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Based on observation, interview, record review, and policy review the hospital failed to ensure that Patient Safety Assistant (PSA) observation flowsheets were completed for two discharged patients (#67 and #70) out of two discharged patients with PSA orders reviewed. The hospital also failed to appropriately date intravenous (IV, in the vein) dressings for 11 current patients (#4, #14, #23, #31, #33, #34, #35, #74, #75, #77, and #78) out of 19 patients observed. The hospital census was 689.

This failed practice resulted in a systemic failure and noncompliance with 42 CFR 482.23 Condition of Participation (CoP): Nursing Services.

Please refer to A-0395.


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49404

Based on observation, interview and policy review, the hospital failed to ensure:
- Surfaces, equipment and floors in the kitchen were properly cleaned;
- Pots and pans were properly sanitized (to reduce or eliminate bacteria on the surface);
- Food items located in the kitchen refrigerators, kitchen freezers, and the dry goods area were properly dated;
- Expired food items were removed from the kitchen refrigerators, kitchen freezers and the dry goods area;
- Prepared leftover/prepared foods were properly labeled, dated and stored in the refrigerator;
- Cleaning solutions (mixture of two or more substances) were properly labeled, dated, and stored in the dishwashing area of the kitchen;
- Personal items were removed from the front service area of the kitchen;
- An effective pest control plan was in place; and
- The Infection Prevention and Control Plan was followed to maintain a sanitary environment.

The severity and cumulative effects of the systemic failures resulted in the hospital being out of compliance with 42 CFR 482.42 Condition of Participation (CoP): Infection Prevention and Control and Antibiotic Stewardship.

Please refer to A-0749.

Based on observation, interview, record review, and policy review the hospital failed to ensure that Patient Safety Assistant (PSA) observation flowsheets were completed for two discharged patients (#67 and #70) out of two discharged patients with PSA orders reviewed. The hospital also failed to appropriately date intravenous (IV, in the vein) dressings for 11 current patients (#4, #14, #23, #31, #33, #34, #35, #74, #75, #77, and #78) out of 19 patients observed. The hospital census was 689.

Findings included:

Review of the hospital's policy titled, "Continuous Observation for Patient Safety: Use of PSA or Tele Sitter (caregivers that watch at-risk patients via monitor and report to the primary caregiver)," reviewed 04/10/25, showed:
- A PSA was a trained observer utilized to prevent safety events such as falls, line/drain/airway dislodgment, wandering, etc.
- Nursing staff were expected to review with the charge nurse or manager the continued need for continuous observation, and to document in the electronic health record (EHR) a minimum of every four hours the need for a PSA and other interventions attempted to keep the patient safe in the PSA Doc flowsheet.
- PSA responsibilities related to continuous visual observation included continuous visualization of the patient and documentation of patient behaviors and activity hourly in the PSA observation flowsheet.
- To discontinue continuous visual observation, the nurse would assess the patient's physical condition, behaviors, and emotional status to determine if continuous visual observation of the patient was still required to ensure the patient's safety. Risk factors for continuation or discontinuation included that the patient was able and willing to follow safety instructions, no longer had a medical or behavioral need for continuous observation, or the patient was no longer a wandering or elopement (when a patient makes an intentional, unauthorized departure from a medical facility) risk.

Review of Patient #67's medical record showed:
- On 04/15/25, he was a 54-year-old male who presented to the Emergency Department (ED) from his nursing home (NH) related to aggression toward staff and residents. He was alert and oriented to himself but was otherwise a poor historian.
- His history included temporal dementia (a group of brain disorders characterized by the degeneration of the frontal and temporal lobes, often affecting people between ages 45 to 65).
- After a psychological evaluation (observes and measures a patient's behaviors, thoughts, and emotions to determine a diagnosis and appropriate treatment plan), he waited in the ED behavioral unit for inpatient psychiatric placement. He was assigned a PSA due to his aggression and wandering into other patients' rooms.
- On 04/18/25, he fell without injuries. Documentation indicated he was tachycardic (abnormally rapid heart rate, greater than 100 beats per minute) and his labs resulted that he had a urinary tract infection (UTI, an infection in any part of the urinary system, the kidneys, ureters, bladder and urethra). He was admitted to the inpatient medical unit for treatment.
- On 04/19/25 at 8:29 PM, his physician ordered a continuous sitter until specified.
- From 04/19/25 until discharge on 05/09/25, no PSA observation flowsheets were completed.

