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Based on observations in the New Day Senior Care unit, hospital policy and procedure, and interview with staff, it was determined the hospital failed to ensure a safe and ligature risk free environment was maintained for psychiatric patients.

Findings include:

Hospital Policy: Unit Safety Checks
Policy Number: None
Revised Date: 8/17/22

I. Purpose:

To ensure a safe patient environment and the safety of each patient on the unit.

II. Policy:

The charge registered nurse (RN), or designee, at the beginning of the shift, will inspect the entire unit. A log will be kept to include...any deficiencies...found on the unit.

III. Procedure:

A. The charge RN, or designee, will walk the entire unit at sometime near the start of the shift.
B. The inspection will include all the areas of the unit.
...F. Any deficiencies will be immediately corrected by the program staff. If this is not possible, a report will be made to the appropriate hospital department.
G. The program director will review the worksheets on a weekly basis to ensure compliance and patient safety. Issues identified on a recurring basis will be addressed as part of the program's CQI (continuous quality improvement) process.

1. A tour of the New Day Senior Care unit was conducted on 10/1/24 at 11:28 AM with Employee Identifier (EI) # 4, Program Director. The unit consisted of nine patient care rooms.

The following ligature risks were observed within patient rooms 201, 202, 203, 204, 206, and 208:

A. Windows with a "T" shaped handle extending approximately five inches from window base.

B. Bathtubs with waterspout extending approximately six inches from the tub

EI # 4 was present during the tour and confirmed the ligature risks.

Based on review of medical records (MR), Alabama Board of Nursing Administrative Code Chapter 610-X-6 Standards of Nursing Practice, and interviews with the staff it was determined the facility failed to ensure the staff documented the wound care performed.

This affected MR # 16, one of two wound care MR's reviewed and had the potential to affect all patients treated by this hospital.

Findings include:

Administrative Code Chapter 610-X-6-.04

Practice Of Professional Nursing (Registered Nurse Practice)...

(1) The practice of professional nursing includes, but is not limited to:

...(f) Documentation of nursing interventions and responses to care in an accurate, timely, thorough and clear manner...

Administrative Code Chapter 610-X-6-.05

Practice Of Practical Nursing (Licensed Practical Nurse Practice)...

(1) The practice of practical nursing includes, but is not limited to:

...(h) Documentation of nursing interventions and responses to care in an accurate, timely, thorough and clear manner...


1. MR # 16 was admitted to the hospital with cellulitis to the left lower leg on 7/17/24.

A review of physicians orders dated 7/17/24 revealed, "Wrap leg BID (twice daily) with Lotrimin cream, abd pads and kerlix. apply cream to pads, then apply to ulcerations on leg, secure with Kerlix and paper tape."

A review of the medical record dated 7/17/24 to 7/20/24 revealed no documentation wound care was provided.

An interview was conducted on 10/3/24 at 5:00 PM with Employee Indentifier (EI) # 2, Director of Nursing, who confirmed the staff failed to document the wound care provided during the dates of 7/17/24 to 7/20/24.

Based on observations, review of hospital policies and procedures, and interviews with staff it was determined the hospital failed to ensure:

1. Safe storage of food items in the dietary department.

2. Foods were labeled with the date opened and use by date or expiration date.

3. Foods placed in the steam table were covered when not being served.

This had the potential to affect all patients admitted to this hospital.

Findings include:

Hospital Policy: Food Storage ( Dry, Refrigerated, and Frozen)
Policy Number: None
Issued: None
Revised: 9/25/16

Policy:

Guideline:

Food shall be stored on shelves in a clean, dry area, free from contaminants. Food shall be stored at appropriate temperatures and using the appropriate methods to ensure the highest level of food safety.

Procedure:

1. General storage guidelines to be followed:
a. All food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed or discarded...

Hospital Policy: Serving Temperatures for Hot and Cold Foods.
Policy Number: None
Issued: None
Revised: None

Guideline: Staff will follow the guidelines below when serving hot and cold beverages and food.

Procedure:

...6. Foods will be covered when not being served. During service, lids to cover one half of the pans will be used...


1. A tour of the dietary department was conducted on 10/1/24 at 11:10 AM with Employee Identifier (EI) #15, Cook, which included observations in the following areas:

a. Dry storage:

One bag of classic Barilla noodles with an open date of 9/10/24 unsecured on the shelf with no expiration date.

One opened bag of noodles without a label and an expiration date.

One opened bag of Grits without an expiration date.

b. Salad prep counter:

10 bottles of various dry seasoning were observed opened with no expiration date or open date.

The staff failed to ensure foods were labeled, and stored appropriately.

