HospitalInspections.org

Based on document review and interview it was determined that the hospital failed to comply with the Condition of Participation 42 CFR 482.13, Patient Rights.

Findings include:

1. The hospital failed to ensure that allegations of abuse were reported and escalated up to leadership in order for a thorough investigation to be completed. (A-145)

Based on document review, and interview, it was determined that the hospital failed to comply with the Condition of Participation, 42 CFR 482.23, Nursing Services.

Findings include:

1. The hospital failed to ensure appropriate provision of hospital-wide nursing service under the direction of one registered nurse. See A 386.

Based on document review and interview it was determined that the hospital failed to comply with the Condition of Participation 42 CFR 482.28, Food and Dietetic Services.

Findings include:

1. The hospital's Director of Dietary Services failed to ensure that staff followed manufacturer's directions for testing and use of sanitizing solutions. (A-620 A)

2. The Director of Dietary Services failed to ensure that times of each meal service were documented and taste/appearance/temperatures checks of each food item served were completed. (A-620 B)

The Life Safety Code portion of a Full Survey Due to a Complaint survey was conducted on 2/25-2/26/2025. The requirements of 42 CFR Subpart 482.41 Physical Environment are NOT MET as evidenced by the deficiencies cited under the K-Tags.

Based on document review and interview, it was determined that for 1 (Pt. #20) of 2 psychiatric patient records reviewed, the hospital failed to ensure that allegations of abuse were reported and escalated up to leadership in order for a thorough investigation to be completed.

Findings include:

1. The hospital's policy titled, "Abuse and Neglect: Allegations, Reporting, Prevention and Management" (revision 4/2024), was reviewed and required, "...To provide procedures for reporting, investigating, and following up when an allegation of patient abuse or neglect is made, or when other information is received indicating that patient abuse or neglect may have occurred... Immediately report allegation to the Nursing Supervisor and/or Director... The Nursing Supervisor will contact the Administrator on Call (AOC), the Chief Human Resources Officer (CHRO), and the Risk Manager (RM) immediately... A thorough investigation will be conducted by leadership and documented... Complete an incident report in the electronic occurrence reporting system..."

2. The clinical record of Pt. #20 was reviewed on 02/24/2025, at approximately 2:30 PM. Pt. #20 was admitted on 02/08/2025 to the Geropsych Unit (behavioral health unit for patients 50 and above), with a diagnosis of schizoaffective disorder (mental health condition). The cognitive test completed by a nurse on 02/08/2025 at 1:31 PM indicated that Pt. #20 had none to no significant cognitive impairment. The Psychiatrist (MD#2) note, dated 02/09/2025 included, "...[Pt. #20] has been having recurrent psychotic episodes with VH+ [visual hallucinations] and AH+ [auditory hallucinations]... with commands/patient has been obviously in episodic distress due to the content of hallucinations... patient has been admitted after getting very agitated, unable to sleep, unable to relax..." MD#2's note, dated 02/10/2025 at 8:49 PM, included "...[Pt. #20 stated] '...There were these guys, on the unit trying to rape me. They asked me to remove my clothes and try to rape me. I didn't let them do it. They took my phone from me. They will put naked pictures on all Internet and [social media]... didn't point to any staff members or peers trying/being the ones trying to rape her...' ...The patient was asked if [Pt. #20] will agree with trying to get a rape kit. [Pt. #20] started to be hesitant [and stated] 'no I will not allow anybody to touch me.'... All staff were instructed to have only female staff helping with patient with all services... will have 1 to 1 sitter till dc [discharge] from the unit... patient didn't make any specific people accusation, only mentioned 2 men..." The record indicated that a sitter was ordered for Pt. #20 on 02/11/2025 at 2:08 AM (after MD#2 signed the note indicating Pt. #20 reported attempted abuse). MD#2's note on 02/13/2025 included, "...[Pt. #20 stated] 'It is elderly abuse. They rape me 2 days ago! You don't believe me!' When I asked to describe the abuser, [Pt. #20] described a tall guy with pony tail..." MD#2's note on 02/19/2025 included, "...Cont[inues] to focus on 'rape'...[Pt. #20 stated] 'don't tell what happened... I know he tried to rape me!' Patient is not able to f/u [follow-up] on the chronological events and time. I tried to educate [Pt. #20] we do not have any staff with long hair and pony tail/ and perhaps [Pt. #20] is a little 'confused' about the settings. [Pt. #20] continues to focus on the staff who get [Pt. #20] naked, took picture of [Pt. #20]..."

