HospitalInspections.org

Based on interview and record review the facility failed to:

A. provide supervision to an licensed vocation nurse (LVN) providing medication administration per gastrostomy tube (G-tube). LVN (staff # 7) used scalding hot water to dissolve medication for G-tube administration resulting in internal and external burns to 1 of 2 patients (# 4) reviewed.The facility failed to ensure the quality department monitored incidents and patient injuries as well as failed to report injuries as required in 1 of 2 patients (patient # 4) charts reviewed.

Refer to Tag A-0144


B. follow it own policy and procedures for complaints and grievances. The facility failed to follow the grievance process in a timely manner, to have a Grievance Review Committee, and failed to report all complaints and grievances to the Governing Board in 2 of 2 (Patient #1 and #3) complaints reviewed.

Refer to Tag A0118


C. ensure the facility bylaws were clear on the definition of the "Company Managers" and the process in which the governing board reports to the cooperation's company managers. The governing board bylaws failed to address how the Chief Executive Officer (CEO) would be held accountable as a CEO if he/she was also appointed as the chairperson of the governing body. The Chairman of Governing Board/CEO failed to speak to the process of reporting up to the company managers.

Review of the Governing Body (GB) bylaws approved on 6/1/22 revealed the hospital governing board consisted of three members. The Chairperson, Secretary and the medical director. The bylaws stated, "The Governing Board shall have all responsibility and authority needed for governing the conduct of the hospital." The facility is owned by a cooperation.

Review of the bylaws revealed under Article I- Adoption, Ownership, and Authority stated, "The Governing Body is legally responsible for the operations of the hospital and such duties conferred to it herein and as further required by the Laws and Accreditation Standards. The Governing Board shall report to the manager or managers of the company (the "Company Managers").

Article II Governing Board Members. Appointment of Governing Board. The company managers shall appoint the members of the Governing Board ..." Review of the bylaws revealed there was no information on who the "Company Managers" were, how the GB reports to the company managers and how often.

An interview was conducted with Staff #1 on 8/31/22. Staff #1 Chief Executive Officer (CEO) stated that he was the Chairperson of the Governing Board, Staff #13 Regional Director was the Secretary of the Board and Staff #14 Medical Director was the third member. Review of the bylaws revealed they had been appointed by the "Company Managers." Staff #1 was asked how the Governing Board reported up to the company managers or was the GB for the facility the ultimate authority. Staff #1 stated the GB was the ultimate authority however, the company managers were involved in the workings of the facility. Staff #1 was unable to provide any written reports or able to speak to the process of reporting on the company mangers. Staff #1 gave this surveyor a sticky note of Staff #15's (Executive Vice President and President of Business Services) name and phone number. Staff #1 stated, "You need to call this guy he can tell you how all that works."

Review of the bylaws under Article VII- Chief Executive Officer stated, "Section 3. Responsibilities. The Chief Executive Officer shall represent the Hospital in all aspects of its operations. He/she will make periodic reports to the Governing Board on the overall activities, developments and inspections affecting the Hospital, but his /her line of authority shall derive from the Company Managers. The duties of the Chief Executive Officer shall include but not limited to the following,

... Liaison among the Company Managers, Governing Board, administrative staff and Medical Staff and between the Hospital and local community ..."

An interview was conducted with Staff #1 on 8/31/22. Staff #1 was asked if he is the chair of the GB, how does he report to himself, and how was he held accountable for hospital actions as the CEO if he was also the chair of the GB? Staff #1 again was unable to speak to the process. He stated that he made calls to corporate but was not able to speak to any processes in reporting. Staff #1 was asked if Staff #14, the secretary of the board, was reporting anything to the company managers? Staff #1 stated that he was not sure and that she was no longer in that position currently.

Based on interview and record review the facility failed to,


A. follow it own policy and procedures for complaints and grievances. The facility failed to follow the grievance process in a timely manner, to have a Grievance Review Committee, and failed to report all complaints and grievances to the Governing Board in 2 of 2 (Patient #1 and #3) complaints reviewed.

Refer to Tag A0118



B. provide supervision to an licensed vocation nurse (LVN) providing medication administration per gastrostomy tube (G-tube). LVN (staff # 7) used scalding hot water to dissolve medication for G-tube administration resulting in internal and external burns 1 of 2 patients (# 4). The facility failed to ensure the quality department monitored incidents and patient injuries, as well as failed to report injuries as required in 1 of 2 patient (patient # 4) charts reviewed.

Refer to Tag A0144

Based on record review and interview the Long-Term Acute Care hospital (facility) failed to specify, the expectation of where radiology services would be provided. The facility was unable to provide portable sonogram services to a patient with a physician's order because the service provider would not come to the facility and provide the service, for 1 (pt. #3) of 11 patients (#1 through #11) from 3/272022 through 3/28/2022.

