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Based on observations and interviews, the hospital failed to ensure patients received care in a safe setting as evidenced by patients' beds having a non- functional nurse call feature on the bedrail for 4 (a, b, c, d) of 4 (a, b, c, d) licensed patient beds checked for bedrail functioning nurse call bell.

Findings:

During the tour of the hospital on 10/31/2022 at 11:30 a.m. failed to reveal functioning nurse call feature on the bedrail in rooms (a, b, c, d).

In an interview on 10/31/2022 at 11:45 a.m. S2CNO verified the nonfunctioning nurse call features as noted above.

Based on record review and interviews, the hospital failed to ensure blood transfusions were administered in accordance with hospital policies and procedures as evidenced by failure to have the physician order the rate or duration at which the blood was to be transfused for 2 (#10, #11) of 2 (#10. #11) patient records reviewed who had a blood transfusion from a total sample of 30 patients.

Findings:

Review of the hospital's policy titled "Administration of - Blood and Blood Components" revealed in part, physician's order will specify type of blood products, number of units to be given, and when possible rate or duration. In non-emergency situations, a unit of blood should be transfused within a timeframe of 2-4 hours unless physician orders specify a shorter timeframe. If a unit of blood is not transfused within four (4) hours, it shall be discontinued along with the tubing. Further review of this policy revealed in part, start infusion slowly. All infusions will be administered via volumetric pump. Remain in room with patient for 15 minutes after blood starts to infuse into patient to observe for possible signs of transfusion reaction. If signs, symptoms of transfusion reaction occur, stop infusion and follow procedure as outlined in adverse transfusion reaction policy. Observe patient closely, and check vital signs 15 minutes after infusion starts, document on intervention. After 15 minutes, if patient's condition is satisfactory, the rate of infusion can be increased to that specified in the clinical order.

Patient #10
Review of Patient #10's medical record revealed an admission date of 08/26/2022 with an admitting diagnosis of shortness of breath. Review of the physician orders revealed an order dated 09/01/2022 at 8:19 a.m. to transfuse 1 unit of PRBCs (packed red blood cells) when ready. Further review of the physician's order revealed no documented evidence of rate or duration in which to transfuse the 1 unit of PRBCs.

Patient #11
Review of Patient #11's medical record revealed an admission date of 09/19/2022 with an admitting diagnosis of chronic anemia. Review of the physician orders revealed an order dated 09/19/2022 at 11:13 a.m. to transfuse 2 units of PRBCs (packed red blood cells). Further review of the physician's order revealed no documented evidence of rate or duration in which to transfuse the 2 units of PRBCs.

In an interview on 11/02/2022 at 12:00 p.m. S2CNO stated the physician never includes a rate or duration to transfuse PRBCs. S2CNO verified the physician orders to transfuse PRBCs for Patient #10 and Patient #11 did not indicate a rate or duration to transfuse PRBCs.

Based on observation and interview the hospital failed to ensure equipment was maintained to ensure an acceptable level of safety and quality as evidenced by the following areas:

a. Rust on patient beds or stretchers in rooms a, b, c, d, e, f, g, h, i, j;
b. Rust on the metal cabinet in room a and rust covering the bottom the a drawer in patient room f;
c. 7 rolling chairs in the emergency department nurses' station with tears exposing the cushions;
d. 8 rusted metal clips affixed to the headboards and the bathroom door of patient room h;
e. 2 chairs with rust on the frame in room j; and
f. Call bell remote broken in patient room h;



Findings:

Observations of the hospital were conducted on 10/31/2022 and 11/01/2022 and the following were identified:

a. Rust on patient beds or stretchers in rooms a, b, c, d, e, f, g, h, i, and j.
b. Rust on the metal cabinet in room a and rust covering the bottom of the drawer in patient room f.
c. 7 rolling chairs in the emergency department nurses' station with tears exposing the cushions.
d. 8 rusted metal clips affixed to the headboards and the bathroom door of patient room h.
e. 2 chairs with rust on the frame in room j.
f. Call bell remote broken in patient room h.