Review of Patient #70's medical record showed:
- On 03/13/25, he was a 42-year-old male who presented to the ED due to shortness of breath, altered mental status (mental functioning ranging from slight confusion to coma) and weakness.
- He had a past medical history of high blood pressure (BP, normal adult blood pressure is between 90/60 and 120/80), diabetes (a disease that affects how the body produces or uses blood sugar and can cause poor healing), autism (developmental disorder that impairs communication and social interaction) and was nonverbal at baseline.
- He was diagnosed with diabetic ketoacidosis (DKA, a life-threatening condition affecting people with diabetes; occurs when the body breaks down fat too fast causing the blood to become acidic) and acute (sudden onset) hypoxic respiratory failure (a condition where there is not enough oxygen reaching the tissues of the body caused by a failure of the respiratory system).
- On 03/14/25, he was admitted to the Intensive Care Unit (ICU, a unit where critically ill patients are cared for) for DKA and was intubated (process where a healthcare provider inserts a tube through a person's mouth or nose down into their windpipe when a person is not breathing on their own).
- On 03/16/25 at 10:42 PM, Staff ZZZZ, MD, ordered a PSA at bedside.
- On 03/18/25 at 8:22 PM, Staff QQQQ, MD, ordered a PSA at bedside and documented that Patient #70 had autism, an intellectual disability, was non-verbal, and would wonder around the floor without supervision. He required a one to one (1:1, continuous visual contact with close physical proximity) sitter.
- From 03/16/25 through 03/18/25, showed no documentation within the PSA observation flowsheet.
- On 03/18/2025 at 4:22 PM, Staff LLLLL, MD, documented that Patient #70 could transfer to the general medical floor and would require a PSA for observation.
- On 03/19/25 from 12:00 AM through 7:15 AM, documentation showed the PSA observation flowsheet was completed.
- On 03/20/2025 at 1:27 PM, Staff PPPP, MD, documented that due to Patient #70's underlying diagnosis of Autism, they were to continue the PSA.
- On 03/20/25 from 7:00 AM through 4:45 PM, documentation showed the PSA observation flowsheet was completed.
- On 03/20/25 at 7:25 pm, Staff RRRR, Registered Nurse (RN), documented Patient #70 was an elopement risk but there was no longer a need for a continuous PSA visual observation. There was no documentation the medical provider was contacted and there was no order for a discontinuation of the continuous PSA. There was no documentation of a PSA from 4:45 PM until the next day 03/21/25.
- From 03/21/25 at 7:00 AM until discharge on 03/23/25, the PSA observation flowsheet was documented.

Although requested, additional PSA observation flowsheet documentation was not provided for Patient #67 or Patient #70.

During an interview on 07/10/25 at 12:30 PM, Staff GGGGG, Chief Nursing Officer (CNO), and Staff FFFFF, Assistant Chief Nursing Officer (ACNO), stated that if a nurse felt a patient no longer needed a PSA, they should discuss discontinuation with the medical team. An order for a PSA should be discontinued when a PSA was no longer appropriate; however, if the order was still active and not discontinued, she expected staff to observe the patient per policy. The PSA observation flowsheet should have been completed per policy even when the PSA role was completed by a nurse. If staff had concerns about staffing a PSA, they should have escalated those concerns to the house supervisor.

During a telephone interview on 07/14/25 at 9:30 AM, Staff KKKKK, Physician, stated that Patient #67 was admitted for psychological evaluation to help with aggression. He was monitored in the ED and had an order placed for a PSA after his admission to the medical unit. Patient #67's medical record did not show PSA documentation, nor did he see that the order was discontinued.

During an interview on 07/09/25 at 12:15 PM, Staff I, Social Worker (SW), stated that on 03/17/25, she had assessed Patient #70 in the ICU and there was no 1:1 observation. He was by himself, and no one was watching him. During a phone call to update Patient #70's family, the family asked if he was by himself and stated that he should not be by himself and should have 1:1 continuous supervision. She called and spoke to the nurse and asked why the patient did not have a PSA and was told there was an order for a PSA and she assumed that the nurse would assign a PSA. She did not follow up to ensure Patient #70 was assigned a PSA. She stated the family was very upset that Patient #70 did not have a PSA in the room with his medical history of autism and a known risk for elopement.