This deficient practice had the likelihood to affect all patients of the extended care hospital.

Findings included:

On the morning of 8/30/2022 with the assistance of the Director of Nurses, staff #2, the medical record (MR) for patient (Pt/pt.) #3 was reviewed.

Pt #3 had come into the Long-Term Acute Care hospital (LTAC) via the emergency department, transferred from an acute hospital, with a diagnosis of COVID-19 and related Pneumonia requiring long term IV (intravenous) antibiotics. Pt #3 was in the facility from 2/28/2022 until 3/29/2022.

On 3/27/2022 pt. #3 had blood test with elevated Ammonia of 54 (Normal high is 52) and liver dysfunction and/or disease was suspected. On 3/28/2022 pt. #3's physician ordered a liver sonogram. The sonogram was not completed. On 3/28/2022 per pt. #3's MR, his ammonia level was 64.

A review of the physician's orders found no order to cancel the liver sonogram. Staff #2 was asked why the test was not completed. She confirmed the patient was not stable to transfer by ambulance to the acute hospital for the portable test. Staff #2 was asked why patient #3 should be transferred for a potable sonogram test? She explained they (Nursing staff) could not get the radiology provider to come to their facility. All patients were transferred via ambulance to the hospital for radiology services unless the test could be competed with a portable X-ray.

On 8/30/2022 at 10:30 am, an interview with the Administrator, staff #1, confirmed the contracted radiology service provider was the same entity that held the LTAC's building lease and they would not come to the facility to do a portable sonogram. The contracted service (the acute hospital) owned the building and provided only a portable x-ray machine that was shared between the LTAC on the second floor and their Rehab hospital on the first floor. All patients who had radiology orders, other than those which could be completed by portable x-ray, were transferred via ambulance to the acute care hospital. The Administrator was asked if he had investigated a second contracted service that would provide portable radiology services rather than transfer the patient to the hospital each time a test was ordered. He replied, he had not investigated this service.

The contract for Radiology services was reviewed. The contract stated:

"Attachment B-9
Radiology Services
Upon request of Hospital, Contractor shall provide radiology services in compliance with the Conditions of Participation and any standard, ruling, or regulation of the State DOH, Joint Commission, DBES, CMS or any other federal, State, or local governmental agency exercising authority with respect to such services.

Radiology Services shall include, without limitation:
1. Radiology, CT scan, MRI, nuclear medicine, ultrasound and diagnostic services; (sic)
2. Filing and recording of signed and dated reports of x-ray and other diagnostic services; (sic)
3. Providing appropriate storage, use and disposal of radioactive materials; (Sic)
4. Maintaining records of radiologic services; and
5. Providing adequate shielding to protect Personnel, Patients, and Facility".


On 3/28/2022, when the test was not completed, the attending physician wrote an order to discharge pt. #3 to the family's hospital of choice. The patient was denied at his desired hospital. Staff #2 confirmed pt. #3 was denied because he was too ill. The acute facility, which owned the building they leased, accepted the patient on 3/29/2022.

The LTAC hospital was unable to provide Radiology services resulting in pt. #3 being transferred from the LTAC to the contracted service providers facility.

Based on review and interview the facility failed to follow it's own policy and procedures for complaints and grievances. The facility failed to follow the grievance process in a timely manner, to have a Grievance Review Committee, and failed to report all complaints and grievances to the Governing Board in 2 of 2 (Patient #1 and #3) complaints reviewed.

Review of Patient #1's chart revealed he was admitted to the facility on March 12, 2021, with diagnosis of status post gastrointestinal bleed with cautery procedure. Review of the occurrence reports revealed Patient #1's wife made a formal complaint about her husband's care. The occurrence report was written on 4/8/22 at 12:00PM per Case Manager. The incident stated, "Patient's wife came to my office and verbalized some concerns from issues over the weekend. She stated Sunday morning when she arrived patients' oxygen saturations were low around 89 and Dr.____ (staff #14) came shortly after and stated he was concerned with possible aspiration. She stated pt had just had a coughing spell but that he would get RT to see and order a chest x-ray. After approximately 15 minutes no one had returned to the room and O2 sats were dropping. After RT arrived, they provided a treatment and patient improved. She asked about why if x-ray was ordered then why did it not get performed until the next morning. Provided explanation/education on orders and routine vs stat. Wife also stated that she calls routinely and rarely receives return calls back and that she did not know until last night at 10 pm that patient had to be put back on vent and will need bronchoscopy today. Also requested we keep window shut. Wife also mentioned that a staff member informed her that pt cannot use fan in room because it will affect ventilator operation. I did ask ____RT to review this and discuss with wife."