3. The Staffing Schedules for the Gero-Psych Unit were reviewed for February 2025 and indicated that there were male staff working on the unit between 02/08/2025 and 02/10/2025.

4. The hospital's Complaints/Grievances/Occurrence Log for February 2025 was reviewed and did not include any complaints, grievances, or incidents filed for Pt. #20. Per the Executive Director of Quality (E#11) on 02/25/2025 at 12:10 PM, E#11 confirmed there were no reports filed for Pt. #20 and spoke with the Nursing Leadership (E#4) who was not made aware that Pt. #20 had made an allegation of abuse. E#11 stated that they were not made aware of the allegation and therefore have not completed an investigation in regards to Pt. #20's allegation of abuse.

5. An interview was conducted with Registered Nurse (E#35) on 02/24/2025, at approximately 3:00 PM. E#35 stated that if a patient makes an allegation of abuse to E#35, E#35 would report it to the doctor and manager but would not file a report in Clarity (the hospital's occurrence reporting system).

6. An interview was conducted with the Manager of the Behavioral Health Unit (E#7) on 02/25/2025, at approximately 1:55 PM. E#7 stated that E#7 was not made aware of the allegation until days after the patient made the allegation. E#7 stated that it should have been reported up the chain of command, all the way up to Risk Management. E#7 stated that the Psychiatrist who received the allegation of abuse never reported it. E#7 stated that they only found out about it, when they requested for a sitter and were told the reason for the sitter. E#7 stated that nobody filed a report in Clarity.

7. An interview was conducted with Pt. #20 on 02/25/2025, at approximately 3:55 PM. Pt. #20 stated that Pt. #20 has a sitter with Pt. #20 at all times but didn't know why. Pt. #20 stated that it was always a female sitter "because something happened elsewhere and here with male staff." Pt. #20 stated that Pt. #20 did not feel comfortable talking about what happened. Pt. #20 stated that some days Pt. #20 feels safe and some days not. Pt. #20 wouldn't elaborate on when Pt. #20 didn't feel safe.

8. An interview was conducted with Registered Nurse (E#36) on 02/25/2025, at approximately 4:10 PM. E#36 stated that E#36 would notify the supervisor if a patient made an allegation of abuse. When asked about filing a report in Clarity, E#36 did not affirm that E#36 would file a report in Clarity and stated in Pt. #20's case, Pt. #20 was hallucinating and the male staff have worked over 30 years on the unit and are so dedicated to the patients that they would never do something like that.

9. An interview was conducted with Psychiatrist (MD#2) on 02/26/2025, at approximately 9:05 AM. MD#2 stated that most bipolar patients when manic are sexually preoccupied. MD#2 stated that when MD#2 first saw Pt. #20, Pt. #20 made the allegation that two men tried to rape Pt. #20. MD#2 stated that Pt. #20 did not give a description of the men at the time but continued to bring it up every day. MD#2 stated that MD#2 placed Pt. #20 with a female sitter and female staff only immediately after Pt. #20 made the allegation. MD#2 stated that MD#2 asked Pt. #20 if Pt. #20 was sure this happened here and the patient stated that it did happen here. MD#2 stated that Pt. #20 did not report any actual abuse, just attempted abuse. MD#2 stated that days later, Pt. #20 stated that one of the men had a ponytail but MD#2 stated that there were no male staff that had a ponytail. MD#2 stated that MD#2 investigated Pt. #20's allegation of abuse and stated "it didn't happen." MD#2 stated that MD#2 did report it to administration because they knew why they needed a sitter.

Based on document review and interview, it was determined that the hospital failed to ensure that for 1 of 3 (Pt.#21) clinical records reviewed for restraints that physical holds used to administer forced medications were considered as restraints. This has the potential to affect any patients forcibly placed in a physical hold.

Finding includes:

1. The hospital's policy titled, "Restraint Management Policy" (revised 04/2022), was reviewed and required, "...Physical Hold: 1. Considered a restraint when holding a patient in a manner that restricts the patient's movement against his or her will... Each episode of restraint or seclusion must be ordered by a physician or an authorized licensed practitioner responsible for the patient's ongoing care. The order shall include the type of restraint... In the event that the physician or authorized licensed practitioner does not place the order for restraint, he/she will be notified as soon as possible, and an ordered obtained within the appropriate timeframe... If the attending physician is not available, and emergency use of restraint and/or seclusion is required, a registered nurse may initiate its use. An order is obtained within one (1) hour of the initiation of the restraint and/or seclusion. Staff will document the rationale for the restraints and/or seclusion..."