In an interview during the observations S1CNO, S3QAD, and S4RN verified the above findings.



44763

Based on observation and interview the hospital failed to ensure the infection prevention and control program included maintaining a clean and sanitary environment to avoid sources and transmission of infection as evidenced by:

1. the emergency department patient nourishment refrigerator contained 2 burritos and an open can of evaporated milk that did not belong to any patient;
2. the door between the dirty procedure room and the clean supply room in the surgical unit propped opened;
3. the door to the endoscopy storage cabinet in the surgical unit was left open; and
4. 2 vital sign machines and EKG machine were stored uncovered in the clean supply room located in the inpatient unit.

Findings:

1. The emergency department patient nourishment refrigerator contained 2 burritos and an open can of evaporated milk that did not belong to any patient.

A review of the hospital policy titled Nursing/ Infection Control: Handling and movement of food last reviewed 10/22 revealed in part:
6.b. Nursing personnel should not store their food items in refrigerators that contain patient nourishment.

During the tour of the emergency department patient nourishment refrigerator on 10/31/2022 at 11:55 a.m. revealed 2 burritos wrapped in paper and an open undated can of evaporated milk.

In an interview on 10/31/2022 at 11:55 a.m. S11RN verified the 2 burritos and open can of evaporated milk should not have been in the patient nourishment refrigerator and it was an infection control issue.

2. The door between the dirty procedure room and the clean supply room in the surgical unit propped opened.

In an observation on 11/01/2022 at 10:50 a.m. of the surgical unit with S4RN revealed the door between the dirty procedure room and the clean supply room was propped open.

In an interview during this observation S4RN verified the door should have been closed between the dirty procedure room and the clean supply room.

3. The door to the endoscopy storage cabinet in the surgical unit was left open.

Review of the hospital's policy titled "Care of Endoscopy Equipment" revealed in part, after processing hang scopes in vertical position in scope cabinet to facilitate drying. Cabinet door must remain closed and the fan must be kept on at all times.

In an observation on 11/01/2022 at 10:50 a.m. of the surgical unit with S4RN revealed the door of the endoscopy storage cabinet was left open.

In an interview during this observation S4RN verified the door to the endoscopy storage cabinet should have been closed.

4. 2 vital sign machines and EKG machine were stored uncovered in the clean supply room located in the inpatient unit.

In an observation of the hospital on 10/31/2022 of the inpatient unit with S3QAD revealed 2 vital sign machines and 1 EKG machine stored uncovered in the clean supply room.

In an interview during the observation S3QAD verified the above stated equipment should have been stored covered.


44763

Based on record reviews and interview, the hospital failed to ensure an updated examination of the patient, including any changes in the patient's condition, must be completed and documented within 24 hours after admission or registration when the medical history and physical examination are completed within 30 days before admission or registration. This deficient practice was evidenced by patient record with no documented evidence that an updated examination within 24 hours after admission or registration was conducted for 1 (#25) of 3 (#25, #26, #27) patient records reviewed from a total sample of 30 patients.

Findings:

Review of Patient #25's medical record revealed an admission date of 10/04/2022 and underwent a surgical procedure with MAC (monitored anesthesia care) sedation. Further review revealed a history and physical dated 09/14/2022. This history and physical included a stamp that stated "I have reviewed the patient's H&P/consult. There are no changes from initial assessment" with lines for physician signature, date, and time. This was not signed, dated, or timed by the physician.

In an interview on 11/02/2022 at 11:20 a.m. while reviewing Patient #25's medical record S16ACCO verified this stamp was used as the verification of the updated examination within 24 hours after admission or registration when the medical history and physical examination was completed within 30 days before admission or registration. S16ACCO verified this update was not signed, dated, or timed by the physician.