025, at 7 a.m., was reviewed. The document indicated patient had a pain score of 8. There was no documented evidence Patient 12's pain was addressed.

On April 3, 2025, at 2:15 p.m., an interview with the I-ED/ICU Director was conducted. The I-ED/ICU Director stated, when a patient expresses pain, it should be addressed immediately. The I-ED/ICU Director stated the policy was to address pain, and Patient 12 should have gotten pain medication that was ordered.

3c. On April 3, 2025, at 10 a.m., Patient 15's medical record was reviewed with the Director Inpatient Services (DIS). It indicated Patient 15 was seen in the ED for evaluation of parasite infection, and soft stool.

The facility document titled, "Emergency Department Record," dated March 25, 2025, at 3:50 a.m., was reviewed. The document indicated Patient 15 was triaged and reported pain of 7/10 [7 being moderate pain].

The facility document titled, "Vital Sign Report," dated March 25, 2025, at 3:06 a.m., was reviewed. The document indicated Patient 15 had a pain score of 7. There was no documented evidence Patient 15's pain was addressed.

The facility document titled, "CPOE Orders Report", dated March 25, 2025, was reviewed. There was no documented evidence pain medications were ordered for pain scale of 7/10 for Patient 15.

On April 3, 2025, at 10:15 a.m., an interview with the DIS was conducted. The DIS stated, there was no pain medications given or documented pain interventions for 7/10 pain when there should have been.

3d. On April 2, 2025, at 2:44 p.m., a concurrent record review and interview with the Tele 2 Charge Nurse (TCN) was conducted. A facility document titled, "History and Physical," dated February 12, 2025, was reviewed. The document indicated Patient 30 was admitted February 11, 2025, for underlying alcohol, polysubstance used disorder, and presented for detox.

A facility undated and untitled document was reviewed. The document indicated, "...2/14/25 [February 14, 2025]...20:28 [8:28 p.m.]...pain score...5..."

A facility document titled, "Medication Administration Record" dated April 2, 2025, was reviewed. The document indicated no medication was given to Patient 30 on February 14, 2025, at 8:28 p.m., for reported pain of 5/10.

There was no documented evidence the pain assessed on February 14, 2025, at 8:28 p.m. was reported and treated.

On April 2, 2025, at 3:15 p.m., an interview with the TCN was conducted. The TCN stated based on the pain assessment the patient's pain was 5/10. The patient should have been given pain medication. There was no documented evidence indicating Patient 30 was given any medication for pain.

4a. On April 2, 2025, at 3:35 p.m., Patient 5's medical record was reviewed with the I-ED/ICU Director. It indicated Patient 5 was seen in the ED after a fall at home.

The facility document titled, "[Name of the facility] Triage Report," dated March 18, 2025, at 7:44 p.m., was reviewed. The document indicated Patient 5 was triaged at 7:11 p.m., and reported pain of 6/10 [6 moderate pain].

The facility document titled, "EMERGENCY PHYSCIAN RECORD," dated March 18, 2025, at 7:30 p.m., was reviewed. The document indicated Patient 5's chief complaint was left wrist pain, fall. The document further indicated, "...severity of pain...moderate..."

The facility document titled, "ED Summary Report", dated March 18, 2025, was reviewed. The document indicated, "...Chief Complaint...Mechanical Fall...Vital Signs...03/18/2025 20:50 [8:50 p.m.]...Pain...7...Medication Orders....OCYCODONE-ACETAMINOPHEN...ORAL...Last Given...03/18/2025 [March 18, 2025] 20:59 [8:59 p.m.]..." There was no documented evidence Patient 5 was reassessed for pain after Oxycodone-Acetaminophen was given.

On April 2, 2025, at 3:44 p.m., an interview with the I-ED/ICU Director was conducted. The I-ED/ICU Director stated the expectation was for staff to reassess for pain after pain medication was given. She further stated pain reassessment should have been completed within 15-60 minutes per policy.

4b. On April 2, 2025, at 1:15 p.m., Patient 29's medical record was reviewed with the TCN.

A facility document titled, "History and Physical," dated April 2, 2025, was reviewed. The document indicated Patient 29 was admitted January 6, 2025, for underlying history of alcohol abuse and was being admitted for detox.

