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Based on observation, clinical record review, staff interview and facility document review during the course of a complaint investigation, the facility staff failed to ensure patient received considerate, dignified, and compassionate care and treatment (Patient #3).

Patient #3 expired on 7/2/22 and had been placed in the facility morgue until there was a determination of who would be responsible for the disposition of the remains. Patient #3's remains, unfortunately, remained in the morgue from 7/2/22 until 9/1/22. The facility was not monitoring the temperature of the morgue cooler and during that time, the cooler malfunctioned, thus hastening the decomposition of the body.

The physical environment of the morgue, upon observation (9/26/22) was unkept and dirty which did not promote a dignified environment for any patient remains and facility staff were not aware as to who was responsible for cleaning of the area.

Patient #3 had complained of pain on 7/2/22, and as it was documented in the clinical record, they were told by the Registered Nurse, it was not "time" for pain medication yet. The Registered Nurse went to lunch and when (nurse) returned and went to check on the patient, found the patient deceased.

Please refer to A0129 for further information.

Based on observation, clinical record review, staff interview and facility document review during the course of a complaint investigation, the facility staff failed to ensure a patient (Patient #3) received considerate, respectful, compassionate, and dignified care.

1. Patient #3's remains were held in the facility morgue from 7/2/22 until 9/1/22. During that time, the cooler malfunctioned, thus hastening the decomposition of the patient's remains as the facility was not monitoring the temperature of the cooler. The facility repaired the cooler, however, had not been monitoring temperatures for an unknown amount of time and the cooler was not at the recommended temperature setting. It was also observed that the morgue area was dirty and unkempt and not a dignified area for the storage of patient remains.

2. Patient #3 was documented as experiencing pain. The nurse documented they (the nurse) "went to lunch" and when they (the nurse) returned the patient had expired without receiving any pain medication.


The findings included:

1. Patient #3, according to the clinical record, was admitted on 7/1/22. Diagnoses included, but were not limited to: hepatocellular cancer (liver cancer), and history of stroke. According to the admission information, Patient#3 had been receiving hospice services at home and had a fall. The caregiver (who was not a family member but a friend) for the patient stated they were no longer able to care for (patient) and had called 911. The clinical record documented the patient had no family and no one to assist them at home. The patient expired on 7/2/22. According to documents provided to the surveyor on 9/26/22 at 3:48 p.m., the body was released on 9/1/22 to the funeral home.

On 9/26/22 at approximately 12:20 p.m., the surveyor requested to be escorted to the facility morgue. Staff Member #2 (VP of Quality and Patient Safety) accompanied the surveyor. When arriving at the morgue, Staff Member #6 (Nursing Supervisor) joined the surveyor and unlocked the door for entrance. Upon entering the morgue, the surveyor observed the floor to be dirty with brown wheel marks, as if a cart or stretcher had been rolled into the room with mud on the wheels. There was a large metal table on the left side of the room which was dirty with a dried yellow/white material in the center. Behind, and to the left of the stretcher, in the back of the room were two tables with various items, containers, and instruments which were soiled and the tables appeared to have rust on the sides. On the right side of the room in the corner of a large cooler was a pile of discarded linens, towels, and hospital gowns that appeared to be soiled. The surveyor inquired as to who was responsible for cleaning the room and was told by SM #2 "Environmental Services". SM #7 (Director of Facility Maintenance) had joined the surveyor and was interviewed as to whether the facility had a problem with the coolers. SM #7 stated there had been a "problem with the compressor on the top of the cooler and it had to be replaced." The surveyor asked SM #6 whether they had been aware of a problem with the cooler. SM #6 stated, "I am not sure of the exact date but about a month or a month and a half ago I called maintenance about the temperature and they did come..." SM #7 stated, "We used a portable AC (air conditioning) unit to keep things cool in here and it had a digital read out which ran down to fifty-eight (58) degrees. We connected it to the top right door of the cooler so that it would cool the entire chest..." The surveyor inquired as to how often the temperature of the cooler was monitored and where the temperature monitoring log was located. SM #7 stated they were "not sure" and would have to "check on that". The surveyor observed a small silver box on the upper left side of the cooler with a blue wire running from it. The surveyor asked if this was a digital temperature monitor. Staff Member #7 stated, "The electronic temperature monitoring sends an alarm to the manager of the department." The surveyor observed on the front of the cooler above the right lower door there was an attached thermometer which read fifty-five (55) degrees. The surveyor inquired as to whether this thermometer was accurate and Staff Member #7 stated, "Yes, I think so." The surveyor asked where the temperature monitoring for the digital thermometer was received. SM #7 stated, "I am not sure if its the lab or back in maintenance or biomed; I'll check on that." The surveyor asked SM #7 what the temperature range for the coolers should be and SM #7 stated, "I think it should not be above fifty eight (58)." The surveyor requested the monitoring logs for the morgue coolers for the past twelve (12) months as well as an answer as to who was responsible for the log and where the digital thermometer read out was located. The surveyor inquired as to whether the facility had a deceased patient in the morgue for an extended period. Staff Member #6 stated, "Yes we did. (Name of patient - Patient #3) was here about two months." The surveyor inquired as to whether there had been an odor from the cooler/body during that time. SM #6 stated, "Yes".

