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Based on record review and interview, the hospital failed to ensure pain was reassessed and treated for one of twenty-eight patients sampled (Patient #26) when the Registered Nurse (RN) documented the patient rated pain as an eight on a scale of zero to ten with zero being no pain and ten being severe pain, failed to reassess P 26's pain, and did not administer a dose of as needed (PRN) pain medication.

The findings are:

On December 21, 2022, a concurrent interview and review of P 26's medical record was conducted with Registered Nurse (RN) #3. The medical record indicated the patient was an 80 year old admitted with a diagnosis of pancreatic cancer. The nursing assessment dated November 27, 2022 at 9:00 PM revealed "Pain Intensity Scale Type ...0-10 ...Numerical Rating Scale (0-10) Score ...8 ...Wong-Baker FACES Pain Rating
[a type of pain scale ranging from zero to ten with ten being severe pain] ...8 ...Pain Frequency ...Constant/continuous ...Patient's Stated Pain Goal ...No pain ...".

The patient's Medication Administration Record (MAR) dated November 27, 2022 revealed Patient #26 received a dose of regularly scheduled Gabapentin (medication used to treat nerve pain). The MAR indicated a PRN physician's order for Acetaminophen and for Tramadol (both medications used to treat pain) were available to treat the patient's pain. There was no documentation on the MAR indicating the patient received a dose of PRN pain medication for a pain level of 8, and no documentation in the medical record that Patient 26's pain was reassessed for over 11 hours. The nursing assessment documented the following morning, November 28, 2022, revealed the registered nurse should have reassessed the patient's pain " ...about an hour later ..." after administering the regularly scheduled Gabapentin at 9:00 PM. RN #3 stated " ...pain goal was zero ...".

On December 21, 2022, hospital policy, titled, "Assessment and Reassessment of the Patient," dated "01/2022," reads, "Each patient's physical ...status is ...reassessed ...if the patient's condition changes ...Reassessments are documented in the medical record ...A focused nursing reassessment is performed with change in condition ...The reassessment may include ...Pain ...".

Hospital policy, titled, "Pain Management," dated "07/2022", reads, "The hospital responds and supports the right of patients to pain management ...A patient's pain is assessed ...With each new report of pain ...Administer prescribed analgesic regimen ...".

Based on observations, interviews, and review of the facility's policy and procedure, the hospital failed to ensure the dietary kitchen staff checked the temperatures of all foods brought to the kitchen from the contracted food service vendor prior to the food being served to patients.

The findings include:

Observations on 12/20/22 at 11:26 AM in the kitchen during meal preparations revealed the Hot Box arrived from the contracted food service from Hospital B with a digital temperature of 167 degrees Fahrenheit (F). Observations of random foods removed from the Hot Box revealed the following food items on the trayline were temperature checked by Nursing Assistant (NA) #3 prior to serving: ground chicken 148 degrees, baked chicken breast 130 degrees reheated in the microwave to a temperature of 180 degrees and chicken Romano 150 degrees reheated again at 12:15 PM to a temperature of 178 degrees. Further observations revealed during the trayline preparation revealed NA #3 removed a serving of cube steak and a piece of cornbread on a plate from the Hot Box, plated it on a clean plate in the kitchen, and prepared it for delivery to a patient with no temperature obtained. A serving of chicken wings with rice and gravy and a barbeque sandwich with a serving of macaroni and cheese were removed from the Hot Box with no temperature obtained prior to preparation for delivery to the patient.

Observations on 12/21/22 at 11:34 AM in the kitchen during meal preparations revealed the Hot Box arrived from the contracted food service from Hospital B with a digital temperature of 164 degrees. The following special food items were temperature checked but were not documented on the trayline form: pasta noodles 146 degrees, gravy 148 degrees, chicken Alfredo 130 degrees, hamburgers 140 degrees, chicken vegetable soup 170 degrees, white rice 158 degrees, baked potato 150 degrees, carrots 156 degrees, french fries 142 degrees, pureed pork 140 degrees, pureed green beans 140 degrees, pizza slice 130 degrees reheated to 180 degrees, grilled cheese sandwich 124 degrees reheated to 200 degrees, and red roasted potatoes 150 degrees.

Observations on 12/21/22 at 1:11 PM of a test tray from the kitchen to 2 west patient unit revealed the temperatures of food from the trayline: barbeque sandwich 122 degrees, a cup of cole slaw 48 degrees, and baked beans 132 degrees. The findings were temperature checked and verified by Nutrition Assistant (NA) #1.

Review of staff training on 12/21/22 at 3:04 PM revealed Director #3 with ServSafe Certification training to expire 10/16/24. On 12/20/22 at 1:16 PM, Director 3 stated, "The temp (temperature) log is sent to the contracted food kitchen the day before. When they (contracted food kitchen) finish the food, they put in the final temps for the trayline hot food sent. There is a separate one for cold items. As long as the Hot Box is above 140 degrees, then the food is acceptable and we re-temp the food prior to serving. We fill in what's on the main menu. We will check some of the off items (special order food items) prior to service, but we don't document those temps. The special order items are checked but not documented for temps. Nutrition Assistant (NA) #3 should have checked at least one of them (special order food items). Training is provided by me and/or the NA's help to train other new NA's".