A facility undated document titled, "Social Service/Case Management," was reviewed. The document indicated, "...1/10/2025 [January 10, 2025]...pain score...6..."

A facility undated document titled, "Medication Administration," was reviewed. The document indicated, "...Medication...Ibuprofen [600 MG]...Tablet...Dose 600 MG [unit of measurement]...Route...Oral...admin [administration] time...1/10/25 [January 10, 2025] 2135 [9:35 p.m.]...Vitals...Pain Score...6...numeric general internal lateral...1/10/25 [January 10, 2025] 21:35 [9:35 p.m.]..."

A facility undated, and untitled document was reviewed. The document indicated, "...Ibuprofen [600 MG]...Tablet...600 mg...Motrin...start...1/6/25 [January 6, 2025]...stop...1/13/25 [January 6, 2025]...oral three times a day as needed...[1 x 600 mg per dose]...indication: Pain...comment...PRN[pro re nata, as needed]" For Mild to Moderate Skeletal Pain..."

There was no documented evidence Patient 29's pain was reassessed after pain medication was administered on January 10, 2025, at 9:35 p.m.

On April 2, 2025, at 1:40 p.m., an interview with the TCN was conducted. The TCN stated there was no documented evidence Patient 29's pain was reassessment after the medication was administered on January 10, 2025, at 9:35 p.m. The TCN further stated the nurse should have assessed the pain an hour after the medication was administered.

A review of the policy and procedure (P&P) titled, "PAIN MANAGEMENT," dated October 2024, was conducted. The P&P indicated, "...To assure...patients receive an assessment and management of their pain...Patients have the right to pain management. It is the policy of [name of facility], to provide individualized pain management for all patients...patient's stated level of pain is unique to the patient and it is the best indicator of the amount of pain he/she is experiencing...appropriate assessment and reassessment of a patient's pain should be conducted...treatment and service provided in the specific care setting in which the patient is being managed...Achieving optimum pain management is a joint effort between the patient...the physician and interdisciplinary team...patient will be reassessed for the presence of pain no less frequently than the minimum requirements for the taking of vital signs in the care setting...In the ED...should also be reassessed at the time of discharge...in general...shall receive treatment for any active pain issue...when intensity exceeds their acceptable level...Reassessment Following Treatment for Pain...if a treatment intervention for pain is provided, the response to that intervention should be reassessed...Reassessment is recommended to occur within 15-60 minutes following treatment...Numeric Scale: 0-10: The numerical rating scale is designed to be used by those over age 9, 0 would mean the patient is experiencing no pain...Pain scored 7-10 would be considered severe pain..."

Based on interview and record review, the facility failed to ensure laboratory services were provided timely in accordance with the facility's policy and procedure for three of 30 sampled patients (Patient 17, 23, and 25), when:

1. For Patient 23, send out labs (sending a patient's blood/urine sample to a different, specialized location for testing when the primary lab in unable) were not sent out to the appropriate location timely; and

2. For Patient 17, and 25, a STAT (an order that requires immediate attention) order did not result timely.

These failures resulted in delayed laboratory results for patient 17, 23 and 25. These failures also had the potential to prolong appropriate treatment and cause patient harm.

Findings:

1. On April 2, 2025, at 1:40 p.m., a review of Patient 23's record was conducted with the Director of Inpatient Services (DIS). An untitled facility document, dated February 10, 2025, at 2:04 a.m., was reviewed and indicated Patient 23 was admitted to the facility on February 10, 2025, for chest discomfort, shortness of breath (difficulty breathing), and generalized edema (fluid buildup in the body's tissue).

A facility undated document titled, "Test Request Form," was reviewed for Patent 23. The document indicated, C3 Serum (a blood test that measures the amount of complement C3 protein in the blood) was ordered on February 11, 2025.

A facility undated document titled, "Test Request Form," was reviewed for Patient 23. The document indicated, ANCA screen (Antineutrophil cytoplasmic antibody-a blood test used to detect antibodies that target neutrophils, a type of white blood cell) was ordered on February 11, 2025.

