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Based on policy review, record review and interview, the facility failed to ensure total joint replacement surgery patients were not routinely ordered scheduled Observation Services (services provided to a patient that is classified as an outpatient that receive services from the hospital, however, the patient is not admitted to the hospital) for recovery before surgical services were provided for two (#12 and #17) of two current patients and for nine (#3, #27, #28, #29, #30, #31, #32, #33 and #34) of nine discharged patients for a total of 11 patients' Electronic Medical Health Records (EMHR) reviewed for post-surgical Observation Services. This failed practice was an inappropriate use of Observation Services and had the potential to affect all patients seeking total joint replacement surgery at the facility. The facility census was zero Acute care patients, five Swing Bed patients and three Observation patients, for a total census of eight.

Findings included:

1. Review of the facility's policy titled, "Utilization Management Process," dated 03/2021, showed staff directives:
- Oversees and implements the medical necessity determination process.
- The UR (Utilization Review) department shall comply with payers guidelines.
- Monthly utilization review stats are reported at the Medicine meeting for Observation admits.

Review of the facility's policy titled, "Observation," dated 03/2023 showed staff directives:
- SGCMH shall report observation hours in the hospital setting in a manner consistent with Medicare guidelines/regulations.
- Observation: Is a short-term treatment, assessment and reassessment to decide if a patient needs further inpatient treatment or can be discharged. In general, 48 hour limit for total hours billed to Medicare and 24 hour limit for total hours billed to Medicaid. A minimum of 6 hours shall be the minimum threshold to bill a patient for observation hours depending on insurance.
- Carving out procedure time: Is defined as time that is deducted from total number of hours reported on the claim for diagnostic or therapeutic services for which active monitoring is part of the procedure. Services include but are not limited to Outpatient surgery.

2. Review of the facility's Total Joint Replacement Surgery Log showed:
- In May 2023 five total joint replacements were conducted;
- In June 2023 two total joint replacements were conducted;
- In July 2023 two total joint replacements were conducted; and
- From 08/01/23 to 08/14/23, two joint replacements were conducted.
The total count for total joint replacements from May 1, 2023 to August 14, 2023, showed the facility has conducted a total of 11 total joint replacements.

3. Review of Patients' Electronic Medical Health Records (EMHR) showed:
Current Patients
- Patient #12 and Patient #17 were admitted to Observation Services on 08/14/23 from Same Day Care following post-surgical care related to a right total knee arthroplasty (TKA, total knee replacement).
Discharged Patients
- Patient #3 and Patient #27 were admitted to Observation Services on 05/04/23 from Same Day Care following post-surgical care related to TKA.
- Patient #28 and Patient #29 were admitted to Observation Services on 05/08/23 from Same Day Care following post-surgical care related to TKA.
- Patient #30 was admitted to Observation Services on 05/18/23 from Same Day Care following post-surgical care related to shoulder arthroplasty (shoulder replacement surgery).
- Patient #31 was admitted to Observation Services on 05/22/23 from Same Day Care following post-surgical care related to TKA.
- Patient #32 was admitted to Observation Services on 06/26/23 from Same Day Care following post-surgical care related to TKA.
- Patient #33 was admitted to Observation Services on 07/06/23 from Same Day Care following post-surgical care related to TKA.
Patient #34 was admitted to Observation Services on 07/20/23 from Same Day Care following post-surgical care related to total hip arthroplasty (hip replacement).
Eleven out of eleven patients' EMHRs reviewed showed Same Day Care patients were admitted to Observation Services post-surgical procedures.

4. During an interview on 08/16/23 at 11:20 AM, Staff U, Registered Nurse, Family Nurse Practitioner (FNP), stated for all total knee replacement and/or total joint replacement surgeries, she pre-registered the patients for surgery and the pre-registration included a scheduled Observation stay following the surgical procedure. Staff U stated when she meets with patients before surgery she informed the patients they will be scheduled for at least one Observation stay following their surgical procedure. At 12:00 PM, Staff U stated the direction she received from the facility's case manager was to always place patients from Same Day Care into Observation Services instead of Inpatient Services.