An interview was conducted on 10/1/24 at 11:20 AM with EI # 15, who confirmed foods were not stored and labeled per policy.

2. An observation was conducted on 10/2/24 at 11:30 AM with EI # 14, Dietary Relief, while preparing patient trays.

The staff failed to protect the prepared foods from possible contamination by leaving containers uncovered on the steam table.

An interview was conducted on 10/2/24 at 5:22 PM with EI # 2, Director of Nursing, who confirmed the staff did not follow the policy regarding keeping the foods covered while in the steam table.

Based on observations and interviews with staff during a tour of the hospital by Life Safety Code and health surveyors, it was determined the hospital was not constructed, arranged and maintained to ensure patient safety.

This had the potential to affect all patients served by this hospital.

Findings include:

Refer to tags: K-0211, K-0293, K-0353, K-0781, K-0923 and A-0724

Based on observations, review of hospital policy, and staff interviews it was determined the hospital failed to ensure expired supplies were not available for patient use.

This deficient practice had the potential to negatively affect all patients served by the hospital.

Findings include:

Hospital Policy: Handling of Medicines, Medical Consumables, and Chemicals
Policy Number: 140.13
Written: 8/23/12
Approved by Medical Staff: 8/11/15

This policy applies to all medications, medical consumables...stored in this facility.

Purpose:
To identify expired products/items...
To avoid the use of expired...medical consumables...
To arrange return/disposal of expired...medical consumables...

Policy:
...All...medical consumables...are to be considered expired on the manufacturer stated day of expiration or at the last day of the manufacturer stated month of expiration.
...Medical consumables...which have expired are not to be used in the facility.
...Medical consumables/supplies...are to be returned to the dispensing department and/or disposed of in an appropriate manner based upon the item.

Procedure:
...Staff are to check the expiration date of the products on a regular basis...
...All products are to be checked monthly for expiration...
All expired...medical products are to be collected, labeled clearly as expired items, and kept in a separate place for proper disposal.
Expired...medical consumables...are to be removed from all patient care areas.
...Discard or return to purchasing expired supplies.
Table: Expiration Date of Open Medicine Containers in Patient Care Areas
...Topicals...Creams, ointments, lotions, pastes...Expiration date...30 days after opening...
Manufacture containers of items such as ... alcohol are to be considered expired on the manufacturer stated day of expiration ... it is recommended they be used as single patient use items...

1. A tour of the Emergency Department (ED) was conducted on 10/1/24 at 11:30 AM.

The following supplies were found to be expired in the supply cabinet in Room ED 1.

Eight Ear Curette Loop, Sterile with an expiration date of 4/6/24.

Two Large Airlife SeeBreath Carbon Dioxide Detectors with an expiration date of 5/9/24.

An interview was conducted on 10/3/24 at 5:30 PM with Employee Identifier (EI) # 2, Director of Nursing, who confirmed the supplies were expired and available for patient use.

2. A tour of the New Day Senior Care Unit Nurse Station was conducted on 10/1/24 at 12:58 PM which included review of the crash cart. The following items were observed in the crash cart as expired and available for patient use:

Two 6.5 millimeter (mm) Shiley Hi-Lo Oral/Nasal Tracheal cuffed tubes with expiration date 8/20/24.

Three Cardinal Health IV (intravenous) start kits with expiration date 9/1/24.

EI # 4, Program Director, was present during the tour and confirmed the items were expired and available for patient use.

3. A tour of the Surgical Department including the Post Anesthesia Care Unit (PACU) and Supply Room was conducted on 10/1/24 at 1:30 PM with EI # 10, Surgery Manager, the following items were observed expired on the unit and available for patient use:

One Urinary catheter tray with an expiration date 9/20/23.

Five sets of Laproscopy Suction/Irrigation Tubes with an expiration date of 2/18/24.

One bottle of Isopropyl Alcohol 16 fluid ounces with a date opened label of 6/5/24.

EZ Lubricating Jelly, (brand name), with a date opened label of 8/3/24.

One bottle of Iodoform Packing Strip, one inch, with an expiration date of 7/20/24.

One bottle of Iodoform Packing Strip, one inch, with an expiration date of 8/12/24.

An interview was conducted on 10/1/24 at 2:00 PM with EI # 10, who confirmed the items were available for patient use and were expired and should have been discarded.

4. A tour of the Medical/Surgical unit was conducted on 10/1/24 at 1:50 PM.

The following supplies were found to be expired in the crash cart:

One Covidien Shiley Intubating Stylet with an expiration date of 5/22/22.

One Infusomat Space Pump IV set with an expiration date of 5/31/24.

Two 14 Gauge (G) STRL Intravenous (IV) Start Kits, one with an expiration date of 3/1/24, and one with an expiration date of 4/1/24.