A facility undated document titled, "Test Request Form," was reviewed for Patient 23. The document indicated, Complement CHC (a blood test that measures the levels and/or a group of proteins) was ordered on February 13, 2025.

A facility undated and untitled document was reviewed for Patient 23. The document indicated, "C3 Nephritic factor [a system associated with various kidney disease] was received: 2/28/2025 [February 28, 2025] at 18:19 [6:19 p.m.] and reported: 03/05/2025 [March 05, 2025] at 08:11 [8:11 a.m.]...Set up schedule; Report available: 3 [three] days..."

A facility undated, and untitled document was reviewed for Patient 23. The document indicated, "ANCA screen was received: 2/28/2025 [February 28, 2025] at 18:42 [6:42 p.m.] and reported: 03/05/2025 [March 05, 2025] at 14:05 [2:05 p.m.]...Set up: Mon [Monday]-Sat [Saturday] Report available: 3-5 [five] days..."

A facility undated, and untitled document was reviewed for Patient 23. The document indicated, "C4 Serum [a blood test that measures the amount of C4 protein in your blood] was received: 2/28/2025 [February 28, 2025] at 18:30 [6:30 p.m.] and reported: 03/05/2025 [March 05, 2025] at 10:56 [10:56 a.m.]...Set up: Sun [Sunday]-Fri [Friday]: Report available: 2 [two]-3 days..."

An interview was conducted on April 4, 2025, at 9 a.m., with the Director of Laboratory Services (DLS). The DLS stated the labs collected on February 11, 2025, for Patient 23 remained frozen until they were sent out on February 28, 2025. The DLS stated, due to having issues with the laboratory contract, "the results were delayed," and should have been resulted three to five days later, on February 14, 2025, or February 15, 2025.

2a. On April 2, 2025, at 1:45 p.m., a review of Patient 25's medical record was conducted with the DIS. An untitled facility document, dated February 21, 2025, at 10:31 p.m., was reviewed and indicated Patient 25 was admitted to the facility on February 21, 2025, for left leg pain and swelling (a condition where extra fluid gathers in the body's tissue, causing it to be become enlarged).

A facility untitled document dated February 20, 2025, was reviewed for Patient 25. The document indicated, "...CBC [Complete Blood Count-a common blood test that measures the different types and amounts of cells in your blood] was Ordered For: 20-Feb [February]- 2025 at 18:34 [6:34 p.m.]...Collected: 20-Feb-2025 at 18:45 [6:45 p.m.]...Released: 20-Feb-2025 at 20:06 [8:06 p.m.]..."

A facility untitled document dated February 20, 2025, was reviewed for Patient 25. The document indicated, "...Erythrocyte Sed Rate [ESR-a blood test that measures the rate at which blood cells settle to the bottom of a tube over a period of one hour] was Ordered For: 20-Feb [February]- 2025 at 18:32 [6:32 p.m.]...Collected: 20-Feb-2025 at 18:45 [6:45 p.m.]...Released: 20-Feb-2025 at 20:06 [8:06 p.m.]..."

A facility untitled document dated February 20, 2025, was reviewed for Patient 25. The document indicated, "...Partial Prothrombin Time [PT- a blood test that measures how long it takes for blood to clot], and Partial Thromboplastin Time [a blood test that times how long it takes a patient's blood to form a clot as measured in seconds] was Ordered For: 20-Feb [February]- 2025 at 18:34 [6:34 p.m.]...Collected: 20-Feb-2025 at 21:50 [9:50 p.m.]...Released: 20-Feb-2025 at 22:25 [10:25 p.m.]..."

An interview was conducted on April 2, 2025, at 1:45 p.m., with the DIS. The DIS stated the CBC and ESR results took over an hour to be released which goes against the STAT order timeframe. The DIS stated the PT and PTT was collected over an hour late which goes against the STAT collection timeframe. The DIS further stated, there was no documentation indicating why the results of the CBC and ESR were delayed, or why the collection of PT and PTT was delayed.

2b. On April 3, 2025, at 11 a.m., a review of Patient 17's medical record was conducted with the DIS. A facility document titled, "History & Physical," dated March 22, 2025, at 10:11 a.m., was reviewed and indicated Patient 17 was admitted on March 21, 2025, for cellulitis (bacteria infection of skin) for two open lesions.