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Based on policy review, medical record review and interview the hospital failed to ensure staff completed informed consents for three surgical procedures for patient's (#5, #6, and #8) of six reviewed and failed to ensure staff completed informed consents for anesthesia for five patient's (#4, #5, #6, #7 and #8) of six reviewed. These failures had the potential to affect the quality of care for all patients that presented for surgical procedures. The hospital census was zero Acute Care patients, five Swing Bed patients and three Observation patients for a total census of eight.

Findings included:

1. Review of the hospital's policy titled, "Informed Consent for Anesthesia," last reviewed on 09/22/22, showed that the consent for anesthesia during a surgical treatment was required prior to the procedure.

Review of the hospital's Medical Staff Bylaws, last amended on 04/25/22, showed that written, signed, informed, surgical consent shall be obtained prior to any operative procedure except in those situations wherin the patient's life was in jeopardy and suitable signatures could not be obtained due to the condition of the patient. The Medical Staff Bylaws, also showed that all clinical entries in the patient's medical record should be accurately dated and authenticated.

2. Review of Patient #7's medical record dated 08/01/23, showed Staff D, Anesthetist, failed to provide a date and time of signature that showed the completion of the informed consent to perform anesthesia for the procedure.

Review of Patient #8's medical record dated 08/01/23, showed Staff BB, Gastrointestinal (GI) Physician, failed to provide a signature, date and time that showed the completion of the informed consent to perform the procedure and showed Staff D, Anesthetist, failed to date and time their signature that showed the completion of the informed consent to perform anesthesia during the procedure.

Review of Patient #4's medical record dated 06/06/23, showed Staff CC, Anesthetist, failed to provide a date and time of signature that showed the completion of the informed consent to perform anesthesia for the procedure.

Review of Patient #5's medical record dated 07/12/23, showed Staff F, Surgeon, failed to provide a signature, date and time that showed the completion of the informed consent to perform the procedure and showed Staff CC, Anesthetist, failed to date and time their signature that showed the completion of the informed consent to perform anesthesia during the procedure.

Review of Patient #6's medical record dated 07/13/23, showed Staff AA, Surgeon, failed to provide a signature, date and time that showed the completion of the informed consent to perform the procedure and showed Staff D, Anesthetist, failed to date and time their signature that showed the completion of the informed consent to perform anesthesia during the procedure.

3. During an interview on 08/16/23 at 9:15 AM, Staff C, Director of Perioperative Services, stated that she expected all surgeons, anesthetists and staff to complete the consent forms with dates and times.

Based on observation, interview and policy review, the hospital failed to ensure staff followed infection control policies and infection prevention standards when the staff failed to:
- Provide space for the separation of soiled and clean linen during the washing process.
- Remove rust (reddish brown oxidation of metal that can harbor bacteria) from six rusted table legs in the kitchen.
- Label salad dressings, mayonnaise and heavy cream in the kitchen refrigerators with expiration dates.
- Remove rust from one rusted cabinet in the "dirty" central sterile room.
- Remove three expired supplies and one container with wound packing strips and no expiration date from the wound care cart.
- Cover one linen cart that was used for wound care.
- Perform hand hygiene prior to medication removal for four patients (# 12, #15, #16 and #20) of four observed.
- Perform hand hygiene prior to administration of medications for four patients (#12, #15, #16, and #20) of four observed.
- Perform hand hygiene after glove removal for three patients (#12, #16 and #20) of four observed.
- Provide a policy for antibiotic stewardship for notifying the provider after a patient was on antibiotics for 72 hours.
- Provide a policy for antibiotic stewardship to prevent infection for antibiotic resistant organisms.
These failed practices had the potential to expose all patients, visitors and staff to cross-contamination and increased the potential to spread infection. The hospital census was zero Acute Care patients, five Swing Bed patients and three Observation patients for a total census of eight.

Findings included:

LAUNDRY ROOM
1. Review of the hospital's policy titled, "Storage of Clean Linen," dated 08/2023, showed the direction for staff to keep all linen free of contamination to minimize microbial contamination.