Review of the occurrence report did not reveal any of the complaints were handled immediately or if they were resolved. There was no found documentation that The Director of Respiratory Therapy (DRT) was able to address all these complaints immediately. There was no grievance process started for the unresolved complaint. Under "Follow up /Resolution" the occurrence report stated, "Re-educated staff on communication with family members." There was no information on what type of education was done and who was educated.

Review of Patient #3's incident report dated 3/12/22 at 7:15AM stated patient #3 made a complaint about staff and care. Review of the report stated, "Called to pt room by primary nurse ____ (Staff #7 LVN) @7:30pm. Pt c/o being left dirty by day shift nurse____ (Staff #16 RN). Patient claims he called for a bedpan around 6:15PM and no one came. He stated he was unable to hold it and "pooped" on himself around 630-640pm when no one had come to put him on the bedpan, patient also claims that ____ (Staff #16 RN) came in right after he pooped on himself and said he would be back and never came on initial rounds@715pm pt found dirty by _____ (Staff #7 LVN) LVN. Pt cleaned at that time by nurse and CNA. Patient requested to talk to charge nurse and I spoke to him at that time. Daughter called charge nurse at 9pm voicing her concerns after speaking to the patient about the incident. Daughter claims this is the 3rd time this week this has happened, and she was very upset that it keeps happening." (SIC)

Review of the follow up revealed the nurse manager addressed the issue two days later with the patient and daughter on 3/14/22 at 9:08AM. The Manager documented, "Spoke with patient who states that the nurse stated he would be back but was not and he lay in feces for an extended time. ____ (Staff #16 RN) states that _____ (Staff #7LVN) said she would take care of it but did not. Stressed the importance of rounding with the nurses to address their needs together. Apologies made to the patient."

Review of the incident revealed that the Director of Quality Management reviewed the complaint. There were no comments from the director, no grievance written, and no grievance response made to the patient or family found.

Review of the policy and procedure Grievance Resolution Process stated,
"II. POLICY All patients have the right to initiate the grievance resolution process. Patients who file a grievance will not be retaliated against by any employee or any other representative of the hospital. If the patient care complaint cannot be resolved at the time of the complaint by the staff present, is postponed for later resolution, is referred to other staff for later resolution, requires investigation, and/or requires further actions for resolution, then the complaint is a grievance.

III. DEFINITIONS
A. Grievance- Written or verbal complaint made to the hospital by patient or representative related to: a. Patient care (when not resolved at the time) b. Abuse or Neglect c. Noncompliance with CoP's d. Medicare beneficiary complaint Any complaint asked to be treated as a grievance e. AMA

B. Complaint-a. Complaint resolved at the time of the complaint by the staff present b. Most billing issues c. Information from Patient Satisfaction Surveys d. Verbal communication after discharge that would have been routinely handled by staff present if it had been communicated."

An interview was conducted with Staff #3 on 8/31/22. Staff #3 confirmed there was not a grievance done on the patient because it was resolved. Staff #3 was asked what documentation she had to reveal it was addressed immediately and all parties were agreed it was resolved. Staff #3 stated she did not have that documentation and could not confirm it was resolved.

Review of the policy and procedure Grievance Resolution Process revealed, "5. The Director of Quality Management or designee will meet with the patient to discuss their complaint and resolve the issue if possible. If the complaint is unable to be resolved, the grievance process will be initiated. Should the grievance involve more than one specific concern, each concern will be addressed individually within the written response.

6. The Director of Quality Management refers the grievance to the Grievance Review Committee. The committee will meet and provide written documentation to the patient within seven business days on average from the date the grievance request was received. The hospital must attempt to resolve all grievances as soon as possible and must demonstrate the capability to resolve almost all grievances within the 7 day business timeframe. If unable to complete the investigation within 7 business days the hospital will notify the patient in writing of ongoing investigation with completion of investigation and written notification in 30 days.

7. The governing body has delegated the responsibility of reviewing grievances to the Grievance Review Committee which will be chaired by the hospital Director of Quality Management and comprised of not less than two hospital management personnel chosen by the chairperson based on the nature of the grievance.

8. The Grievance Review Committee performs the following functions: a. Reviews the grievance and any informal action already taken. b. Recommends appropriate action to the hospital CEO. c. After conferring with the hospital CEO, the Grievance Review Committee chairperson will provide a written response to the patient with: 1) Name of the hospital contact person, 2) The steps taken on behalf of the patient to investigate the grievance, 3) The results of the grievance process, and 4) The date of completion of the grievance process."

An interview was conducted with Staff #3 on 8/31/22. Staff #3 stated that there was not a Grievance Review Committee. Staff #3 stated that she talks to the CNO and CEO about the grievances, but they do not go through a committee. Staff #3 was unable to speak to how the information gets to Governing Board or to the corporate level.