A facility untitled document dated March 21, 2025, was reviewed. The document indicated, "...Comprehensive Metabolic Panel...Ordered For...21-Mar-2025 16:18 [March 21, 2025 4:18 p.m.]...Collected...21-Mar-2025 16:15 [March 21, 2025 4:15 p.m.]...Priority STAT...Released...21-MR-17:29 [March 21, 2025 5:29 p.m.]..." This STAT lab draw resulted one hour and 11 minutes after it was ordered.

A facility untitled document dated March 21, 2025, was reviewed. The document indicated, "...BLOOD ALC [Blood Alcohol]...Ordered For...21-Mar-2025 16:18 [March 21, 2025 4:18 p.m.]...Collected...21-Mar-2025 16:15 [March 21, 2025 4:15 p.m.]...Priority STAT...Released...21-MR-17:29 [March 21, 2025 5:29 p.m.]..." This STAT lab draw resulted one hour and 11 minutes after it was ordered.

An interview was conducted on April 3, 2025, at 11:20 a.m., with the DIS. The DIS stated the labs collected on March 21, 2025, for Patient 17, resulted over an hour after the STAT order was placed and there was no documentation from the laboratory tech indicating why the results were delayed. The DIS further stated, the laboratory techs have the ability to make notes in the charting for notification purposes such as these.

The facility policy and procedure (P&P) titled, "Requests for Laboratory Tests," dated February 2024, was reviewed and indicated, "...requests for tests ordered as STAT will be collected within 10-15 minutes from the time they were ordered otherwise they will be drawn within 60 minutes...Reference Lab test...routine orders will be processed and completed within four (4) hour period of the time collected...Once received into the Clinical Laboratory, all STAT orders will be processed to completion in less than 60 minutes. When operational circumstances exist which prevent the Clinical Laboratory from satisfying the requirement...the originator of the laboratory order will be notified....strict adherence to this policy is of paramount importance for the efficient delivery of laboratory services and for the care of patients will indeed benefit by the speedy and accurate reporting of emergency laboratory testing..."

Based on observation, interview, and record review, the facility failed to ensure an adequate method of communication was in place for two of four patient bathrooms in accordance with the facility's policy and procedure.

This failure had the potential for patient harm and delayed staff response during a routine or emergency situation.

Findings:

On April 1, 2025, at 10:20 a.m., a tour of the Medical Detox Unit (MDU-a unit that helps people safely withdraw from addictive substances, typically under the care of a healthcare professional) was conducted with the Director of Inpatient Services (DIS) and the Program Director of Medical Detox Unit (DMDU). During the tour, it was observed in a patient bathroom (Bathroom #1), the bathroom failed to have a pull-down cord for the emergency call light system near the toilet and in the shower. During the tour it was observed in a patient bathroom (Bathroom #2), the emergency call light was tested. During this test, the emergency cord pulled out of the wall and failed to activate the call light system.

During an interview, on April 1, 2025, at 10:21 a.m., conducted with the DIS and DMDU, the DIS stated, there should be a pull-down call light in "every bathroom and every shower" regardless of if there is a patient in the room or not. The DMDU stated, the call light emergency cord was "not placed correctly" in bathroom #2.

The facility policy and procedure (P&P) titled, "Nurse Call System Failure," dated March 2021, was reviewed and indicated, "...The nurse call system provides audible communication between patients and nursing staff for assistance in routine or emergency situations...Warning signs or indicators of failure include: Lack of audible communication, call lights not illuminated, lack of system response...Reasons for nurse call system failure...Equipment malfunction, individual component failure..."

Based on observation, interview, and record review, the facility failed to ensure available supplies were ready for use when:

1. Multiple expired supplies were found;

2. Crash cart log did not match the crash cart lock number in Unit A: and

3. The glucometer on Unit A was not ready for use when the quality control (QC) was not completed per policy.

These failures had the potential to delay patient care and services and/or cause patient harm.