Hospital policy, entitled, "Distribution and Administration of Food and Nutrition Products", revealed, "2. Medical Nutrition therapy Nutrition Assistants, 2.1 Ensures transported hot food temperature is at or above 135 degrees Fahrenheit and cold food temperature is at or below 41 degrees Fahrenheit before removing food from transportation boxes. If the food temperature are outside of the acceptable range the Nutrition Assistant will use the following as a guide:
2.2 HOT FOOD:
2.2.1 If food temperature is below 135 degrees Fahrenheit and food has ben held less than 2 hours, reheat one time so that all parts of the food reaches and maintains a temperature of 165 degrees Fahrenheit for 15 seconds and food rotated or stirred, covered and allowed to stand covered for 2 minutes after reheating within 2 hours. If the food is below 135 degrees for a total of 2 hours or longer, discard food
2.3 COLD FOOD:
2.3.1 If food temperature is above 41 degrees Fahrenheit and food has been held less than 2 hours, refrigerate immediately achieve temperature below 41 degrees Fahrenheit within 2 hours. If food is above 41 41 degrees for a total of 2 hours or longer, discard food...".

Based on observations, interviews, and record reviews, the hospital failed to ensure its staff followed accepted practices for infection control for one of one Respiratory Therapist (RT #1) providing tracheostomy and stoma care and for 2 of 2 Registered Nurses (RN #7 And RN #8) who when observed failed to sanitize equipment and perform hand hygiene to prevent potential cross contamination of infectious agents in the hospital setting.

The findings are:

On December 20, 2022 at 8:21 AM, RT #1 was observed providing respiratory therapy services to Patient #30 wearing gloves removing the nebulizer tubing from the patient. RT #1, without removing the soiled gloves or performing hand hygiene, removed the dressing from the patient's tracheostomy stoma site, provided care to the site, and applied a new dressing, touched the patient's blue ventilator tubing , and then changed the patient's tracheostomy canula. RT #1 did not remove the soiled gloves, perform hand hygiene, or apply clean gloves after touching the nebulizer tubing or after touching the ventilator tubing. RT #1 performed tracheostomy site care, wound care, and changed the inner canula wearing soiled gloves.

On December 20, 2022 at 8:30 AM, RT #1 was asked if it was according to hospital procedure to touch the nebulizer tubing and then provide tracheostomy site care wearing the same gloves, RT #1 stated, "I should have put on clean gloves." When asked if it was according to hospital procedure to touch the ventilator tubing and then change the tracheostomy inner canula wearing the same gloves, RT #1 stated, "No, I should have put clean gloves on."

On December 20, 2022, RT #4 stated his/her job was to orient newly hired respiratory therapists and to provide respiratory care to patients. When asked to describe how a RT should perform tracheostomy site care and change the inner canula of the tracheostomy, RT #4 described the process. When asked what the RT should do if they touch the nebulizer tubing or ventilator tubing during the procedure, RT #4 stated, "Remove gloves, perform hand hygiene, and put on clean gloves...if anything in the environment is touched."

On December 20, 2022, review of Patient 30's medical record revealed the patient was an 83 year old male admitted with diagnoses of muscle weakness and difficulty walking. Physician orders dated December 1, 2022 revealed " ...Wound care midline neck ...Change daily due to trach secretions ...".

Observations on 12/20/2022 at 8:10 AM revealed RN #7 used a stethoscope to assess a patient's nasogastric (NG) tube placement prior to administering medications. RN #7 failed to sanitize the stethoscope before placing it around his/her neck. RN #7 was observed at 8:46 AM reaching into his/her uniform pocket wearing a glove to retrieve alcohol packets twice. RN #7 verified the observations at 9:10 AM.

Observations on 12/20/2022 at 12:40 PM in Room 207 revealed RN #8 brought a thermometer from outside the room, placed the thermometer on a paper towel, and then proceeded with the patient's assessment. RN #8 failed to perform hand hygiene after removing gloves and failed to sanitize the thermometer before exiting the patient's room with the thermometer in his/her hands. Room 207 had a sign on the door indicating contact precautions and respiratory precautions. Interview on 12/21/2022 at 9:00 AM with RN #3 revealed "I will speak with them."

On December 20, 2022, hospital policy, titled, "Hand Hygiene," dated, "07/2022", revealed, " ...Hand hygiene is a critical component of patient ...safety ...According to The World Health Organization (WHO), hand hygiene is performed at a minimum ...Before a clean or aseptic procedure ...After touching the patient's surroundings, including equipment or devices ...Before donning sterile or clean gloves ...".