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47397


Based on observations, record reviews, and interviews, the hospital failed to meet the requirements of the Condition of Participation of Infection Control. This deficient practice is evidenced by the hospital failure to implement isolation precautions for entire admission dated 08/18/2023-08/22/2023 on 1 (#5) of 1 (#5) patients sampled with a diagnosis of MRSA.
(See findings in A-0750)

Based on observation and interviews, the hospital failed to ensure patients received care in a safe setting as evidenced by:
1) Bathroom cc with a window that would not close allowing exposure to the outdoor elements and the potential for insects to enter the building; and,
2) Room p with a portable air conditioner vent leading to the outside window broken and allowing exposure to the outdoor elements and the potential for insets entering the building.
Findings:

1) Bathroom cc with a window that would not close and no screen allowing exposure to the outdoor elements and the potential for insects to enter the building; and

An observation on 08/28/2023 at 1:53 p.m. of bathroom cc with a window that would not close and letting in warm air making the bathroom uncomfortably hot.

In an interview on 08/28/2023 at 1:53 p.m. S1AA verified the observation.

3) Patient room p with a portable air conditioner vent leading to the outside window broken and allowing exposure to the outdoor elements, no screen and the potential for insets entering the building. Further observation revealed a warm, uncomfortable temperature in the patient room.

An observation on 08/28/2023 at 1:58 p.m. of room p revealed the outgoing vent from the portable air conditioner was torn apart from the window allowing hot air into the room and no screening on that section of the window allowing for insects to enter the building.

In an interview on 08/28/2023 at 1:58 p.m., S1AA verified the finding.

Based on policy review, observation and interview, the hospital failed to ensure patients had the right to confidentiality of his or her clinical records. This deficient practice is evidenced by failing to ensure a patient medical record, accessible to visitors, patients and staff, was not left unattended in 1 (#1) of 4 current patients.
Findings:

Review of hospital policy dated 03/2023 titled "Patient Rights/Responsibilities" revealed, in part: Patient Bill of Rights, in part: Every patient and /or his designated representative, will whenever possible, have the right to, in part: To have his/her medical record, including all computerized medical information, kept confidential.

An observation on 08/28/2023 at 2:15 p.m. of Room 'y' revealed Patient #1's medical record on the desk of S11PT who was not present to ensure the security of the medical record.

In an interview on 08/28/2023 at 2:16 p.m. S2CNO indicated the S11PT was not present in Room 'y' and that she did not know where she was. S2CNO verified Patient #1's medical record was left unattended allowing for a potential breech in patient confidentiality.

Based on record review, observation, and interview, the hospital failed to ensure the RN supervised and evaluated the nursing care of each patient. This deficient practice was evidenced by:
1) failure of the RN to ensure blood glucose meter controls were being performed daily per policy. This failed practice had the potential to impact the 1 current Diabetic patients ( #1) and all Diabetic patients receiving sliding scale insulin based on capillary blood glucose results obtained via glucose meter;
2) failure of the RN to perform an initial wound assessment on admission in 1 (#4) of 5(#1-#5) patients reviewed.
Findings:

1) Failure of the RN to ensure blood glucose meter controls were performed daily per policy. This failed practice had the potential to impact the 1 current Diabetic patients ( #1) and all Diabetic patients receiving sliding scale insulin based on capillary blood glucose results obtained via glucose meter.
Review of hospital policy dated 01/02/2001, titled "Glucose Monitoring" revealed, in part: It is the responsibility of the nursing staff to ensure proper functioning of the machine on a daily basis. Glucose Control Testing. Testing of the meter is to be done daily. This duty is to be performed on the night shift.

Review of Patient #1's medical record revealed an admit date of 08/23/2023 and diagnoses that included diabetes mellitus with orders for sliding scale insulin and Accuchecks before meals and at bedtime.

Further review revealed Patient #1 received 3 units of insulin on 08/28/2023 at 4:30 p.m. based on a blood glucose level of 230.

Review of hospital document titled "Optium Blood Glucose Quality Results Log" on 08/28/2023 at 1:05 p.m., revealed no evidence of control testing of the glucose monitor on 08/26/2023, 08/27/2023, 08/28/2023. A second review of the results log on 08/28/2023 at 4:35 p.m. revealed the controls were tested at 3:00 p.m.

In an interview on 08/28/2023 at 1:05 p.m., S6LPN verified the controls were not logged on 08/26/2023, 8/27/2023, and 08/28/2023. S6LPN reported there was one patient on the census with diabetes.