Findings:

1a. A tour of Unit A was conducted on April 1, 2025, 10:20 a.m., with the Director of Impatient Services (DIS), and the Director of Surgical Services (DSS). During the tour on Unit 1, the following expired products and supplies were observed:

-Curad Oil Emulsion Dressing 3x8 in (inches) (a primary wound dressing to provide or support a moist wound environment), with an expiration date of December 23, 2024;

-Cathgrip tube securement device (a device used to keep tubes secured in place), with an expiration date of November 30, 2024;

-Cathgrip tube securement device, with an expiration date of December 31, 2023;

- Mens liberty acute external catheter re-application kit (directs urine away from the skin to avoid moisture -related skin breakdown), with an expiration date of February 29, 2024; and

-Three packages of Mens liberty acute external catheter re-application kit, with an expiration date of July, 31, 2024.

An interview was conducted on April 1, 2025, at 10:45 a.m., with the DIS. The DIS stated the supplies were expired and should have been removed from the supply carts.

An interview was conducted on April 1, 2025, at 10:54 a.m., with the DSS. The DSS stated the supplies were expired and should not have been in the supply carts. The expired supplies should have been removed.

1b. On April 1, 2025, 11:43 a.m., a tour of Unit 2 was conducted with DIS and DSS. During the tour of Unit 2, the following expired products and supplies were observed.

- Two packages of Y-type Minibore PCA Set (tubing used for a specific IV pump), with an expiration date of January 1, 2025;

- Bardex IC 22ch/fr 30 cc/ml 3-way foley Cath Ribbed balloon (special catheter used to help reduce infection), with an expiration date of February 28, 2025; and

- Bardex IC 24ch/fr 30 cc/ml 3-way foley Cath Ribbed balloon, with an expiration date of November 30, 2024.

An interview was conducted on April 1, 2025, at 12:15 p.m., with the DSS. The DSS stated the supplies were expired and should not have been on the supply carts. She further stated the expired supplies should have been removed.

1c. A tour of the Medical Detox Unit (MDU- a facility that helps people safety withdraw from addictive substances, typically under the care of a healthcare professional) was conducted on April 1, 2025, at 10:20 a.m., with the DIS and DSS. During the tour of the Medical Detox Unit, in the clean utility room, the following expired products and supplies were observed:

-Four Clorapreop prep clear (skin solution to help reduce the risk of infection by limiting the amount of bacteria on the skin), with expiration date of January 2024;

-One CG4 + (a testing tool that aids in the diagnosis and monitoring of respiratory and metabolic conditions), with expiration date of June 21, 2023;

-Two Chem 8 (a group of eight blood tests that assess kidney function, blood sugar levels, and electrolyte balance), with expiration date of November 2, 2023;

-Two Point of Care testing (a laboratory test that allows for rapid results and timely treatment decisions), with expiration date of February 2, 2024;

-Four blue top blood vacutainers (a tube that is used for collecting blood samples for clotting studies), with expiration date of November 20, 2024; and

-Three gray top blood vacutainers (a tube that is used for collecting blood samples for glucose and lactate levels), with expiration date of January 1, 2025.

An interview was conducted on April 1, 2025, at 10:20 a.m., with the DIS and DSS. The DIS stated the materials management department stocks and maintains the supply room. The DIS further stated, the items were expired and should not be in the storage room for patient use and should have been removed immediately.

1d. A tour of the Telemetry 2 Unit (a unit designed for cardiac monitoring) was conducted on April 1, 2025, at 11:43 a.m., with the DIS and DSS. During the tour of the Telemetry 2 Unit, in the clean supply room, the following expired products and supplies were observed:

-Two Acute Dual Lumen Catheter Tray (a pre-packaged kit containing all the necessary supplies for inserting and maintaining the catheter), with expiration date of June 30, 2024;

-One Cathgrip Tube Securement Device (a device that securely and comfortably holds different types of medical tubes in place), with expiration date of July 31, 2024;

An interview was conducted on April 1, 2025, at 11:42 a.m., with the DIS and DSS. The DIS stated the materials management department stocks and maintains the supply room. The DIS further stated, the items were expired and should not be in the storage room for patient use and should have been removed immediately.