At 3:50 p.m. on 9/26/22 SM #1 (Director of Quality) informed the surveyor there were "no temperature monitoring logs for the morgue and no procedure for monitoring. We have checked numerous areas and cannot find any recordings of temperatures. We are checking bio-med, but there's nothing in maintenance, the lab, or environmental services. We cannot find if the temperatures are being monitored and if they are, where they read out to. No one knows where the temperatures go or if it is even functional..."


On 9/27/22 at 9:30 a.m., the surveyor interviewed SM #9 (Case Management) regarding Patient #3 and why the patient's body had remained at the facility for two months. SM #9 stated, "The patient had been here previously and had been discharged with home health, then placed on hospice. (Patient) had known liver cancer. When (patient) was admitted on July first, (patient) had been on hospice for two weeks and the caregiver could no longer help or provide care for (patient). (Patient) was only here one day before (patient) passed. I did not see the patient but another case manager saw (patient) and did the evaluation for discharge planning. The plan was for (patient) to return home with hospice care of go to a facility if there was no one who could provide home assistance. (Patient #3) was living with a friend and (they) let us know there was no family. Hospice discharged (patient) apparently, when (patient) was admitted. We had sent a referral for hospice again to see what they could provide or if we needed to look into a facility but (patient) passed the next day. When we did not have any known family and the friend was not able to help, we have to reach out to the sheriff locally and they try to help locate any family. After ten days if there is no family found, then they (sheriff) assume custody of the remains and they are cremated."

At 10:00 a.m. on 9/27/22 Nursing Supervisor (SM #10) stated, "I was aware on August 20th at 1:39 a.m. that the cooler wasn't working in the morgue. I had gone down to meet the funeral home to pick up another patient and discovered the room and the cooler was hot. I called maintenance and immediately took the body out of the cooler and placed it on ice. I took the body out of the cooler because it was cooler in the room that it was in the cooler. A portable air conditioner unit was set up by maintenance on day shift. There were no other bodies at that time. It wasn't a quick fix for the cooler, but it was better when they set up the portable AC..." The surveyor inquired as to the condition of Patient #3's body and SM #10 stated, There was an odor; there was an odor before the AC went out though, for quite some time..."


The surveyor reviewed documents provided by the facility titled "House Report" for the dates 7/11/22, 8/1/22, 8/6/22, 8/19/22, 8/20/22, 8/30/22, 8/31/22, 9/1/22, and 9/2/22. These documents were identified by SM #1 as the house Supervisor reports. The documents contained a "Morgue List" which evidenced Patient #3 was placed in the morgue on 7/2/22 and remained until 9/1/22. The documents also evidenced that on 8/19/22 SM # 10 had documented under the section "Issues/Concerns/Notes: 0725 (7:25 a.m.) Morgue cooler still isn't working. (Name) updated on situation. Cooler guy should be back today. Spoke to (SM # 7) and maintenance guys. They will keep me updated about the situation. (Names- SM #16 and #15) have been updated as well. 1712 (5:12 p.m.) Part was found. Team will be here first thing in the morning to get it fixed." On 8/20/22 the "House Report" documented: "0139 (1:39 a.m.) Called (name) from Maintenance about the morgue cooler not being cool. (They) came in and checked everything and stated that (they) would need to call someone to get it fixed. 0445 (4:45 a.m.) Spoke to (SM #17) (SM #16) and called (name of maintenance) back. Gonna place portable AC unit in the morgue. I've already packed the patient with ice. (Name) stated (they) spoke with (name) about the situation as well."