During an interview on 07/09/25 at 12:00 PM, Staff RRRR, RN, stated if a PSA was ordered, the nurse would notify the charge nurse (CN) and the house supervisor. All PSAs should have one person dedicated to continuous observation of the patient. Nurses should do an assessment every four hours for the continuation of the PSA. Due to staffing shortages, often times they did not have a staff member to assign as the PSA. She stated, "It happens almost daily and there is no one to do the PSA's." The staff will do their best to watch the patient or move them closer to the nurse's station. Typically, a nurse would be assigned six patients, and a patient care technician (PCT) would be assigned 12 patients. "At times, the nurse would be responsible as the PSA while caring for other patients." Management was aware of the situation.

During an interview on 07/09/25 at 2:00 PM, Staff C, Director, stated if a patient had an order for a PSA in the ICU a 1:1 nurse would be placed during the shift. If staffing was not available, safety alternatives such as bed alarms and visualization were often used when they had a PSA patient in the ICU. The alarms would sound off and the nurses in ICU would immediately go see the patient. The nurse would be expected to document hourly for a 1:1 in the nursing assessment. ICU nurses did not use the PSA observation flowsheet. The nurse would assess the need for a continued PSA every four hours. She was sure that Patient #70 had a 1:1 nurse and would provide me with staffing sheets. No staffing sheets were provided and there was no documentation in the medical record to show there was a 1:1 nurse or PSA.
During a telephone interview on 07/09/25 at 4:00 PM, Staff ZZZZ, MD, stated Patient #70 was very calm at times but would have episodes of outburst even while sedated. At times, when a patient was in the ICU, the nurse would act as the PSA. Patient #70 required a PSA due to the outbursts and after he was extubated, he would wander in the unit. He was unaware that there was no documentation for a PSA and expected the nurse to ensure that a PSA was present and there was documentation.

During a telephone interview on 07/15/25 at 12:30 PM, Staff QQQQ, MD stated she would order a PSA when a patient was aggressive, agitated, not following commands and was a danger to self or others. She was not notified by staff that Patient #70 did not have a sitter at times. "This patient had an altered mental status, and I expected him to have a sitter in place. I also ordered a benzodiazepine (medication used to relieve anxiety and muscle spasms and reduce seizures; produce sedation) two hours later due to his instability. I expected my orders to be implemented or to be notified if this did not happen." Sitters were often not available as needed and "sometimes I am notified and other times I am not. The nurses are not able to safely care for a patient needing a sitter and take care of other patients as well." Staffing was an on-going issue especially at night, leaving patients and staff at risk for harm. Bed alarms were not the solution when a sitter was ordered. "The patient and staff were not safe, and a sitter was needed not a bed alarm."

Review of the hospital's policy titled, "Peripheral Intravenous Catheter Insertions, Management, and Removal," revised 11/19/24, showed IVs should be labeled with the date the dressing was applied.

Observation on 07/07/25 at 3:30 PM, showed that Patient #4's IV dressing was not dated.

Observation on 07/08/25 at 9:30 AM, showed that Patient #14's IV dressing was not dated.

Observation on 07/08/25 at 1:22 PM, showed that Patient #23's IV dressing was not dated.

Observation on 07/08/25 at 9:50 AM, showed that Patient #31's IV dressing was not dated.

Observation on 07/07/25 at 3:16 PM, showed that Patient #33's IV dressing was not dated.

Observation on 07/07/25 at 3:22 PM, showed that Patient #34's IV dressing was not dated.

Observation on 07/08/25 at 8:51 AM, showed that Patient #35's IV dressing was not dated.

Observation on 07/08/25 at 10:30 AM, showed that Patient #74's IV dressing was not dated.

Observation on 07/08/25 at 9:55 AM, showed that Patient #75's IV dressing was not dated.

Observation on 07/08/25 at 10:30 AM, showed that Patient #77's IV dressing was not dated.