Observation with concurrent interview on 08/14/23 at 9:30 AM, the laundry room showed the washers and dryers shared space with mechanical equipment for the hospital and large coolers for dietary and during an interview with Staff L, Environmental Services Supervisor, stated the hospital launders cubicle curtains from the patient rooms, scrubs and patient bedding in that area.

During an interview on 08/14/23 at 10:45 AM, Staff H, Infection Control, stated there was no space for separating the soiled and clean linens during the washing and drying process.

KITCHEN AND FOOD SAFETY
2. Review of the hospital's policy titled, "Food Safety," last reviewed on 06/01/23, showed the direction for staff to report any cracked or worn equipment to prevent holding pathogens, label items to indicate when the food must be used by, place the earliest expiration dates in front of new items being added and check use-by or expiration dates before use.

Observation on 08/14/23 at 1:50 PM, in the hospital's kitchen, showed:
- Rusted prep sink legs and unclean area under the sink.
- Rusted prep table legs.
- Rusted prep compartment sink legs.
- Rusted and unclean area underneath the dish receiving table and garbage disposal.
- No expiration dates on one mayonnaise, one miracle whip and one honey mustard in the current refrigerator.
- One heavy cream with an expiration date of 08/09/23 in the current refrigerator.
- No expiration dates on one ranch dressing, one honey mustard and one creamy Caesar dressing.

During an interview on 08/16/23 at 8:30 AM, Staff H, Infection Preventionist, stated that she expected the staff to alert her of all rusted items that could harbor bacteria and she also expected the staff to label food items with expiration dates.

ENVIRONMENTAL CLEANING AND CENTRAL SERVICES
3. Review of the hospital's policy titled, "Environmental Cleaning of Central Service," last reviewed on 03/02/23, showed the direction for staff to maintain a standard of environmental cleanliness in the Central Sterilization department.

Observation on 08/15/23 at 9:30 AM, in the "dirty" central sterile room, showed one sink cabinet rusted.

During an interview on 08/16/23 at 8:30 AM, Staff H, Infection Preventionist, stated that she expected the staff to alert her of all rusted items that could harbor bacteria.

EXPIRED SUPPLIES AND LINEN CART
4. Review of the hospital's policy titled, "Management of Outdated Supplies," dated 12/05/22, showed the direction for the staff to check supplies monthly and outdated should be disposed of and replaced.

Observation on 08/14/23 at 1:23 PM, on the Medical Surgical Floor, outside of the outpatient wound care rooms, showed one container of hydrogen peroxide wipes with an expiration date of 06/10/23, one container of sani-cloth with an expiration date of 11/2022, one container of anti-bacterial wipes with an expiration date of 08/28/22 and one container of wound packing strips with no expiration date.

During an interview on 08/16/23 at 8:30 AM, Staff H, Infection Preventionist, stated that she expected the staff to discard expired supplies and didn't expect staff to use expired packing strips to pack wounds.

5. Review of the hospital's policy titled, "Storage of Clean Linen," dated 08/2023, showed that carts containing clean linen, that were in circulation for patient us, should be covered to minimize microbial contamination from surface contact and airborne particles.

Observation on 08/14/23 at 1:23 PM, on the Medical Surgical Floor, outside of the outpatient wound care rooms, showed one clean linen cart (used in the wound care process), uncovered open to the hallway traffic.

During an interview on 08/16/23 at 8:30 AM, Staff H, Infection Preventionist, stated that she expected staff to cover all of the linens exposed to the hallway.

MEDICATION ADMINISTRATION - HAND HYGIENE
6. Review of the hospital's policy titled, "Hand Hygiene & Fingernail Care," dated 09/2022, showed staff directives:
- To perform hand hygiene procedures that included the use of alcohol-based hand rubs (containing 60%-95% alcohol) and hand washing with soap and water.
- Handwashing is the single most effective deterrent to the spread of infection.
- Hospital personnel shall wash/decontaminate their hands to prevent the spread of infections:
- When coming on duty;
- Before applying and after removing gloves;
- When the hands were obviously soiled; and
- Between handling of patients.
- CDC guidelines recommend an alcohol based rub to be used to routinely decontaminate hands if they were not visibly soiled.