The facility policy for "Sensoscientific Monitoring" was reviewed and evidenced, in part: "...Laboratory: Optimal temperature storage recommendations for all laboratory products are based on recommendations from CAP (college of American Pathologists) and reagent manufacturers. Below are recommendations for optimal temperature storage...M. Morgue: 2C - 8C (two degrees Celsius to eight degrees Celsius - converts to 35-46 degrees Fahrenheit)..."

2. Further review of the clinical record revealed documentation in the "Nurse Notes" dated 7/2/22 at 1256 (12:56 p.m.) by Registered Nurse Staff Member #17 (SM #17). The documentation evidenced the following: "Patient was in significant pain this morning, a Roxicodone (narcotic pain medication) given, (Patient) rested for a bit and started groaning before I went to lunch. I told (patient) when I got back, I could bring (patient) (their) pain meds and if (patient) couldn't wait, I could contact the doctor. When I got back from lunch, I went to take (patient) vitals and (patient) was dead."

According to the physician orders and review of the Medication Administration Record (MAR) for Patient #3 the patient was ordered "Oxycodone HCL (Brand name Roxicodone) 10 mg (milligrams) Q4HR PRN (every four hours as needed) PO (by mouth) for pain- Oxycodone HCL Immediate Release Roxicodone". Documentation on the MAR revealed Patient #3 last received a dose of the pain medication at 9:09 a.m.

The surveyor requested the facility policies regarding the administration of PRN (as needed) pain medications and the allowable time frames for administration. The surveyor was provided a policy "Time Critical Scheduled Medications" which evidenced, "The following medications have been selected as time critical scheduled medications: a. parenteral anticoagulants...intravenous anticonvulsants...intravenous antibiotics...C. For non-time critical scheduled medications,the nurse will administer within a two-hour window (1 [one] hour before and up to 1 [one] hour after) the due time of the medication". The surveyor inquired on 9/27/22 at 10:45 a.m. if this was the policy that would apply to PRN medications for pain. SM #1 stated this was the only policy they could find and that, "Yes it would apply to pain medications".

The surveyor requested the actual lunch time for SM #17 for the date 7/2/22 and when it was provided, it evidenced the SM #17 clocked out for lunch at 11:51 a.m. and clocked back in at 12:27 p.m. According to the last time the medication was documented for Patient #3 (9:09 a.m.) and the facility policy, Patient #3 could have received pain medication at 12:09 p.m. The record evidenced SM #17 did not go back to check on Patient #3 until 12:56 p.m., approximately 47 (forty-seven) minutes later, when the SM knew the patient was experiencing pain before they left for lunch. There was no evidence in the clinical record that any other nurse administered medications during that time, nor was the physician contacted.

The facility policy "Pain Management" revealed in part: "...B. Institutional responsibility begins with the affirmation that patients have the right to the optimum level of pain relief that can safely be provided. The patient's right to pain management is respected and supported. This includes: ...2. Prompt and appropriate treatment of reported pain..."