Observation on 07/08/25 at 10:45 AM, showed that Patient #78's IV dressing was not dated.

During an interview on 07/10/25 at 12:30 PM, Staff GGGGG, CNO, and Staff FFFFF, ACNO, stated that IVs should be labeled with the date of insertion. They were aware there was an issue with the labeled sticker falling off the IV dressing.

During an interview on 07/07/25 at 3:32 PM, Staff WW, RN, stated that IVs should be labeled with the date and time it was initiated. The new dressing the hospital provided contained a sticker where the date would be written and then attached to the main IV dressing. The sticker would often fall off, so she was not surprised there were IVs without a proper label.


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Based on observation, interview and policy review, the hospital failed to ensure:
- Surfaces, equipment and floors in the kitchen were properly cleaned;
- Pots and pans were properly sanitized (to reduce or eliminate bacteria on the surface);
- Food items located in the kitchen refrigerators, kitchen freezers, and the dry goods area were properly dated;
- Expired food items were removed from the kitchen refrigerators, kitchen freezers and the dry goods area;
- Prepared leftover/prepared foods were properly labeled, dated and stored in the refrigerator;
- Cleaning solutions (mixture of two or more substances) were properly labeled, dated, and stored in the dishwashing area of the kitchen;
- Personal items were removed from the front service area of the kitchen;
- An effective pest control plan was in place; and
- The Infection Prevention and Control Plan was followed to maintain a sanitary environment.

These failures had the potential to expose all patients, visitors and staff to cross contamination and increased the potential to spread infection.

Findings included:

Review of the hospital's undated policy titled, "Food Safety/Management and Personnel," showed direction for kitchen staff that refrigerated, ready to eat, time/temperature controlled (TCS) and potentially hazardous food (PHF, foods that require specific time and temperature controls to prevent the growth of harmful bacteria and formation of toxins) prepared and held in a food establishment must be clearly marked with a consume by/discard date. Consume by/discard date cannot exceed seven days. Operations should note that some culinary standards may have a shelf life of less than seven days. Refrigerated, ready to eat, TCS/PHF food prepared and packaged by a food processing plant shall be clearly marked at the time the original container is opened. The date marked may not exceed the manufacturer's use by date. Food that is required to be date marked must be discarded if it is in a container or package that does not bear a date or day.

Review of the hospital's policy titled, "Interdisciplinary Infection Prevention and Control Annual Plan 2025," dated 11/22/24, showed a clean hospital environment and mitigating the risk of exposure to harmful hospital pathogens is essential for patient safety, regardless of setting. Environmental hygiene is a multifaceted and multidisciplinary approach that requires ongoing assessment and monitoring to maintain. In the context of environmental hygiene, hospital acquired infection (HAI) prevention will include horizontal interventions such as instrument reprocessing, air quality, water quality, and the physical environment. Therefore, this section of the infection prevention and control plan will include the audit (Tracer [a method of evaluating a healthcare organization's process and systems by reviewing specific processes through the organization]) cadence and use of the infection prevention committee to identify opportunities for improvement and situational awareness for safe practice within the environment of care.

Review of the hospital's Food and Nutrition contract with Facility F titled, "Master Services Agreement," dated 08/31/23, showed the contracted service was responsible for:
- Removal of trash from the kitchen to the dumpster;
- Sweeping and mopping between meals and at the end of the day;
- Cleaning kitchen equipment, food carts and the fryer; and
- Hair covering including facial hair.
The agreement showed the hospital was responsible for a quarterly terminal clean of the floors.

Review of the hospital's contract with Facility G, titled, "Pest Control, Inc.," dated 05/31/24, showed the contracted service was for professional pest and termite elimination. The contract covered fruit flies and gnats. The contracted service was to service the kitchen and dish room bi-weekly. Inspect and treat for fruit flies in the kitchen and dish room at each bi-weekly service. In the kitchen area service and inspect four vector plasma fly light traps (light used for quick fly control) monthly.

Review of the hospital's policy titled, "Kitchen Sanitation," dated 06/01/22, showed the purpose was to promote a clean, safe and effective environment and to prevent the transmission of disease carrying organisms. Equipment, walls, floors, and storage areas are cleaned with designated cleaning equipment and chemicals per the Facility F cleaning procedures.