2) Failure of the RN to perform an initial wound assessment on admission in 1 (#4) of 5(#1-#5) patients reviewed.
Review of Patient #4's medical record revealed an admission date of 07/17/2023 with diagnosis of Right Extremity Cellulitis.

Further review revealed Patient #4's Nursing Admission Assessment dated 07/17/2023. Continued review failed to reveal evidence of a documented description of the appearance of the wound.

In an interview on 08/29/2023 at 2:45 p.m., S5DON confirmed that a wound assessment was not completed and stated that a wound care assessment should have been documented in the admission nursing assessment.

Based on record review and interview, the hospital failed to ensure drugs and biologicals were administered in accordance with accepted standards of practice and hospital policy. This deficient practice was evidenced by failure to have documentation 2 licensed nurses checked the amount of insulin ordered against the amount of insulin prepared prior to administration of the insulin dose in 1(#1) of 5 (#1-#5) patients reviewed.
Findings:

Review of hospital policy dated 03/2023, titled "Medication Administration" revealed, in part: Purpose: To provide a safe and effective process for administering medications across a patient's continuum of care. Medication Administration, in part: ii. Two (2) licensed nurses must check the amount ordered against the amount prepared prior to administration of insulin dose.

Review of Patient #1's medical record revealed an admit date of 08/23/2023. Further review revealed diagnoses that included diabetes mellitus with orders for sliding scale insulin and Accuchecks before meals and at bedtime. Further review revealed Patient #1 received 3 units of insulin on 08/28/2023 at 4:30 p.m. based on a blood glucose level of 230; however, review failed to reveal documentation that 2 licensed nurses checked the amount of insulin ordered against the amount of insulin prepared prior to administration of the insulin dose.

In an interview on 08/29/2023 at 2:50 p.m., S5DON verified that the medication administration record dated 08/28/2023 failed to reveal documentation that 2 licensed nurses checked the amount of insulin ordered against the amount of insulin prepared prior to administration of the insulin dose.

Based on record review and interview, the hospital failed to ensure drugs and biologicals were controlled and distributed in accordance with applicable standards of practice, consistent with state law and hospital policy. This deficient practice was evidenced by failing to ensure all medication orders (except in emergency situations) were reviewed by a pharmacist before the first dose was dispensed for therapeutic appropriateness, duplication of a medication regimen, appropriateness of the drug and route, appropriateness of the dose and frequency, possible medication interactions, patient allergies and sensitivities, variations in criteria for use, and other contraindications. Findings:

Review of the Louisiana Administrative Code, Professional and Occupational Standards,
Title 46: LIII, Pharmacist, Chapter 15, Hospital Pharmacy, §1511. Revealed in part:
Prescription Drug Orders: A. The pharmacist shall review the practitioner's medical order prior to dispensing the initial dose of medication, except in cases of emergency.

Review of hospital policy dated 03/2023, titled "First Dose Food/Drug Interactions" revealed, in part: Purpose: To ensure that all patient's medications are reviewed upon admission and / or the addition of any medications so that patients remain free of any potential interactions that may occur with their diet and medication's. Procedure, in part: The pharmacy will initiate a Food/Drug Interaction Form by reviewing all medications on admission and any new medication orders. A pharmacist will review the patient's medication profile for drugs that have a potential for interactions with foods. The pharmacist will send a form back to the nursing unit within 24 hours of the patient's admission or new drug order indicating whether interactions exist. The Food. Drug Interaction form will be placed in the patient's medical record.

Review of hospital document dated 03/20/2017 titled "Provider Agreement" revealed, in part: Whereas, Company A and hospital desire to enter into this agreement whereby Company A will supply to patients within hospital confines, the following: A drug delivery system for hospital patients to encompass all oral, and enteral, IV medications (and/or medical equipment and supplies as hospital desires), to comply with hospital policies and procedures.

On 08/29/2023 a review of Patient #1 and Patient #5's medical record failed to reveal any documentation related to the first medication dose being reviewed by a pharmacist before the first dose was dispensed for therapeutic appropriateness, duplication of a medication regimen, appropriateness of the drug and route, appropriateness of the dose and frequency, possible medication interactions, patient allergies and sensitivities, variations in criteria for use, and other contraindications.

A review of all medication documentation as provided by S5DON failed to reveal the first dose review for Patient #1 and Patient #5.