1e. A tour of the Laboratory was conducted on April 2, 2025, at 2:46 p.m., with the DIS and the Director of Laboratory Services (DLS). During the tour the following expired products and supplies were observed:

-Two Hemoblast Bellows (a powered device used in surgery to control bleeding), with expiration date of July 5, 2023; and

-Viral transport medium bottle (a solution used to preserve virus specimens), with expiration date of August 2024.

An interview was conducted on April 2, 2025, at 2:26 p.m., with the DLS. The DLS stated the Hemoblast Bellows were expired and should not have been in the refrigerator for patient use. The DLS further stated, the Viral transport medium was expired and should not have been in the refrigerator.

The facility policy and procedure (P&P) titled, "Central Supply-General Organization," dated April 2024, was reviewed and indicated, "...Purpose: To provide general guidelines for the organization and maintenance of the Central Supply area within the hospital...It is the responsibility of the Materials Management Leader and the department's personnel staff to ensure that the proper rotation of all supply items is maintained...All supply items are to be stored so as to ensure that the oldest items are used first. All supply items should be reviewed weekly and upon issuance in respect to expiration dates...All expired items will be immediately removed from the storage location..."

A review of facility P&P titled, "Material Resource Management," dated April 2024, was reviewed. The document indicated, "...All supply items are to be stored so as to ensure that the oldest items are used first...all supply items should be reviewed weekly and upon issuance in respect to expiration dates...All expired items will be immediately removed from the storage location..."

2. A tour of Unit A was conducted on April 1, 2025, at 11:20 a.m., with the Deputy Regional Director of Quality (DRDQ). During the tour, Crash Cart #4's lock number and the Crash Cart Main Pharmacy Seal Serial # (number) on the log were observed to not have matching lock numbers. The log indicated the lock number was 255414; the lock on the Crash Cart Main Pharmacy Seal Serial # (number) read 255699. The DRDQ stated the crash carts should have been checked daily and staff was expected to verify the number on the lock matched the number on the log. She further stated if there was a discrepancy, the staff should have called the pharmacy to inspect or swap out the crash cart.

On April 1, 2025, at 11:25 a.m., an interview was conducted with Registered Nurse (RN) 1. RN 1 stated she was the staff who checked crash cart #4 on April 1, 2025. RN 1 stated she might have not seen the numbers clearly when she verified the lock on crash cart #4.

On April 4, 2025, at 10:35 a.m., an interview and concurrent record review of the facility document titled, "DAILY CRASH CART CHECK [NAME OF UNIT] MONTH: MARCH 2025," was conducted with the DRDQ. The DRDQ stated this was the log for crash cart #4 for the month of March 2025. The document indicated the Crash Cart Main Pharmacy Seal Serial # (number) read 255414 from March 5, 2025, through March 31, 2025. The DRDQ stated staff was expected to verify the number on the lock when documenting in the log. She further stated it looked like RN 1 just copied the last entry of the March log and did not actually verify the number on the lock.

A review of the facility's policy and procedure titled. "Crash Cart," May 2024, was conducted. The policy indicated, "...crash cart is stocked with supplies and equipment necessary to ensure the effectiveness of cardio-pulmonary resuscitation...When not in use, all crash carts are to be locked with two (2) plastic seals...Verification of the contents of the crash cart is to be checked according to the following...All twenty-four (24) hour nursing units are to do a crash cart checks every twelve (12) hours by a licensed Nurse or designated licensed personnel...Verification of completing the crash cart checklist will be documented on the Crash Cart Check Form once per shift..."

3. A tour of Unit A was conducted on April 1, 2025, at 11:27 a.m., with the DRDQ and Registered Nurse (RN) 1. The glucose monitor (a machine that is used to measure the sugar in patient's blood) was observed in the dock station at the nurses station in Unit A. When the glucose monitor was turned on, the screen read "ACCU-CHEK...QC Due Immediately..."

An interview was conducted on April 1, 2025, at 11:30 a.m., with Registered Nurse (RN) 1. RN 1 stated the glucometer is usually quality controlled by the night shift. She stated they hadn't had any DKA (diabetic ketoacidosis-serious complication of blood sugar regualtion) patients on this unit lately, so the glucometer hadn't been used and the quality control check had not been completed.