2. The clinical record of Pt. #21 was reviewed on 02/24/2025. Pt. #21 was admitted on 02/18/2025 with a diagnosis of schizoaffective disorder (mental health condition). The record indicated that Pt. #21 received a dose of hydroxyzine (medication used to calm patient when agitated) intramuscularly on 02/23/2025 at 9:35 AM. The nurse's (E#35) note, dated 02/23/2025 at 9:43 AM included "...Pt was destructive, pulled name sign off wall... Pt refused all medications, Pt threw medications at nurse. RN [registered nurse] attempted three times. Pt got a PRN [as needed medication] 0935 AM... Pt was agitated and not re-directable..."

3. An interview was conducted with Psychiatric Unit Registered Nurse (E#35) on 02/24/2025, at approximately 3:00 PM. E#35 stated that they do not use physical (mechanical) restraints on the psychiatric unit. E#35 stated that a patient becomes combative/aggressive, they try to redirect the patient and if they can't be redirected, they will call a Code Gray (security alert) and security will come up to the unit. E#35 stated that security will come up and will hold the patient while the nurse administers as needed medications to calm the patient down. E#35 stated that they had to call security up for Pt. #21 just yesterday because Pt. #21 was becoming combative and threw the medications back at E#35. E#35 stated that security had to hold Pt. #21 for E#35 to give the medication because Pt. #35 was still being combative and refusing to take the medication. E#35 stated that they do not notify the doctor or get any order when a physical hold is used. E#35 stated that E#35 will document a shift note in the patient's record and stated that the doctor can read their nurses notes. E#35 stated that there is no way to keep track of when a physical hold is used on their patients.

4. An interview with the Manager of Behavioral Health (E#7) on 2/25/2025, at approximately 2:25 PM . E#7 stated that there is no way in the system to put an order for a physical hold. E#7 stated that besides a shift note, they do not keep track of when physical holds are used.

Based on document review, observation, and interview, it was determined that for 1 of 3 (Pt #28) clinical records reviewed for restraints, the hospital failed to ensure that restraints were applied in accordance with a physician's order.

Findings include:

1. The hospital's policy titled, "Restraint Management" (dated 12/2024), was reviewed, and required, " ...Procedure: Each episode of restraint or seclusion must be ordered by a physician or an authorized licensed practitioner responsible for the patient's ongoing care. The order shall include the type of restraint ...Non-violent, Non-Self-Destructive: For the restraint applied for non-violent or non-self-behavior. Physician's order ..."

2. The clinical record for Pt #28 reviewed on 2/25/2025. Pt #28 was admitted on 2/17/2025, with a diagnosis of sepsis (bloodstream infection). Pt #28's physician orders were reviewed. The orders included an order for non-violent restraints (soft upper limbs), dated 2/19/25 and 2/20/25, "order valid for 1 calendar day." The clinical record did not include any additional restraint orders.

3. On 2/24/2025 at 1:15 PM, an observational tour of 3 South/North Medical Surgical unit, was conducted. During the tour, observation of Pt #28, was conducted with the Registered Nurse (E #19/Pt #28's assigned nurse). Pt #28 had bilateral wrist restraints applied.

4. On 2/24/2025 at 1:25 PM, an interview was conducted with E #19. E#19 stated that E #19 received report stating that Pt #28 no longer had restraints applied. E #19 stated that E #19 was not aware that Pt #28 had restraints on. Pt #28's clinical record lacked a current restraint order.

5. On 2/24/2025 at 1:30 PM, an interview was conducted with the Medical Surgical Manager (E #22). E #22 stated that non -violent restraints should be renewed every 24 hours. E #22 acknowledged that Pt #28's clinical record lacked a current restraint order.

Based on document review and interview, it was determined that for 1 of 3 (Pt #28) clinical records reviewed for restraints, the hospital failed to ensure that patient was monitored while in restraints, was done in accordance with policy.

Findings include:

1. The hospital's policy titled, "Restraint Management" (dated 12/2024), was reviewed and required, " ...Non-violent, Non-Self-Destructive: The patient shall be monitored at regular intervals, not to exceed every 2 hours interval, to be determined consistent with physician orders and/or patient condition and will have documented assessments to assure patient is free from adverse events and to determine if restraint shall be continued ..."