One 24 G IV Start Kit with an expiration date of 4/1/24.

One Covidien 8 millimeter (mm) Hi/Lo Oral/Nasal Tracheal Tube, Cuffed with an expiration date of 12/19/23.

One Covidien 8 mm Hi/Lo Oral/Nasal Tracheal Tube, Cuffed with an expiration date of 1/22/24.

An interview was conducted on 10/3/24 at 5:30 PM with EI # 2, who confirmed the supplies were expired and available for patient use.




41624




41623

Based on observations, CDC (Centers for Disease Control) Hand Hygiene in Healthcare Settings guidelines, and interviews with staff it was determined the hospital failed to ensure staff performed hand hygiene per CDC guidelines.

This deficient practice affected one of one observations of terminal cleaning, one of three observations of medication administration, and had the potential to affect all patients admitted to this hospital.

Findings include:

CDC Hand Hygiene in Healthcare Settings:

January 2020

The Core Infection Prevention and Control Practices for Safe Care Delivery in All
Healthcare Settings recommendations of the Healthcare Infection Control Practices
Advisory Committee (HICPAC) include the following strong recommendations for
hand hygiene in healthcare settings.

Healthcare personnel should use an alcohol-based hand rub or wash with soap and
water for the following clinical indications:

Immediately before touching a patient...

After touching a patient or the patient 's immediate environment...

After contact with blood, body fluids, or contaminated surfaces

Immediately after glove removal.

1. An observation of terminal cleaning for patient room 205 by EI # 18, Housekeeping Tech (Technician), was conducted on 10/2/24 at 8:46 AM.

EI # 18 applied gloves without performing hand hygiene (HH), and changed gloves five times between the tasks of cleaning/disinfecting the patient bed frame and mattress, light switches, door handles, windowsill, air conditioning unit, sweeping/mopping the floor and placing clean linens on the bed without performing HH.

The surveyor asked EI # 18 at the completion of the terminal cleaning his/her understanding of HH and glove changes. EI # 18 stated he/she changed gloves between tasks, and used hand sanitizer after completion of room cleaning.

An interview was conducted on 10/3/24 at 5:22 PM with EI # 2 who confirmed EI # 18 failed to follow the CDC hand hygiene guidelines and perform HH between glove changes.

2. An observation of oral medication administration by EI # 19, registered nurse, to an unsampled patient was conducted on 10/3/24 at 9:06 AM for four medications.

EI # 19 obtained the individual oral tablets from the automated dispensing system, applied gloves without performing HH, went to the patient nourishment refrigerator, unlocked the refrigerator, removed a bottle of water and entered the patient's room while wearing the same gloves. Still wearing the gloves, EI # 19 opened the individual medications, dropped them in a medication cup and administered the medications to the patient. EI # 19 returned to the nurse station, removed the gloves without performing HH, documented the administration of the medications on the computer and then performed HH.

EI # 19 failed to perform HH with gloving per CDC hand hygiene guidelines.

An interview was conducted on 10/3/24 at 5:22 PM with EI # 2 who confirmed EI # 19 failed to perform HH per the CDC hand hygiene guidelines.



41624

Based on observations, review of Scope Buddy Flushing Aid User Manual, hospital policy and procedure, and interviews, it was determined the facility failed to ensure staff followed the manufacturer's recommended use and facility policy for Personal Protective Equipment (PPE) use.

This affected one of one observation of endoscope cleaning in the endoscope unit and had the potential to affect all staff performing procedures requiring use of PPE.

Findings include:

Scope Buddy Endoscope Flushing Aid User Manual

Copyright: 2009 Minntech Corporation

...Operator Safety

1. This device is only to be operated by properly trained and qualified personnel...

2. Avoid biological contamination and chemical burns. Always wear appropriate personal protective (PPE) including clothing, gloves, and safety glasses when handling used endoscopes...

Facility Policy: Isolation/Contact Precautions

Policy Number: Not Listed

Revised: 6/15/2017

Policy:

1. The nursing staff will adhere to universal precautions...

3. Wear protective equipment as indicated for specific precaution/situation...

An observation of endoscope cleaning was conducted on 10/2/24 at 9:35 AM. Employee Identifier (EI) # 11, Operating Room Technician, donned a splash proof gown, surgical mask, and gloves. EI # 11 was wearing prescription glasses that did not have splash protection.

EI # 11 proceeded to clean the endoscope in the sink using the Scope Buddy.

EI # 11 failed to use PPE for eye protection.

An interview was conducted on 10/3/24 at 5:15 PM with EI # 2, Director of Nursing, who confirmed the staff failed to wear the appropriate PPE while cleaning the endoscope.