Based on record review and interview, nursing failed to provide supervision to an licensed vocation nurse (LVN) providing medication administration per gastrostomy tube (G-tube). LVN (staff # 7) used scalding hot water to dissolve medication for G-tube administration resulting in internal and external burns 1 of 2 patients (# 4). The facility failed to ensure the quality department monitored incidents and patient injuries, as well as failed to report injuries as required in 1 of 2 patient (patient # 4) charts reviewed.

Review of patient # 4's chart revealed he was admitted on 2/02/22 with a diagnosis of Lou Gehrig's disease. Upon admission patient # 4 had a double procedure for insertion of a tracheostomy (airway surgically placed to provide oxygenation to the lungs) and gastrostomy tube (tube for nutritional feeding inserted directing through the stomach below the umbilical).

Review of the incident report dated 4/2/22 revealed patient # 4 had a 2nd degree burn (noted blistering and skin shearing or peeling with bright red tissue and clear drainage). The incident report documented "at 10:00 am patient # 4 stated to RN that his lower abdomen felt like it was burning. RN stated that she pulled the patient's blanket back and noticed a red mark with blisters on his lower abdomen. The patient mouthed to RN that the night shift nurse did it when she gave his medication early this morning. Patient stated she spilled hot water on him while trying to give his medication and his peg tube was clogged and she used hot water to unclog it and got it on his skin and it burned him. The night shift nurse taking care of patient # 4, staff # 7. Apologies were made to the patient and to the family. The patient was seen by the wound care RN staff # 8. The burn was documented and treated accordingly." This incident resulted in bodily harm from scalding hot water from the employee coffee pot to G-tube and 2nd degree burn to lower abdomen measuring 15 cm x 8 cm x 0.01 cm.

Review of the chart revealed minimal documentation of the incident and patient condition.. Staff # 8 according to medical record was notified at 12:00 pm of burn on 4/2/22 in nurses notes. At 3:25 pm staff # 8 performed wound care. Review of medical record revealed there was no physician or family notification of the incident. Staff # 8 utilized policy guidelines for burn treatment. Review of the physician progress notes revealed that the physician did not address the burn until 4/4/22. There was no evidence found that the patient was assessed, or physician ordered any diagnostic test to evaluate patency of G-tube related to complaints of internal burning and pain voiced by the patient during medication administration. Review of the nurses' notes dated 4/2/22 at 12:15 pm revealed spouse at bedside of patient # 4 and was shown the burn to the abdomen.

An interview was conducted on 8/31/22 with staff # 2, # 1, # 7. Staff # 2 stated that on 4/2/22 day RN informed her of the incident to patient # 4's abdomen. Staff # 2 notified staff # 1 of patient incident and was told it was not reportable to the nursing board or CMS. Staff # 2 inquired again immediately after and staff # 1 stated she could ask corporate. Staff # 2 stated she notified corporate but was not given any resolution to her questions. Staff # 1 confirmed he was aware of patient injury and suggested staff # 2 call corporate with questions. According to document education follow up, on 4/7/22 staff # 2 verbally educated staff # 7 regarding policy for medication administration via tube feedings. Review of staff # 7's employee file revealed she received education from staff # 2; however, there was no information on what education or any return demonstration of skill. Further review of staff # 7's employee record revealed she performed and was signed off by a preceptor on 4/23/22 to have completed a total of 236 skills with 22 subsets for preparation of intravenous access (IV) for admixtures, 13 subsets of g-tube medication administration, and 9 subsets of turning/moving patients with an artificial airway in a 12-hour period.

There was no evidence found that staff # 7 was able to safely administer medication via tube feeding. Staff # 2 was unable to provide any investigation or education related to staff development or competencies regarding medication safety with G-tube feedings. Staff # 2 stated they planned on educating other nursing staff during the skills fair late September which is 5 months post patient injury.

Staff # 7 stated that she was given verbal education regarding the administration of medications via enteral feeding tubes. Staff # 7 stated she was "not aware that diluting medications with scalding hot water was inappropriate, it just makes it dissolve faster." Staff # 7 stated she ran the water in the sink until hot then put it through the staff coffee pot to get hotter prior to adding the medications which needed dissolving for tube administration. Staff # 7 was allowed to continue to administer medications via tubes without any observed return demonstration on a mannequin or patient.

An interview was conducted on 8/31/22 with staff # 3 concerning the burn to patient # 4, staff # 3 stated she was aware of the burn and started a root cause analysis (RCA); however, she stated "you will be disappointed in me because I didn't follow through." Review of RCA reveals incomplete and minimal resolution and that staff # 7 did not follow policy guidelines. Review of the QAPI meeting minutes July 28, 2022, revealed no patient incidents reported to governing body.