2. The clinical record for Pt #28 reviewed on 2/25/2025. Pt #28 was admitted on 2/17/2025, with a diagnosis of sepsis (bloodstream infection). Pt #28's physician orders were reviewed. The orders included an order for non-violent restraints (soft upper limbs), dated 2/19/25 and 2/20/25, "Restraint Monitoring Non-Violent Behavior, every 2 hr [hours]". Pt #28's flowsheet was reviewed for restraint monitoring. The most recent restraint assessment was dated 2/19/25 at 4:00 AM (5 days prior).

3. On 2/24/2025 at 1:25 PM, an interview was conducted with the Registered Nurse (E #19/Pt #28's assigned nurse). E #19 acknowledged that there was no restraint monitoring documentation since E #19 was not aware that Pt #28 had restraints applied. E #19 was not able to verbalize the required time frame for restraint monitoring.

4. On 2/24/2025 at 1:30 PM, an interview was conducted with the Medical Surgical Manager (E #22). E #22 stated that non-violent restraints monitoring is required every 2 hours.

Based on document review and interview, it was determined that for 1 of 1 Director of Nursing (E #4/Executive Director of Nursing) the hospital failed to ensure appropriate provision of hospital-wide nursing service under the direction of one registered nurse.

Findings include:

1. On 2/25/2025, the personnel file for E #4 (Executive Director of Nursing) was reviewed. E #4's personnel file included a document, dated 9/27/2024, that indicated, "(Signed by E #4)... Functional Name: Chief Nursing Officer/Executive Director... The Chief Nursing Officer practices within the scope of the Illinois Nurse Practice Act... Provides overall leadership, administration, and coordination of patient care and nursing services... Adheres to the mission, values, and philosophy of (Name of Another Hospital)..."

2. On 2/24/2025, the hospital's meeting minutes for 2024 and 2025 discussing provision of hospital-wide nursing issues were requested. On 2/25/2025 at approximately 9:30 AM, E #4 stated that there has been no nursing minutes for 2024 and 2025.

3. On 2/25/2025, an interview was conducted with E #4. E #4 stated that E #4 was originally hired to be the Director of Nursing at (Name of Another Hospital). As of October 2024, E #4 stated that E #4 was delegated and also appointed to be the Director of Nursing at this hospital and (Name of Another Hospital). E #4 stated that it has been a challenge to lead and direct the nursing services for two hospitals. E #4 could not provide documentation regarding meetings held discussing appropriate provision of hospital-wide nursing services.

A. Based on observation, document review, and interview, it was determined that for 5 of 5 patients (Pt. #2, Pt #29, Pt. #31, Pt.#32, and Pt. #34) observed receiving intravenous (IV) fluids or medications, the hospital failed to ensure that the IV tubing was labeled, as required.

Findings include:

1. On 2/24/2025 between approximately 10:45 AM through 12:15 PM, during an observational tour of the intensive care unit (ICU), the following was observed:

- Pt. #2 was receiving supplemental nutrition via feeding tube. The feeding tube was not labeled.

2. On 2/24/2025 between approximately 10:50 AM through 11:55 AM, an observational tour of the Medical Surgical Telemetry was conducted. The following were observed:

- Pt.#29-Pt.#31, Pt.#32, Pt #34 had IV bags hanging in their rooms. The IV tubing lines lacked the date and time indicating when the bags were hung.

3. On 2/24/2025, the hospital's policy titled, "Peripheral Intravenous Catheter Placement and Management (Revision Date - 01/2025) was reviewed and required "...Intravenous tubing: Tubing is labeled with date and time..."

4. On 2/24/2025 at approximately 11:18 AM, an interview was conducted with the Clinical Coordinator (E#7). E #7 stated that feeding tube bottles and lines should be labeled and dated and lines should be changed every 24 hours.


B. Based on the observation, document review, and interview, it was determined that for 2 of 2 patients (Pt. #2 and Pt. #30), the hospital failed to label IV (intravenous) sites with insertion date and time as required.

Findings include:

1. On 2/24/2025 at between 10:45 AM to 12:15 PM, a tour of the Intensive Care Unit (ICU) was conducted. During the tour, Pt. #2's peripheral IV's dressing on the right antecubital area (front of elbow and forearm) and right hand was not labeled with insertion date, time, and initial.

2. On 2/24/2025 between approximately 10:50 AM through 11:55 AM, an observational tour of the Medical Surgical Telemetry was conducted. Pt.#30's peripheral IV site was not labeled with the insertion date and time.

3. The policy titled "Peripheral Intravenous Catheter Placement and Management (Revision Date - 1/2025) was reviewed and required "...Document date and time of insertion..."