In an interview on 08/29/2023 at 1:45 p.m., S5DON confirmed that there was no first dose review completed by the pharmacy before Patient #1 and Patient #5 received any of their medications. S5DON stated the pharmacist usually sends the first dose reviews per policy but neglected to send these two first dose reviews to the hospital.

Based on interview and record review, the hospital failed to effectively implement a Utilization Review plan and failed to implement a Utilization Review Committee consisting of two or more practitioners. This deficient practice had the potential to affect any patients receiving care at the hospital.
Findings:

Review of the Medical Executive Committee meeting minutes revealed no minutes associated with a Utilization Review Committee meeting.

Review of a written statement provided by S2CNO revealed a statement, in part, that in the future, a UR report will be a part of the medical staff minutes.

In an interview on 08/20/2023 at 11:55 a.m. S2CNO verified that presently, there was no UR committee.

Based on observations and interviews, the hospital failed to ensure the condition of the physical plant and overall hospital environment was maintained in a manner that provided an acceptable level of safety and well-being for patients, staff, and visitors. The deficient practice is evidenced by:
1) failure to maintain the generator in good repair;
2) over-head light with pull made of a plastic bag;
3) air conditioner hanging from a wall;
4) broken air-conditioning vent hanging from the window;
5) wrong size toilet seat on the toilet bowl;
6) odoriferous bathroom with the wrong sized toilet seat, a non-functioning light, an ill-fitting and loosely connected sink faucet, and no evidence of a garbage can;
7) electric outlet hanging from the wall;
8) dirty and non-function air-conditioning unit on the floor;
9) hole in the ceiling outside of patient room with adhesive strips covering the hole;
10) a hole in the ceiling of hallway with adhesive strips covering the hole;
11) 2 broken tiles on the ceiling above the areas where patients eat.
Findings:

1) Failure to maintain the generator in good repair.
Review of hospital documents revealed a maintenance request notification dated 07/17/2023. Further review revealed the power was out for 40 minutes on 07/16/2023. The generator attempted to automatically start kick on but failed to. The CEO was notified.

Review of the generator log revealed the generator had not been tested from 05/04/2023 until 08/02/2023 during which time the generator did not work during a 40 minute power outage on 07/16/2023.

In an interview on 08/28/2023 at 3:00 p.m., S2CNO stated she did not know if or whom the event was reported to. S2CNO stated the generator was now functioning and that she would provide the documentation from the generator maintenance company who repaired it. The documentation for the repair was not provided.

In an interview on 08/30/2023 at 10:30 a.m. S14Admin verified that there was a 40 minute power outage on 07/16/2023 and the generator did not work.

2) Over-head light with pull made of a plastic bag.
Observation on 08/28/2023 at 2:02 p.m of Room 'q' revealed a bed. Located above the bed was an over-the-bed light with the pull for light switch made of a plastic bag. When pulled the light bulb provided only minimal lightening.

In an interview on 08/28/2023 at 2:02 p.m., S1AA confirmed the light pull made of a plastic bag and the light bulb providing only minimal lighting and stated the light pull and the light bulb should be replaced.

3) Air conditioner hanging from a wall.
Observations on 08/28/2023 at 12:48 p.m. revealed Room 'w' with a broken air conditioner hanging from the wall.

In an interview on 08/28/2023 at 12:48 p.m., S1AA confirmed the air conditioner was hanging from the wall. S1AA stated the equipment was in a state of disrepair and should be replaced.

4) Broken air-conditioning vent hanging from the window
Observation on 08/28/2023 at 1:58 p.m of Room 'p' revealed a air-conditioning vent that was in disrepair and was hanging from the window by tape.

In an interview on 08/28/2023 at 1:58 p.m., S1AA confirmed the broken air-conditioning vent that was hanging from the window with tape and stated it should be repaired.

5) Wrong size toilet seat on the toilet bowl.
An observation on 08/28/2023 at 2:06 p.m.in patient Bathroom 'ee' revealed the wrong size toilet seat on the toilet bowl.

In an interview on 08/28/2023 at 2:06 p.m., S1AA verified the observation.

6) Odoriferous bathroom with the wrong sized toilet seat, a non-functioning light, an ill-fitting and loosely connected sink faucet, and no evidence of a garbage can.
Observation on 08/28/2023 at 1:47 p.m. of Bathroom 'aa' revealed an odoriferous bathroom with the wrong sized toilet seat, a non-functioning light, an ill-fitting and loosely connected sink faucet, and no evidence of a garbage can.

In an interview on 08/28/2023 at 1:47 p.m., S1AA confirmed the above and stated the bathroom in this condition was an infection control risk.