The surveyor interviewed SM #17 on 9/27/22 at 1:20 p.m. SM #17 was interviewed as to whether Patient #3 was able to make their needs knows (alert and conversant) and the situation concerning the administration of pain medications on 7/2/22. SM #17 stated, "I believe the patient was alert and talking, but I am not sure though. I remember the name, but if the patient was getting oral medications (patient) had to be able to swallow so they would have had to be alert enough to do that...Yes, I went to lunch and I did not call the doctor. I don't remember a lot about it. I wish I could remember. The way I wrote the note, (patient) must have been able to communicate. I don't want to say anything that I don't know for sure. I don't have a good recall." When asked as to why the medication was not administered, or report given to another nurse to administer while SM #17 was at lunch, or the physician not notified to administer "early", SM #17 stated, "I should have put the patients needs first. It was inappropriate. I did not call the doctor and I do not remember if the patient talked to me or not." The surveyor also inquired as to the "pain assessment (Critical Care Observation Tool)" which had been documented earlier (7/2/22 at 9:09 a.m.) which evidenced, "...Is the patient extubated and unable to communicate: YES..." SM #17 stated they "couldn't remember".

The surveyor discussed the concerns throughout the survey with SM #1 and #2. On 9/27/22 at approximately 2:00 p.m., the surveyor discussed the findings and concerns with the facility Administrative leaders at the exit conference.

Based on observation, staff interview and facility document review during the course of a complaint investigation, the facility staff failed to maintain an effective Quality program that included all areas of the hospital, including monitoring of temperatures for the morgue.

Due to the lack of monitoring of the temperature, the facility staff failed to recognize when the cooling system was failing until it became completely non-operational and the temperature significantly exceeded the recommended range. This resulted in the hastening of the decomposition of a patient's (Patient #3) remains. At the time of the survey (9/26- 9/27/22), the facility was still not monitoring the morgue cooler's temperatures and the temperature of the cooler per the attached thermometer was observed at fifty-five (55) degrees.

Based on information obtained during staff interviews, the facility Maintenance and Quality Director did not know whether or not the temperature in the cooler was monitored, and if it was, where the temperature read out was located. The facility had no policy regarding the monitoring of the temperatures, however had a policy documenting what the temperature range should be.

The facility had no documented past or ongoing Quality monitoring activity for this area.

Please refer to A0283 for further information.

Based on observation, staff interview and facility document review, the facility staff failed to ensure Quality Program Activity monitored all areas of the hospital environment in order to identify concerns and opportunities for correction and improvement.

The facility Quality Program did not address temperature monitoring for the morgue area, resulting in the morgue cooler being kept at significantly out of range temperatures. The facility staff becoming aware of this issue only when the system completely failed and the cooler malfunctioned.

The findings included:

During a complaint investigation which alleged there was a body in the morgue that had decomposed due to the failure of the morgue cooler, it was discovered the facility did not monitor the morgue temperatures.

A tour of the facility morgue on 9/26/22 at approximately 12:20 p.m., evidenced the following: SM #7 (Director of Facility Maintenance) SM #7 stated there had been a "problem with the compressor on the top of the cooler and it had to be replaced." The surveyor asked SM #6 (Nursing Supervisor) whether they had been aware of a problem with the cooler. SM #6 stated, "I am not sure of the exact date but about a month or a month and a half ago I called maintenance about the temperature and they did come..." SM #7 stated, "We used a portable AC (air conditioning) unit to keep things cool in here and it had a digital read out which ran down to fifty-eight (58) degrees. We connected it to the top right door of the cooler so that it would cool the entire chest..." The surveyor inquired as to how often the temperature of the cooler was monitored and where the temperature monitoring log was located. SM #7 stated they were "not sure" and would have to "check on that". The surveyor observed a small silver box on the upper left side of the cooler with a blue wire running from it. The surveyor asked if this was a digital temperature monitor. Staff Member #7 stated, "The electronic temperature monitoring sends an alarm to the manager of the department." The surveyor observed on the front of the cooler above the right lower door there was an attached thermometer which read fifty-five (55) degrees. The surveyor inquired as to whether this thermometer was accurate and Staff Member #7 stated, "Yes, I think so." The surveyor asked where the temperature monitoring for the digital thermometer was received. SM #7 stated, "I am not sure if its the lab or back in maintenance or biomed; I'll check on that." The surveyor asked SM #7 what should the temperature range be for the coolers and SM #7 stated, "I think it should not be above fifty eight (58)." The surveyor requested the monitoring logs for the morgue coolers for the past twelve (12) months as well as an answer as to who was responsible for the log and where the digital thermometer read out was located.