Based on record review and interview the facility failed to monitor the effectiveness and safety of services and quality of care by analyzing and tracking meaningful data.

Review of the Quality Assessment Performance Improvement (QAPI) meeting minutes for 2022 revealed there was collected data placed into graphs for falls, blood transfusions, restraints, code blues, environment rounding, and medication errors but no analysis of the data was found. Review of the blood transfusions graph stated that the charts with blood transfusions were reviewed daily but never stated the issues found or variances listed. There were no indicators listed. There was no information on what the numbers mean, how long they will continue to monitor or track the data.

An interview was conducted with Staff #3 on 8/31/22. Staff #3 stated that she was collecting data but was unable to speak to the analysis of the data. Staff #3 was asked if she was able to break down the data or divide it into subcategories by group, division, class, or levels that would reveal meaningful information to understand the problem. Staff #3 stated that she had not analyzed the data to find the core problem. Staff #3 confirmed that she had PI processes but just things she was working on. Staff #3 stated they had no PI teams in place or other PI processes involving other staff members.

Review of the QAPI meeting minutes 7/2022 revealed the 9 PI processes. The following processes had no information except graphed data. There was no information on a team, who was involved, what they were monitoring.The PI processes were as follows:
Closed chart, open chart, credential files, hourly rounding, 12 & 24-hour chart check, shift report, HR file, EC rounds, critical drips.

Based on review and interview the facility failed to ensure contracted services and all hospital departments were reviewed and monitored through the Quality Assessment Performance Improvement (QAPI) process in 3 (Dietary, Housekeeping, and contracted services) out of 12 (Therapy, Respiratory,Utilization Review, Infection control/employee health, Pharmacy, Human resources, Dialysis, Laboratory, Risk/Pt. Safety,Dietary, Housekeeping, and Contracted services) departments reviewed.

Review of the QAPI meeting minutes for 7/28/22 revealed not all departments were being monitored in QAPI. Dietary, Housekeeping, Patient Safety regarding emergency preparedness, and contracted services were not represented in any 2022 QAPI meetings nor was there any data from these areas.

An interview was conducted with Staff #3 on 8/31/22. Staff #3 stated that she had not included Dietary, Housekeeping, Patient Safety (regarding emergency preparedness), and Contracted Services in her QAPI monitoring or data collection.

Based on interview and record review the facility failed to act in a timely manner on assessments that indicated 1 of 11 patients (patient #3 of #1 through #11) was not consuming the desired nutrition required for recovery from 2/28/2022 through 3/29/2022, 31 days.

This deficient practice had the likelihood to affect all patients of the facility.

Findings included:

On the morning of 8/30/2022 the medical record (MR) for patient (Pt/pt ) number (#) #3 was reviewed with the assistance of staff #2, the Director or Nursing. During the review it was observed in the nursing documentation that pt #3 was a diabetic and did not like the diet ordered. He did not like the food choices and did not like the taste of the seasonings on the food. The staff told pt #3 his family could bring him meals if he did not like their food. However, the family lived out of state and no friends stepped up to accommodate his food likes.

The MR confirmed that pt #3 consumed 50-100 % of at least 2 meals a day on 12 of the 30 days he was a patient in the facility. Four (4) days pt #3 consumed 50% or less of 2 meals a day and 14 days pt #3 had an oral nutritional intake of zero for 2 meals or more a day.

On 8/31/2022 in the afternoon an interview with the Registered Dietician (RD), staff #5 was conducted. The RD interviewed was not the RD who was employed at the time pt #3 was in the facility. However, RD #5 confirmed there was no policy or protocol guiding staff as to when the pt's physician should be notified of failed intake. There was no policy that the Registered Nurse (RN) followed to guide them to notify the RD that the patient was not eating or had not eaten greater than 50 % for a predetermined number of days. The RD also confirmed that to her knowledge the staff had not been educated on how to determine the percentage of nutritional intake, for example 50% of protein was consumed vs 50% of bread and dessert was consumed.

Pt #3 began to decrease his nutritional intake on 3/14/2022. His admission weight (wt) was recorded as 221.7 pounds (lb). The last wt recorded was on 3/27/2022 at 201 lb. Pt #3 lost 20 pounds while in the LTAC. Although Ensure was ordered twice a day, and replaced with Glucerna three times a day, pt #3 continued to lose weight.

On 3/27/2022 the physician ordered a PICC line (peripherally inserted Central catheter) and Total Parenteral Nutrition IV, (TPN) per PICC.

On 3/28/2022 the physician orders reflected TPN consult per TPN Sheet. The RN documented the TPN had been started but no end of shift tabulation of intake was recorded.

On 3/29/2022 the Intake and output sheet of pt 33's MR indicated TPN was started at 7:00 AM. He was discharged at 1500 (3:00 PM) and 747 ml (milliliters) of TPN had been infused.