Observation on 08/15/23 at 7:57 AM, showed Staff R, Registered Nurse (RN), prepared and administered medications to Patient #12, however, Staff R failed to:
- Perform hand hygiene upon entry into the medication room and prior to retrieving medications from the automated medication dispensing system.
- Remove gloves and perform hand hygiene after Staff R typed on the computer keyboard (contaminated object) in Patient #12's room, scanned the patient's identification arm band and each medication's barcode with the bar scanner (contaminated object) before Staff R administered medications to Patient #12.
- Perform hand hygiene after Staff R removed gloves and before re-gloving to apply medicated powder to the patient's left groin area.

Observation on 08/15/23 at 8:42 AM, showed Staff S, RN, prepared and administered medications to Patient #20, however, Staff S failed to:
- Perform hand hygiene upon entry into the medication room and prior to retrieving medications from the automated medication dispensing system.
- Remove gloves and perform hand hygiene after Staff S typed on the computer keyboard in Patient #20's room, scanned the patient's identification arm band and each medication's barcode before Staff S administered medication to Patient #20.
- Perform hand hygiene after Staff S removed gloves and before re-gloving four times while providing care for the patient.

Observation on 08/16/23 at 10:27 AM, showed Staff V, RN, prepared and administered intravenous (IV, in a vein) medications for Patient #15, however, Staff V failed to wear gloves when Staff V cleaned the patient's saline lock (SL, a thin flexible tube placed into a vein used to administer fluids, medications and/or nutrition through the lock and into the vein) port, connected the IV tubing and programmed the infusion pump.

Observation on 08/16/23 at approximately 11:30 AM, showed Staff V, RN, inserted an IV catheter (a small flexible tube inserted into a vein through the skin to deliver medications or fluids into the bloodstream) into Patient #16's left antecubital, however, Staff V failed to:
- Repeat the cleansing process after Staff V palpated the left antecubital and before Staff V inserted the IV catheter into the patient's left antecubital. Staff's failure to repeat the cleansing process after palpating the area increased the risk for contaminating the site and the possibility for allowing the introduction of bacteria when inserting the IV catheter into the patient's skin.
- Perform hand hygiene after glove removal and before re-gloving to apply tape and an op-site over the IV site and saline lock.

Observation on 08/16/23 at approximately 11:45 AM, showed Staff W, RN, prepared and administered IV medication to Patient #16, however, Staff W failed to perform hand hygiene prior to gloving to clean the patient's SL port, connect IV tubing, and program the infusion pump.

During an interview on 08/15/23 at 1:30 PM, Staff S, RN, stated staff was expected to perform hand hygiene and change gloves:
- Upon entrance/exit of patients' rooms;
- Perform hand hygiene upon removal of gloves;
- Perform hand hygiene anytime hands/gloves are soiled;
- Change gloves after touching inanimate objects, for example, computer keyboards and bar scanner; and
- When going or touching one surface to the next.

During an interview on 08/15/23 at 2:15 PM, Staff R, RN, stated staff was expected to perform hand hygiene and change gloves:
- Foam in upon entry into patients' rooms and foam out upon exiting patients' rooms;
- With any soiling of hands/gloves;
- After removal of gloves; and
- Put gloves on after foam in.

During an interview on 08/16/23 at 8:30 AM, Staff H, Infection Preventionist, stated that staff should have washed their hands prior to entering the medication room and after glove removal.

During an interview on 08/16/23 at 12:45 PM, Staff J, RN, Chief Nursing Officer (CNO), stated staff was expected to repeat the cleansing process before inserting an IV catheter if staff touched/palpated the area staff needed to repeat the cleansing process before staff inserted the IV needle/catheter.

ANTIBIOTIC STEWARDSHIP
7. Although requested the hospital failed to provide policies for a 72 hour antibiotic check and to prevent infection for antibiotic resistant organisms.

During an interview on 08/16/23 at 8:15 AM, Staff H, Infection Preventionist, stated that they did not have any policies related to the 72 hour check or the antibiotic resistant organisms.


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