At 3:50 p.m. on 9/26/22 SM #1 (Director of Quality) informed the surveyor there were "no temperature monitoring logs for the morgue and no procedure for monitoring. We have checked numerous areas and cannot find any recordings of temperatures. We are checking bio-med, but there's nothing in maintenance, the lab, or environmental services. We cannot find if the temperatures are being monitored and if they are where they read out to. No one knows where the temperatures go or if it is even functional...this is not something that we have been looking at in Quality monitoring..."

The Director of Quality did provide the surveyor with a facility policy for "Sensoscientific Monitoring" which was reviewed and evidenced, in part: "...Laboratory: Optimal temperature storage recommendations for all laboratory products are based on recommendations from CAP (College of American Pathologists) and reagent manufacturers. Below are recommendations for optimal temperature storage...M. Morgue: 2C - 8C (two degrees Celsius to eight degrees Celsius - converts to 35-46 degrees Fahrenheit)..."

The review of QAPI meeting minutes for the months of July - September 2022 failed to evidence addressing issues with maintaining morgue cooler in the recommended temperature range and/or any improvement activities directed towards monitoring of performance and maintenance of morgue cooler to prevent reoccurrence in the future.

The surveyor discussed the concerns throughout the survey with SM #1 and 2. On 9/27/22 at approximately 2:00 p.m., the surveyor discussed the findings and concerns with the facility Administrative leaders at the exit conference.

Based on medical record review, document review and interviews, the facility staff failed to monitor Patient #2's vital signs in accordance with their policy and procedure.

The findings included:

A comprehensive review of Patient #2's medical record evidenced the following:
4:30 p.m.- arrival to ER (Emergency Room) with bipap (bilevel positive airway pressure) initiated and O2 (oxygen) saturation 95%
5:16 p.m.- Bipap in place O2 saturation 98%
5:30 p.m.- O2 saturation 94%
5:45 p.m.- O2 saturation 96%
6:00 p.m.- O2 saturation 97%
6:15 p.m.- O2 saturation 97%
6:30 p.m.- O2 saturation 97%

Patient 2 was given a Level 2 acuity level upon presentation to the ER. The facility policy, "Emergency Department Assessments, Reassessments and Documentation, A-7," Last revised 01/2022, evidenced, in part, "Definitions: Level 2: Emergent: Patients who have conditions that may result in loss of life or limb if not treated immediately, vital signs documented every 15 (fifteen) minutes".

O2 saturation levels, nor other vital signs were evidenced as being monitored after 6:30 p.m. on 08/13/22., until 12:49 a.m. on 08/14/22. The surveyor asked Staff Member #5 (SM5- Director of Clinical Informatics) if evidence of vital sign monitoring between 6:30 p.m. to 12:49 a.m. could be located in the medical record. After an extensive review, the surveyor was informed that they could not be located.

The surveyor discussed the concerns throughout the survey with Staff Member #1 and #2. On 9/27/22 at approximately 2:00 p.m., the surveyor discussed the findings and concerns with the facility's Administrative leaders at the exit conference.

Based on observation, staff interview, and facility document review during the course of a complaint investigation, the facility staff failed to ensure the appropriate monitoring of temperatures of the morgue cooler. The facility staff, due to the lack of monitoring of the temperature, failed to recognize when the cooling system was failing until it became completely non-operational and the temperature exceeded the recommended range. This resulted in the hastening of the decomposition of a patient's (Patient #3) remains. At the time of the survey (9/26- 9/27/22), the facility was still not monitoring the temperatures and the temperature of the cooler was observed at fifty-five (55) degrees according to the facility's cooler thermometer.

At the time of morgue tour, the area was observed to contain soiled items, dirt on the floor and equipment lacking maintenance.

Based on information obtained during staff interviews, the facility Maintenance and Quality Director did not know whether or not the temperature in the cooler was monitored, and if it was, where the temperature read out was located. The facility had no policy regarding the monitoring of the temperatures, however had a policy which documented what the temperature range should be.