7) Electric outlet hanging from the wall.
Observations on 08/28/2023 at 1:52 p.m. of Hallway 'b' revealed an electric outlet to the left of Room 'l'. Further observations revealed the outlet was falling out of the wall.

In an interview on 08/28/2023 at 1:52 p.m., S1AA confirmed the outlet was not affixed properly to the wall and was a patient safety concern.

8) Dirty and non-functioning air-conditioning unit on the floor.
Observation on 08/28/2023 at 2:04 p.m. of Room 'y' revealed a dirty and non-functioning air-conditioning unit on the floor.

In an interview on 08/28/2023 at 2:04 p.m., S2CNO confirmed the air-conditioning was dirty and no longer functioning and should be discarded.

9) Hole in the ceiling outside of patient room with adhesive strips covering the hole.
Observation on 08/28/2023 at 1:50 p.m. revealed a hole in the ceiling outside of patient Room 'o' with tape covering the hole.

In an interview on 08/28/2023 at 1:50 p.m., S1AA verified the observation.

10) A hole in the ceiling of hallway with adhesive strips covering the hole.
Observation on 08/28/2023 at 2:40 p.m. revealed a hole in the ceiling of Hallway 'i' with adhesive strips covering the hole.

In an interview on 08/28/2023 at 2:40 p.m., S1AA verified the observation.

11) 2 broken tiles on the ceiling above the areas where patients eat.
Observation on 08/28/2023 at 2:25 p.m. in Room 'x, as labeled on the floor plan provided by the facility, revealed 2 broken tiles on the ceiling above the areas where the patients eat.

In an interview on 08/28/2023 at 2:25 p.m., S1AA verified the observation.

Based on observation and interview, the hospital failed to ensure supplies were maintained to ensure an acceptable level of safety and quality. This deficient practice is evidenced by failure to ensure expired supplies were not available for patient use.
Findings:

Review of hospital policy dated 06/2023, titled "Expired Supplies" revealed, in part: Policy. It is the policy of the Hospital to comply with policies and procedures governing the use and storage of sterile supplies and equipment. Purpose. To follow and implement accepted policies and procedures regarding use of sterile supplies. Procedure, in part: 3. Central Supply will ensure compliance with Hospital regulations regarding the following: a. monitoring and inventory control of the shelf life and expiration date of supplies, as well as the removal from use of expired supplies.

Observation on 08/28/2023 at 10:00 a.m. of Room 'd' revealed (8) Enteral-Feeding Bag with Attached Pump sets with an expiration date of 08/09/2023.

In an interview on 08/28/2023 at 10:05 a.m., S1AA confirmed the Enteral-Feeding Bag Sets were expired and available for patient use and further stated they would be disposed of.

Observation on 08/28/2023 at 1:11 p.m. of Room 'c' revealed (2) Power-Loc Safety Infusion Sets with an expiration date of 07/31/2023 and (1) with the expiration date of 04/30/2023.

In an interview on 08/28/2023 at 1:11 p.m. S22LPN confirmed the Power-Loc Safety Infusion sets were expired and available for patient use and further stated they would be disposed of.

Further observation on 08/28/2023 at 1:20 p.m. of Room 'c' revealed the following expired supplies:
(7) McKesson 20 gauge IV straight hubs with expiration date of 06/30/2023.
(17) McKesson 24 gauge IV straight hubs with expiration date of 06/30/2023.
(20) McKesson 18 gauge IV straight hubs with expiration date of 08/01/2023.
(1) Small Bore IV Ext set with expiration date 04/01/2023.
(5) Ultra Site IV Hubs with the expiration date of 04/1/2023.
(5) Blue top lab vials with the expiration date of 02/01/2023.
(81) Blue top lab vials with the expiration date of 07/31/2023.
(121) Yellow top lab vials with the expiration date of 07/31/2023.
(1) Green top lab vial with the expiration date of 11/30/2021.
(52) Petroleum jelly skin protectant with the expiration date of 05/2023.
(2) Petroleum jelly skin protectant with the expiration date of 04/13/2023.
(1) Gallon of distilled water with the expiration date of 08/10/2023.


In an interview on 08/28/2023 at 1:20 p.m., S22LPN confirmed the above-mentioned supplies were expired and available for patient use. S22LPN further stated they would be disposed of.