Review of the kitchen's cleaning schedule titled, "Master Cleaning Schedule," dated 09/2014, showed kitchen staff were responsible for cleaning and to document the cleaning. Manager/supervisors must ensure cleaning tasks are completed and signed off in appropriate sections of the cleaning schedule. Areas to clean include: floor drains daily, sweeping floors as needed, mopping the floors twice a day, cleaning the char grill/griddle daily, handwashing sinks twice a day, trash cans as needed, warmers as needed and weekly, and ovens as needed and weekly.

Review of the last kitchen tracer titled, "Compliance By Question Report - Summary," dated 03/2025, showed the food prep areas were clean and free of personal items and debris. There were no signs of pest. Prepared food was covered and labeled with an expiration date. The staff were not able to prepare the sanitizing solution and read the test strips appropriately. There were expired items and not all items were labeled with an expiration date. Staff did not have facial hair covered. There were expired items in the dry storage area.

Review of the plant operations work order number 1299608 showed a work order to fix the leaking water valve, at the compartment sink, near tray line one was requested on 03/20/25. The water was leaking copious amount into containers and on the floor. The valve was repaired on 07/10/25.

Review of the undated kitchen staff orientation material titled, "SSM Health Facility F orientation tests and forms," showed no infection prevention training content and the provided infection control test was related to direct patient care.

Although requested, no documentation of scheduled cleaning and sanitization of the kitchen for the last two months were provided.

During concurrent observation and interview on 07/08/25 at 1:15 PM, with Staff LL, Food and Nutrition General Manager, in the kitchen, showed:
- Two tray carts were broken and dirty. Staff LL stated that the broken tray carts should be out of service with a work order placed on the top of the cart. Tray carts were to be cleaned after each use.
- The back pots and pans sink was blocked by a large black trash dumpster full of trash bags.
- The dishwashing area and tray lines had copious amount of food and trash on the floor.
- The dishwashing area had numerous fruit flies and gnats flying around, particularly on a dirty container of water and food that had been left out for several days. Staff LL stated he did not know why the container was still there and was unsure if a call had been made to pest control.
- The tray line area and dishwashing area had a broken garbage disposal that was dirty.
- The tray line area and dishwashing area had accumulated grime build up on the lower walls.
- One oven had grime on the racks and bottom interior with dust and grease build up on the exterior.
- One char grill with built up food and grease. Staff LL stated that the grill was not used today or very often.
- One fryer contained dark brown grease, with lots of sediment within. The exterior of the fryer was covered in dried grease and crumbs of food. Staff LL stated that the grease was changed every three days and that the fryers were to be cleaned daily.
- One container of uncooked rice without an airtight lid.
- Three of three handwashing sinks had grime and dried food accumulation on all surfaces.
- One of two food warmers had dried food on the handle.
- Three of three trash cans had food splattered at various stages of drying.
- Staff with facial hair not covered.

Observation on 07/08/25 at 1:50 PM, at tray line one, showed Staff FFFF, Kitchen Aide, dropped, then picked up a thermometer from the floor. Staff FFFF did not wash the thermometer prior to testing the temperature of food on an active tray line. On further observation, Staff FFFF had his personal bag laid on the floor next to the sink and tray line.

During concurrent observation and interview on 07/09/25 at 2:00 PM, with Staff LL, Food and Nutrition General Manager, in the kitchen, showed:
- A hot water valve on a compartment sink was leaking copious amounts of water into a container and on the floor. Staff LL stated that a work order had been placed.
- Two of two clean plate carts had dirt and food particles accumulated on the sides and bottom surface. Both carts had dirty plates. Staff LL stated that the cart and plates should be clean.
- Two of two handwashing sinks had grime and dried food accumulation on all surfaces.
- A front conveyor toaster had built up grime, crust and grease.
- A tray line shelf of individual cereal boxes had stickers that stated use by 07/12/25. Staff RRRRR, kitchen aide, stated that he was not sure why the stickers were there. Staff LL stated the stickers should not be there.
- The produce refrigerator had cheese, eggs and meat that expired 07/05/25. Staff LL stated he did not know why the food was not discarded.
- The produce refrigerator contained a tube of intense lip gloss.
- The produce refrigerator contained kitchen prepared hamburgers on a tray with no expiration date. Staff LL stated that the hamburgers should have been dated.
- The produce refrigerator had an opened bag of dried tomatoes with no date opened or use by date.
- The meat refrigerator had a full box of pureed breakfast breads with no use by date. Staff LL stated that he was not aware there was no manufactured use by date on this brand of food.
- The freezer had two boxes of ravioli with no use by date.
- The dry storage had multiple boxes of pureed food with no use by date.