Based on record review and interview, the facility failed to follow their own policy and procedures, regarding frequency of nasogastric residual feeding checks and failed to replace dislodged gastric tube in 1 of 1 (# 1) patient reviewed.

Review of the chart reveal patient # 1 was admitted on March 12, 2021, with diagnosis of status post gastrointestinal bleed with cautery procedure. Patient had a nasogastric tube for feedings related to self-dislodgement (patient removed the tube by pulling on it at admission) of internal Peg tube. Review of the policy and procedure "Safe use of enteral therapy," stated, "inadvertent removal of a gastrostomy tube/device demands prompt attention. A replacement tube should be reinserted as soon as possible to prevent closure of tract." No documentation was found denoting any attempt was made to insert a replacement tube.

Review of patient # 1's chart revealed that the policy "Checking Gastric Residual Volume." Policy stated, "Check residual every 4 hours in critically ill and every 6 hours in non-critically ill patients." Review of the chart revealed residuals were only documented once on 4/23/21 in the chart during patients' admission. Patient # 1 was not discharged until May 18, 2021. Staff # 2 during interview on 8/31/22 10:45 am stated "yes, documenting residuals is a known nursing problem." Staff # 2 was unable to provide any education related to checking and documentation of residuals. There was no monitoring in quality for this ongoing issue.

Based on observation, document review and interview the facility failed to provide a clean and sanitary environment to mitigate the spread of infectious diseases and prevent hospital acquired infections in 11 (Emergency Cart near Nurses Station, Medication Room H233D, Biohazard Room H237, Physical Therapy Room, Nurses Station, Hemodialysis Storage Room, Patient Room #208, Clean Utility Room 202A, Soiled Utility Room H239, Clean Utility Room H240, Central Supply Room H248) of 11 areas observed.

Findings:

An observation tour was conducted on 8/30/2022 at 10:00 AM with Staff #3 and Staff #12. The following was observed.

Emergency Cart
A red Crash Cart (Emergency Cart used during patient emergencies) was stationed in a corner across from the nurse's station. The top of the cart was covered with dirt and dust. A green bucket positioned on top of the cart was used to hold patient supplies. On the bottom of the inside of the green bucket was dirt, dust and debris. The bucket was broken on the outside placing all staff at risk for lacerations/puncture injuries during an emergency.

Medication Room H233D
Inside the medication room on the countertop was a pill crusher soiled with dirt and dust. When the top drawer was opened, dirty scissors, trash, dirt, and heavy dust was noted. Underneath the countertop was a cubby hole that stored two coolers used to transport blood products. When the coolers were moved dirt, trash, and dust was noted.


Biohazard Room H237
Inside the Biohazard Room (a room designed to store biohazard waste) were 7 full boxes of biohazard waste and 4 full Steri-cycle bins used to dispose of pharmaceutical hazardous waste. There were 2 large red biohazard plastic bins used for items or bags that would not fit into a biohazard box that were dirty. Also in this room were 9 clean Steri-cycle bins that would be placed into a clean medication room or pharmacy where patient medications are prepared and dispensed. This practice placed all patients at risk of cross contamination of dirty biohazard waste and clean medication preparation that could cause a hospital acquired infection.

A review of the document titled, "Infection Surveillance Policy Number IC 03" with a revised date of April 28, 2022, was as follows:

" ...POLICY:
The Infection Prevention and Control Plan is used to provide the framework for the prevention and control of infections. The surveillance of infection is encompassed in the plan and includes monitoring of patient infections, staff compliance with policies and procedures and adherence to reporting guidelines. Data obtained in the surveillance activities is used to revise and improve infection reduction strategies.

PROCEDURE:
1. Compliance with Policies/Procedures:
a. Ongoing surveillance rounds will be conducted by the Infection Control Professional as well as leadership staff. Data will be collected and forwarded to the Infection Control Committee. Immediate corrective actions will occur for any violations of infection control policies.
b. All departments are expected to adhere to hospital policies related to infection control ..."

Two of three documents presented for review titled, "Infection Control Rounds" did not have an area surveyed documented. Staff #12 completed the Infection Control Rounds on 7/12/2022, 7/26/2022, and 8/2/2022.

An interview was conducted with Staff #12 on 8/30/2022 after 12:00 AM. Staff #12 was asked if infection control surveillance rounds were completed on a regular basis. Staff #12 stated, "They are completed regularly. I do them and the leadership team also completes them." Staff #12 was asked if regular Infection Control Committee meetings were held and if the findings from the surveillance rounds were reported during the meetings. Staff #12 replied, "We do all of our reporting in the Quality meetings. We do not hold separate Infection Control meetings because it just turns out to be too many meetings."