Based on observation and interview, the hospital failed to take measures to prevent infections as evidenced by:
1) failure to implement isolation precautions on 1 (#5) of 1 (#5) patients sampled with a diagnosis of MRSA for his hospital stay of 08/18/2023 to 08/22/2023;
2) failure to ensure that sterile supplies remain sterile for patient use;
3) failure to ensure the hospital maintained a sanitary environment to prevent infections.
Findings:

1) Failure to implement isolation precautions on 1 (#5) of 1 (#5) patients sampled for a diagnosis of MRSA.
Review of hospital policy dated 07/2015, titled "Isolation Precautions" revealed, in part: Purpose, in part: Isolation precautions are designed to interrupt the transfer of microorganisms, thereby preventing transmission. There are two tiers of isolation. The second tier, Transmission-Based Precautions, is for patients documented or suspected to be infected with highly transmissible or epidemiologically important pathogens (e.g. multi drug resistant organisms (MDROs) for which additional precautions beyond Standard Precautions are needed). Policy, in part: All health care workers and visitors must follow CDC isolation precautions. Procedure, in part: C. Contact Precautions, in part: In addition to Standard Precautions, use Contact Precautions, for specified patients known or suspected to be infected or colonized with epidemiologically important microorganisms that can be transmitted by direct contact with the patient or indirect contact with environmental surfaces or patient care items in the patient's environment. 1. Examples of diseases, in part: a, in part: colonization with multidrug resistant organisms (MDROs) of special clinical and epidemiologic significance. 3, in part: Contact. Private room or cohort. Gloves and Gown when entering a patient's room. Dedicated specific patient care equipment. Limit transport and avoid environmental contamination. Dedicate equipment for single patient or cohort of patients.

Review of Patient #5's medical record revealed an admission date of 08/18/2023 and discharge 08/22/2023. Further review revealed a history and physical assessment dated 08/21/2023 revealed diagnosis: MRSA in urine and peritoneal fluid.

Review of Patient #5's Nursing notes dated 08/18/2023 revealed he was not placed on isolation precautions.

In an interview on 08/29/2023 at 1:30 p.m., S5DON stated that Patient #5 should have been on isolation precautions.

2) Failure to ensure that sterile supplies remain sterile for patient use.
Review of hospital policy dated 06/2023, titled "Expired Supplies" revealed, in part: Policy. It is the policy of the Hospital to comply with policies and procedures governing the use and storage of sterile supplies and equipment. Purpose. To follow and implement accepted policies and procedures regarding use of sterile supplies. Procedure, in part: 3. Central Supply will ensure compliance with Hospital regulations regarding the following: e. regular inspection of the areas pertaining to the use and storage of sterile supplies.

Observation On 08/28/2023 at 1:21 p.m., of Room 'c' revealed an 18-gauge IV hub opened and out of the sterile packaging.

In an interview on 08/28/2023 at 1:21 p.m., S22LPN confirmed the IV hub was opened and out of the sterile packaging. S22LPN verified the IV hub was available for patient use and should be discarded.

3) Failure to ensure the hospital maintained a sanitary environment to prevent infections.
Observation on 08/28/2023 at 12:48 p.m. revealed in Room 'v' 2 rolls of toilet paper on the handrail. Further observation revealed an unlabeled grey bin on the floor of the bathroom under the sink.

In an interview on 08/28/2023 at 12:49 p.m., S1AA indicated the rolls of toilet paper do not fit in the dispensers. Further interview indicated the unlabeled bin should not be on the floor.

Observation on 08/28/2023 at 12:58 p.m. revealed patient Room 'u'. This patient was on isolation precautions with a sign outside of the patient's door "Foam in and Foam out". An observation of the sanitizing station on the wall revealed no sanitizer in the dispenser.

In an interview on 08/28/2023 at 12:59 p.m., S1AA verified there was no hand sanitizer in the dispenser.

In an interview on 08/28/2023 at 1:40 p.m., S12IC reported the sanitizer should be available for infection control purposes. S12IC further stated she did not notice the broken sanitizer dispenser on the wall and stated it should be replaced.

Observation on 08/28/2023 at 1:07 p.m. revealed in the Room 'oo", 2 ceiling tiles that contained peeling paint.

Observation on 08/28/2023 at 1:12 p.m. of Room 'c' revealed no barrier between the sink and the area where medication was prepared. This deficient practice potentially impacted the ability to maintain a clean and sanitary environment during medication preparation.

Observation on 08/28/2023 at 1:45 p.m. revealed in Bathroom 'pp' a roll of toilet paper on top of the towel dispenser. Further observation revealed no toilet paper in the dispenser.