Please refer to A0726 for further information.

Based on observation, staff interview, and facility document review during the course of a complaint investigation, the facility staff failed to ensure proper temperature monitoring and controls in the morgue coolers and ensure cleanliness and maintenance of the morgue area.

The findings included:

On 9/26/22 at approximately 12:20 p.m., the surveyor requested to be escorted to the facility morgue. Staff Member #2 (VP of Quality and Patient Safety) accompanied the surveyor. When arriving at the morgue, Staff Member #6 (Nursing Supervisor) joined the surveyor and unlocked the door for entrance. Upon entering the morgue, the surveyor observed the floor to be dirty with brown wheel marks, as if a cart or stretcher had been rolled into the room with mud on the wheels. There was a large metal table on the left side of the room which was dirty with a dried yellow/white material in the center. Behind, and to the left of the stretcher, in the back of the room were two tables with various items, containers, and instruments which were soiled and the tables appeared to have rust on the sides. On the right side of the room in the corner of a large cooler was a pile of discarded linens, towels, and hospital gowns that appeared to be soiled. The surveyor inquired as to who was responsible for cleaning the room and was told by SM #2 "Environmental Services". SM #7 (Director of Facility Maintenance) had joined the surveyor and was interviewed as to whether the facility had a problem with the coolers. SM #7 stated there had been a "problem with the compressor on the top of the cooler and it had to be replaced." The surveyor asked SM #6 (Nursing Supervisor) whether they had been aware of a problem with the cooler. SM #6 stated, "I am not sure of the exact date but about a month or a month and a half ago I called maintenance about the temperature and they did come..." SM #7 stated, "We used a portable AC (air conditioning) unit to keep things cool in here and it had a digital read out which ran down to fifty-eight (58) degrees. We connected it to the top right door of the cooler so that it would cool the entire chest..." The surveyor inquired as to how often the temperature of the cooler was monitored and where the temperature monitoring log was located. SM #7 stated they were "not sure" and would have to "check on that". The surveyor observed a small silver box on the upper left side of the cooler with a blue wire running from it. The surveyor asked if this was a digital temperature monitor. Staff Member #7 stated, "The electronic temperature monitoring sends an alarm to the manager of the department." The surveyor observed on the front of the cooler above the right lower door there was an attached thermometer which read fifty-five (55) degrees. The surveyor inquired as to whether this thermometer was accurate and Staff Member #7 stated, "Yes, I think so." The surveyor asked where the temperature monitoring for the digital thermometer was received. SM #7 stated, "I am not sure if its the lab or back in maintenance or biomed; I'll check on that." The surveyor asked SM #7 what should the temperature range be for the coolers and SM #& stated, "I think it should not be above fifty eight (58)." The surveyor requested the monitoring logs for the morgue coolers for the past twelve (12) months as well as an answer as to who was responsible for the log and where the digital thermometer read out was located. The surveyor inquired as to whether the facility had a deceased patient in the morgue for an extended period. Staff Member #6 stated, "Yes we did. (Name of patient - Patient #3) was here about two months." The surveyor inquired as to whether there had been an odor from the cooler/body during that time. SM #6 stated, "Yes". The surveyor inquired who was responsible or provided oversight of this area of the hospital. Neither Staff Member #7 nor Staff Member #6 could identify the staff or department in charge of the morgue as a unit or department. Surveyor asked to review a policy that outlines how oversight is provided for this area.

At 3:50 p.m. on 9/26/22 SM #1 (Director of Quality) informed the surveyor there were "no temperature monitoring logs for the morgue and no procedure for monitoring. We have checked numerous areas and cannot find any recordings of temperatures. We are checking bio-med, but there's nothing in maintenance, the lab, or environmental services. We cannot find if the temperatures are being monitored and if they are where they read out to. No one knows where the temperatures go or if it is even functional..."