Staff #12 confirmed there was no separate meeting minutes for an Infection Control Committee meeting.

Staff #3 confirmed there was no Infection Control Meeting held separately. All infection control surveillance and identified problems were reported during the Quality meetings. Staff #3 was asked if the Infection Control Committee members attended the Quality meetings. Staff #3 confirmed the members did not always attend the meetings.

Staff #3 and Staff #12 confirmed the findings.





46923

An observation tour was conducted on 8/30/2022 at 10:00 AM with Staff #2 and staff # 12. The following was observed.

Findings:

Physical Therapy Room:

The wooden slide boards had deep crevices, scratches, and sticky residue. The boards exposed the wooden surface beneath creating an environment for bacterial growth. The wooden boards could not be sanitized due to the damaged and porous surface. The base of the large exercise table was heavily soiled with dust and rust. The walking wooden platform was found to be dusty, unvarnished allowing for porous wood and metal bracing were rusted. The base of the stationary arm cycle was soiled with dirt, dust, and hair. Dead bugs were noted behind equipment on the floor. There was a small refrigerator with a sign indicating it was an employee refrigerator, no patient items permitted, had 3 large patient cold therapy packs stored inside. Three out of 8 wheelchairs (marked as clean) were soiled with multiple tears in the upholstery.

Nurses station:

There were 5 personal fans visibly soiled with dirt and debris (inside and outside). This placed all patients and staff at risk of healthcare associated infections. Dust and particulate matter easily dislodges and can cause respiratory issues to staff, patients and family.

The inside of the cabinet under the sink was soiled with dirt, dust, debris and dried liquid. The laminate inside the cabinet was broken and peeling exposing the porous surface. The porous surface could not be cleaned and/or disinfected.

The top of the glucometer case was broken, noted sticky residue on top preventing proper disinfection. Noted rolled adhesive on top of glucometer case resulting in thick adhesive and unable to disinfect. The inside and out was filled with dust, dirt and debris. Unable to disinfect the case related to adhesives, stains and unknown debris. The exposed 2x2 gauze are dirty and unable to disinfect or protect between patients resulting in risk of cross contamination, spreading infectious disease.

Beside the sink at the nurses' station were unopened syringes, biohazard bags, pure wick system, and an open betadine. There was no splash guard to prevent the contamination of the supplies from dirty water spray.
Nurses station desk with worn wood casing around the laminate, allowing porous material unable to disinfect. Two out of 3 nurses chairs were ripped and torn. Between the two medication cabinets, 4 packages of insulin syringes found on the floor. Syringes were covered in dirt, dust, and debris. Noted power strip cords covered in dust, dirt and debris behind computers on top of desk. Underneath the desk were multiple computer cords rolled up and pushed behind a large hard drive on the floor. The cords and hard drive were heavily covered in dust, dirt and hair.

Hemodialysis Supply/Storage Room H207/208

This room was used to store dialysis machines, testing equipment and patient supplies, noted cluttered and disorganized. The metal shelving is covered in dust and debris with patient hemodialysis supplies and employee personal items (lotion, clothing, and food). Noted room temperature logs for August missing temperatures on 08/25/22. Noted test strips (used to assess water pH) for dialysis dated 7/12/2021. Staff # 2 confirms that the strips were expired 30 days after opening according to facilities beyond expiration policy. Plastic bin in hemodialysis room with butter, honey, fingernail clippers and multiple packets of triple antibiotic ointment. Employee personal backpack found on floor next to dialysis equipment. Noted employee scrubs in a plastic bag. Confirmed with Staff # 2 that those were personal items of the hemodialysis nurse. Floor in room with copious dirt and sticky substance trapped between laminate and floor molding.

Patient room H208:

Staff # 2 confirmed this room was ready to receive a new patient and was terminally cleaned. This room was ready to receive a new admit and confirmed with staff # 2. A closet used to store a patient's personal items was noted with torn and peeling laminate on the top surface in two separate areas. This placed all patients at risk of injury or infection. The porous surface could not be sanitized. According to the Centers for Disease Control (CDC), terminally clean means all equipment and room disinfection has been completed.

Upon removing the fitted sheet, the mattress was torn and allowed bodily fluids to seep into the mattress foam exposing patients to cross contamination and infectious diseases. Near the tear in the mattress cover, a piece of crusted or dried patient skin was seen.

The bedside table was dirty with a sticky substance and stained on the top surface. The telephone, bed control, and oxygen concentrators were all piled on the top of the table. Surrounding the sink in the patient restroom was a sticky, yellow-colored substance surrounding the perimeter of the sink and what appeared to be human hair stuck in the unknown substance.

Biohazard trash was present in the trash can from previous patient. Normal saline open syringe with two alcohol pads found on top of the hand sanitizer in patient room.