In an interview on 08/28/2023 at 1:46 p.m., S1AA verified the above observations in Room 'oo', Room 'c', and Bathroom 'pp'.

Observation on 08/28/2023 at 1:49 p.m. of patient Room 'k' revealed in the bathroom an output measuring urinal (hat) on the floor, behind the toilet and unlabeled. Further observation revealed the roll of toilet paper was on top of the toilet paper dispenser and no toilet paper in the dispenser. There was 1 light fixture not working and providing insufficient light for hygiene.

In an interview on 08/28/2023 at 1:49 p.m., S1AA verified the above observations in Room 'k'.

Observation on 08/28/2023 at 1:53 p.m. revealed the threshold of Patient Room 'o' with the flooring missing between the patient room and hallway which did not allow for sufficient cleaning of the floor.

Observation on 08/28/2023 at 1:53 p.m. of patient Room 'o' a bathroom where a window would not close and a roll of toilet paper on top of the dispenser.

In an interview on 08/28/2023 at 1:53 p.m. S1AA verified the above observations in Room 'o'.

Observations on 08/28/2023 at 1:53 p.m. revealed Room 'o' with a bed with rails containing rust, a dripping dark brown substance and peeling paint.

In an interview on 08/28/2023 at 1:53 p.m., S1AA confirmed the condition of the bed rail on Room 'o' was an infection control risk.

Observation on 08/28/2023 at 2:05 p.m. revealed patient Bathroom 'hh' had exposed sheetrock on the side of the soap dispenser providing an insufficient surface for cleaning.

In an interview on 08/28/2023 at 2:05 p.m., S1AA verified the observations in Bathroom 'hh'.

Observation on 08/28/2023 at 2:08 p.m. revealed in patient Bathroom 'dd' the tiles on the wall rigid with no smooth edge for proper cleaning.

In an interview on 08/28/2023 at 2:08 p.m., S1AA verified the above findings in Bathroom 'dd'.

Observations 0n 08/28/2023 at 12:45 p.m. revealed Room 'v' containing a toilet paper dispenser that was not securely affixed to the wall with a roll of toilet paper sitting on top of the dispenser. Further observations revealed a n unlabeled gray bin on the floor next to commode.

In an interview on 08/28/2023 at 12:45 p.m., S1AA verified the toilet paper dispenser with a toll paper sitting on top was not securely affixed to the wall and the wash basis on the floor next to the commode created risks for infection control.

Observation on 08/28/2023 at 2:02 p.m. of Room 'q' revealed a bed with a rusty bed rail that was taped in places.

In an interview on 08/28/2023 at 2:02 p.m., S1AA confirmed the rusty bed rail with tape should be replaced due to infection control risks.

Observation on 08/28/2023 at 1:59 p.m. of Bathroom 'ff' in Hallway 'b' revealed peeling and chipped curtain rods creating an infection control risk.

In an interview on 08/28/2023 at 1:59 p.m., S1AA confirmed the peeling and chipped curtain rod and that it was an infection control risk.

Observation on 08/28/2023 at 2:01 p.m. of bathroom 'gg' in Hallway 'b' revealed underwear hanging over the shower rod and a vent with dust and rust over the handwashing sink.

In an interview on 08/28/2023 at 2:01 p.m., S1AA confirmed the underwear were hanging over the shower rod and the vent with dust and rust over the handwashing sink creating an infection control risk.

Observation on 08/28/2023 at 2:04 p.m. of Room 'y' revealed a dirty and non-function air-conditioning unit on the floor.

In an interview on 08/28/2023 at 2:04 p.m., S2CNO confirmed the air-conditioning was dirty and no longer functioning and should be discarded.

Based on record review and interview, the hospital failed to ensure an effective, hospital-wide antibiotic stewardship program consisted of at least the infection prevention and control program, the QAPI program, the medical staff, nursing services and pharmacy services. This deficient practice had the potential to affect any patients receiving antibiotics in the hospital.
Findings:

Review of the Infection Prevention and Control and Antibiotic Stewardship policy revealed, in part, there will be an on-site staff person designated to monitor the day to day activities of infection control practices.

Review of the organizational chart revealed S13IC was appointed as the Infection Control coordinator.,

Review of the Infection Control binders revealed no evidence of minutes related to antibiotic stewardship meetings.

In an interview on 08/29/2023 at 2:48 p.m., S13IC indicated there was no formal implementation of an antibiotic stewardship program representing all disciplines of the hospital's leadership.