At 10:00 a.m. on 9/27/22 Nursing Supervisor (SM #10) stated, "I was aware on August 20th at 1:39 a.m. that the cooler wasn't working in the morgue. I had gone down to meet the funeral home to pick up another patient and discovered the room and the cooler was hot. I called maintenance and immediately took the body out of the cooler and placed it on ice. I took the body out of the cooler because it was cooler in the room that it was in the cooler. A portable air conditioner unit was set up by maintenance on day shift. There were no other bodies at that time. It wasn't a quick fix for the cooler, but it was better when they set up the portable AC..."

The surveyor reviewed documents provided by the facility titled "House Report" for the dates 7/11/22, 8/1/22, 8/6/22, 8/19/22, 8/20/22, 8/30/22, 8/31/22, 9/1/22, and 9/2/22. These documents were identified by SM #1 as the house Supervisor reports. The documents also evidenced that on 8/19/22 SM #10 had documented under the section "Issues/Concerns/Notes: 0725 (7:25 a.m.) Morgue cooler still isn't working. (Name) updated on situation. Cooler guy should be back today. Spoke to (SM # 7) and maintenance guys. They will keep me updated about the situation. (Names- SM #16 and #15) have been updated as well. 1712 (5:12 p.m.) Part was found. Team will be here first thing in the morning to get it fixed." On 8/20/22 the "House Report" documented: "0139 (1:39 a.m.) Called (name) from Maintenance about the morgue cooler not being cool. (They) came in and checked everything and stated that (they) would need to call someone to get it fixed. 0445 (4:45 a.m.) Spoke to (SM #17) (SM #16) and called (name of maintenance) back. Gonna place portable AC unit in the morgue. I've already packed the patient with ice. (Name) stated (they) spoke with (name) about the situation as well."

The facility policy for "Sensoscientific Monitoring" was reviewed and evidenced, in part: "...Laboratory: Optimal temperature storage recommendations for all laboratory products are based on recommendations from CAP (College of American Pathologists) and reagent manufacturers. Below are recommendations for optimal temperature storage...M. Morgue: 2C - 8C (two degrees Celsius to eight degrees Celsius - 35-46 degrees Fahrenheit)..."

No policy related to morgue oversight was provided to the survey team for review and SM #1 confirmed they were unable to locate such document.

The surveyor discussed the concerns throughout the survey with SM #1 and 2. On 9/27/22 at approximately 2:00 p.m., the surveyor discussed the findings and concerns with the facility Administrative leaders at the exit conference.

Based on an interview and during the course of a complaint investigation, the facility staff failed to maintain infection control practices by donning gloves before collecting blood specimens. This involved Patient #2.

The findings included:

Patient #2 presented to the Emergency Room (ER) on 08/13/22 via Emergency Medical Services (EMS) at 4:30 p.m. Patient #2 was brought from a skilled nursing facility (SNF) due to sudden onset of SOB (shortness of breath). The HPI (history of present illness) on 08/13/22 at 4:45 p.m. evidenced, "on bipap (bi-level positive airway pressure- assistance to breathe) upon arrival...tachycardic (fast heart rate), tachypneic (fast breathing) here. O2 sat (oxygen saturation) here 95%. Patient was in respiratory distress..." Pt's course in the ED concluded on 08/13/22 at 11:45 p.m., when they were admitted and transferred to the medical/surgical floor.

The family had expressed a concern that the staff did not wear gloves when collecting a blood specimen. In an interview with Staff Member #10 (SM10- Nursing Supervisor) on 09/27/22 at 10:15 a.m., they stated, "The (family member) expressed their concern about the nurse not wearing gloves while obtaining blood specimens. This was addressed immediately with the nursing staff because this was not proper protocol. Regardless of what we are doing, when it comes to patient care, we hand sanitize or wash hands, don gloves, dispose of gloves and use hand sanitizer or wash hands. All staff are aware of this technique."

The surveyor asked for a facility policy that detailed proper hand hygiene and/or donning gloves during blood specimen collection but was not provided by the facility.

The surveyor discussed the concerns throughout the survey with SM #1 and 2. On 9/27/22 at approximately 2:00 p.m., the surveyor discussed the findings and concerns with the facility Administrative leaders at the exit conference.