Clean utility room 202A:

This room was used to store clean supplies for patient use mixed with a rack of patient clean linen. Staff #2 confirmed that all items brought into this room were cleaned and covered with a plastic bag to indicate they were properly cleaned and ready for patient use. On the top metal shelf was a cardboard stretcher used for emergency patient evacuations that was covered in dust and when the board was moved flying debris was seen. The metal storage shelves were covered with dirt and dust. The bottom shelf did not have a shelf liner that prevented dirty mop water from contaminating the patient items when the room was cleaned. A bladder scanner was covered with plastic indicating it was ready for patient use. When the plastic covering was removed, the probe was covered in dried conductive jelly and other various dirt and debris which increases risk of healthcare associated infections. Four of 4 intravenous poles were identified as clean; however, when the clean bag was removed the equipment was visibly soiled, dusty, debris, as well as hair and dirt. Two out of 2 Meditherm were covered in dirt, dust, and tape residue. Three out of 3 IV poles were rusted with wheels caked in sticky debris. Three out of 3 portable monitors were found heavily soiled with dust, 2 of 2 with a dried yellow sticky substance and dried red blood residue.

H239 Soiled utility room:

The floor in this room was visibly soiled. Dirt and a sticky substance were packed between the laminate and baseboards. Unknown debris was stuck to the metal shelving. The metal racks were heavily soiled with dust and dirt.

Clean utility H240:

Clean utility room was soiled with stains, rust, and mold. The laminate inside the cabinet was peeling exposing the porous surface, making it unable to be disinfected. Staff #2 confirmed that all items brought into this room were cleaned and covered with a plastic bag to indicate they were properly cleaned and ready for patient use. When the plastic barrier was removed from the patient scale, the bottom of the scale was covered dirt, debris, and a sticky substance.

H248 Central Supply (classified by facility as materials management) room:

This room is the material management/central supply for the facility. It is in congested, mixed with dirty equipment, clean supplies, sterile equipment, contaminated shipping boxes, and broken equipment, storing patient supplies and facility equipment in this small room. Broken printer marked "dead" on the floor next to clean supplies. Broken television on the floor in front of shelving, blocking clean patient supplies. The room has no separation between clean and dirty equipment as evidenced by stacks of plastic tubs filled with broken cords and equipment next too and on top of clean & sterile wound care supplies. There was only one door used to enter and exit. The room was disorganized and no space for storage.

This small room was cluttered as evidenced by piles of paper, bags of batteries, aseptic supplies remaining in shipping boxes, employee personal food items (tuna, open drinks, tea bags), and some type of room perfumed deodorizer adjacent to patient supplies. Clean supply room unorganized and cluttered with broken electronics, boxes of broken cords, shipping boxes on floor and metal stocking shelves next to sterile and aseptic supplies. Room is out of compliance as evidenced by dirty and clean mixed on shame shelf, shipping boxes mixed with sterile supplies, under the sink in the central supply room is dirty with sticky substance adhered and plastic bags. Various broken equipment and patient supplies scattered throughout central supply mixed with patient supplies (sterile and aseptic).
In the back of the room was where Staff #11 had designated workspace, processing of paperwork and storage of receipts/invoices. Metal stocking shelves packed tightly with cardboard shipping boxes, patient supplies, plastic bins with dirt and debris. There were multiple piles of papers that were not filed. Staff #11 confirmed the request for a larger room with more space and the capability to maintain a record system was still pending with no final approval. Under the counter in the back of the room was a small refrigerator that stored personal items such as grapes, sodas, and protein drinks. On a shelf, next to Staff #11's working area was personal food items such as tuna, tea bags, and open drinks.

There were three rows of metal shelving in this room. Sterile items were stored next to corrugated shipping boxes that had been received. Multiple plastic bins were piled on top of each other that contained clean and sterile patient supplies, electrical cords, books, sequential compression machines, and plastic trash. Dirty items were stored on the same shelf as clean and sterile items. On one metal shelf there was no shelf liner on the bottom to prevent cross contamination of dirty mop water to clean patient care items. The shelves were covered with dust. The bottom shelf liners were heavily covered with dust. Trash was noted on the floor under the metal shelving.

All items received on the shipping dock are brought into this room to be opened, stored, and transported to the requested area of the facility. There was no designated dirty area to open the boxes in the clean room.
"External shipping boxes/Corrugated boxes pose a great risk to all patients due to contaminates and insects harboring on and in the corrugation of the boxes, Association for Professionals in Infection Control and Epidemiology (APIC), 2022. External shipping boxes also contain dirt and dust that exposes all sterile patient care items to contamination.

A temperature log for temperature and humidity of sterile storage was missing documentation of the temp and humidity for 5 of 30 days.

Staff # 2 and staff # 12 Confirmed the findings above.