An interview was conducted on April 1, 2025, with the DRDQ. The DRDQ stated this code meant the glucose monitor was not ready for use. She stated the glucose quality control needed to be completed before it was used on a patient. She further stated during an emergency like a code blue (emergency code called when a patient goes into cardiac arrest), this glucometer would not be ready to use.

A review of the facility's policy and procedure titled, "Blood Glucose Monitoring" dated February 2024, was conducted. The policy indicated, "...Performed by Registered Nurses (RN)...Quality Control (QC)...Quality Control is conducted...Every 24 hours (meter is set for 24-hour QC lockout)...No patient testing is allowed until both quality controls showed acceptable results (passed)..."

Based on observation, interview, and record review, the facility failed to ensure temperature logs were maintained and dated for multiple laboratory refrigerators in accordance with the facility's policy and procedure.

These failures had the potential to negatively impact product efficacy and quality.

Findings:

On April 1, 2025, at 2:26 p.m., a tour of the laboratory department was conducted with the Director of Laboratory Services (DLS).

A facility document titled, "Temperature QC [quality control] Monitoring Chart...Double Fridgen 1," dated for 2025, was reviewed for the months of January, February, and March. The following dates were not recorded on the daily temperature log:

-March 30, and 31, 2025.

A facility document titled, "Temperature QC Monitoring Chart...Double Fridgen 2," dated for 2025, was reviewed for the months of January, February, and March. The following dates were not recorded on the daily temperature log:

-March 30, and 31, 2025.

A facility document titled, "Temperature QC Monitoring Chart...Fridgen 3," dated for 2025, was reviewed for the months of January, February, and March. The following dates were not recorded on the daily temperature log:

-January 29, 30, 31, 2025; and

-March 30, and 31, 2025.

A facility document titled, "Temperature QC Monitoring Chart...ABG Fridge," dated for 2025, was reviewed for the months of January, February, and March. The following dates were not recorded on the daily temperature log:

March 30, and 31, 2025.

A facility document titled, "Temperature QC Monitoring Chart...Bacti-Incubator," dated for 2025, was reviewed for the months of January, February, and March. The following dates were not recorded on the daily temperature log:

March 30, and 31, 2025.

A facility document titled, "Temperature QC Monitoring Chart...Freezer," dated for 2025, was reviewed for the months of January, February, and March. The following dates were not recorded on the daily temperature log:

March 30, and 31, 2025.

On April 1, 2025, at 12:27 p.m., an interview was conducted with the DLS. The DLS stated, management is responsible for making sure all temperature logs are maintained. The DLS further stated, the refrigerator temperatures should be checked for accuracy and recorded on the logs, daily, including the weekends.

The facility policy and procedure (P&P) titled, "General Laboratory," dated August 2024, was reviewed and indicated, "...It is the policy of [Name of facility] to maintain proper temperature and humidity conditions for optimal instrument performance based on manufacturer's guidelines and proper temperatures for all equipment (i.e., freezers, refrigerators, water baths, etc.) involving reagent and chemical storage...Record all temperatures on the Temperature Log Sheet..."

Based on observation, interview, and record review, the facility failed to ensure clean linen was stored properly, in accordance with the facility's policy and procedure when the clean linen cart was observed uncovered while not in use.

This failure had the potential for clean linens to be exposed to contamination.

Findings:

On April 1, 2025, at 11:43 a.m., a tour of the Telemetry 2 Unit storage room was conducted. During the tour, one linen cart was observed uncovered, along with pillows stacked on top of the linen cart. A facility sign located above the linen cart indicated, "Please keep linen covered at all times." Another facility sign located above the linen cart indicated, "Keep top of linen chart clear of everything."

On April 1, 2025, at 11:45 a.m., an interview was conducted with the Director of Inpatient Services (DIS). The DIS stated, the linen carts should remain covered when not in use, and the top of the carts should be clear of all items, at all times.

The facility policy and procedure (P&P) titled, "Clean Linen Storage," dated May 2020, was reviewed and indicated, "...It is the policy of this facility to provide procedures for the proper storage of clean linen...General instructions are listed below...The storage area of clean linen is clean and secured...Clean linen will be covered when not in use...covered carts will be used for the delivery of all clean linen..."