During concurrent observation and interview on 07/09/25 at 10:27 AM, with Staff DDDD, Pot Washer, showed he measured the dilution of the current sink sanitizer. He read the test strip as positive for the appropriate dilution in milliliters per liter (ml/L, a unit of measure). The ml/L was 5.86, the EPA approved active range was 2.11 to 4.30 ml/L. Staff DDDD did not know he measured and compared the test strip to the incorrect dilution.

During an interview on 07/08/25 at 1:15 PM, Staff LL, General Manager Food and Nutrition, stated that kitchen staff were responsible for cleaning equipment and the floors.

During an interview on 07/10/25 at 11:04 AM, Staff MMMMM, Kitchen Aide, stated that the kitchen was very dirty. The thickener pump splatters every where when used and staff will not clean it up. The table where juices are prepared does not get wiped down. The staff do not work as a team and some staff do not care. She had reported to supervisors that the kitchen was not clean.

During an interview on 07/10/25 at 11:20 AM, Staff OOOOO, Kitchen Aide, stated that the condition of the kitchen was not acceptable. There was not enough staff to keep the kitchen clean. New staff come in and he trained them but they leave employment or go and hide so they don't have to clean. The newer staff do not work as a team. There were staff that do not care. When the food carts were all washed staff did not help in the dishwashing area. He could not learn by just hearing something in a huddle, he needed to be shown. He felt there were other staff like that. He stated that he did not have the equipment to keep the lower walls clean.

During an interview on 07/10/25 at 12:00 PM, Staff NNNNN, Environmental Services (EVS) Operations Manager, stated that there was a multidisciplinary meeting on 07/09/25 including Facility G. The pest control kitchen plan going forward was to utilize ultraviolet lights, spray drains with chemicals daily and update the floor cleaning chemical which will get into the grout better. He was not responsible for the cleaning of the kitchen and he had previously never been a part of a multidisciplinary meeting related to pest control in the kitchen.

During an interview on 07/10/25 at 1:38 PM, Staff BBBB, Infection Preventionist (IP), stated that she only rounded in Food and Nutrition during biannual environment of care (EOC) rounds and regulatory tracers. It was not acceptable to have fruit flies/gnats in the kitchen and that should be escalated to leadership. She expected clean dishes should be clean and debris free, oven cleaning should be documented, and the cleaning schedule to be followed. There were opportunities for infection prevention training and enforcement of policies for kitchen staff.

During an interview on 07/10/25 at 10:10 AM, Staff LL, General Manager Food and Nutrition and Staff PPPPP, Regional Director of Food and Nutrition stated that they were responsible for the condition of the kitchen. There was an opportunity to fix the process of dated food when opened and expiration dates. The pots and pans rinsed in the unacceptable sanitizer were not re-sanitized. When pests are reported there was no follow up to ensure the pest service responded. Ongoing education was completed in staff huddles. They were in the process of holding staff more accountable. The gnats were not reported until 07/08/25. The communication between EVS and plant operations needed improvement. There was a lack of oversight from the manager and lack of staff education related to infection prevention.

During an interview on 07/10/25 at 12:30 PM, Staff GGGGG, Chief Nursing Officer (CNO) and FFFFF, Assistant Chief Nursing Officer (ACNO), stated that the IP reported to the CNO and ACNO and they were unsure of the role the IP played within the kitchen. There should be clear expectations of the IP for kitchen environment of care.

During an interview on 07/09/25 at 2:15 PM, Staff AAAA, Vice President of Operations (VPO), stated that the observed kitchen environment was not acceptable and there was a gap in infection prevention education. Tracers are followed up on in several different meetings. Her expectation was to improve the cleanliness of the kitchen.