4. On 2/24/2025 at 1:45 PM, an interview was conducted with the Medical Surgical Manager (E #22). E #22 stated that IV sites should be labeled with the date and time that it was inserted so that the nurses can know when to change them or how long they have been in.

Based on document review and interview, it was determined that the hospital failed to ensure medical records were completed within 30 days after discharge.

Findings include:

1. On 2/25/2025, the hospital's Rules & Regulations (dated 6/9/2016) was reviewed and required, "Incomplete/Delinquent Medical Records - Records will be completed within 30 days of discharge."

2. On 2/25/2025, the hospital's letter dated 2/25/2025, from the Manager of Health Information Management (E #16) noted " As of today, the total number of delinquent deficiencies for [the hospital] is 229.

3. On 2/25/2025 at approximately 11:20 AM, an interview was conducted with the E #16. E #16 stated, "Records are considered delinquent if not completed within 30 days, including history & physical and discharge summary." E#16 was unsure of the exact amount of delinquent records, however, would check for the exact number. The above letter was presented later on 2/25/2025.

A. Based on document review, observation, and interview, it was determined that for 2 of 2 staff (E#37 and E#38) observed performing food service sanitization procedures, the Director of Dietary Services failed to ensure that staff followed manufacturer's directions for testing and use of sanitizing solutions. This had the potential to affect all patients receiving dietary services at the hospital.

Findings include:

1. The hospital's policy titled, "Three Compartment Sink" (revised 09/2024), was reviewed and required, "...Make sure to test soap detergent & sanitization detergent for proper temperature degrees as well as QUAT [sanitizer concentration] reading..."

2. The testing strip manufacturer's testing procedures posted on the wall by the dishwashing sink included, "...2. Testing must be done in sanitizer solution that is clean, fresh and at room temperature 65-85 degrees Fahrenheit... 4. Tear off a 1 1/2 - 2 inch strip of test paper. 5. Hold the test strip in the solution for 10 seconds. 6. Do not move the test strip around, as this will give a false high concentration...."

3. The sanitizing solution manufacturer's label for instructions for use included, "...Allow surfaces to drain thoroughly and air dry..."

4. A tour of the kitchen was conducted on 02/24/2025 between approximately 11:00 AM and 1:00 PM. At approximately 12:03 PM, a Food Services Staff (E#37) was observed performing a demonstration of how to test the sanitizer solution. E#37 tore off a 1 centimeter (less than 1.5 inches) strip of testing paper and dipped it in the solution while counting to 10. E#37 did not use a timer or clock to accurately count 10 seconds. E#37 stated that they do not measure the temperature of the water when they test it.

5. During the tour on 02/24/2025 at approximately 12:50 PM, a Food Service Staff (E#38) was observed preparing a tub of sanitizing solution to clean the food trays. E#38 tore off a 1 centimeter piece of testing paper and swished it in the solution (not in accordance with manufacturer's guidelines). E#38 held the test strip in the solution for over a minute until it changed color. E#38 did not measure the temperature of the solution. E#38 then used the solution to sanitize used food trays. After applying the solution to all the trays, E#38 then started to wipe the trays dry with a cloth instead of allowing them to air dry per manufacturer's instructions.

6. An interview was conducted with E#38, at approximately 12:55 PM. E#38 stated that the strip is supposed to be in there for 10 seconds. E#38 stated that they don't measure the temperature of the solution.


B. Based on document review, observation, and interview, it was determined that for 2 of 2 months (January and February 2025) of food temperature logs reviewed, the Director of Dietary Services failed to ensure that times of each meal service were documented and taste/appearance/temperatures checks of each food item served were completed.

Findings include:

1. The hospital's policy titled, "Food Quality & Taste" (revised 09/2024), was reviewed and required, "To ensure that the food quality is held to the highest standards. This includes if the food looks visually appealing and that the food taste is appropriate... Procedure: Cooks are required to take temperatures & taste test before meal services is to be served."

2. The hospital's policy titled, "Food Temperatures for Trayline Service" (revised 09/2024), was reviewed and required, "...To ensure department HACCP [Hazard Analysis Critical Control Point] guidelines are followed as requested by Regulatory Agencies... Cooks are responsible for taking temperatures before Food tray line (B [breakfast], L [lunch], D [dinner] as well as after each meal period has finished. Food is to be discarded after one hour has passed since the tray line was completed for all meal services..."

3. The hospital's Standard Operating Procedures for HACCP Plans (undated), was reviewed and required, "...All potentially hazardous foods must be cooked to... proper minimum internal temperature for 15 seconds.... Review cooking temperature logs... All food items are hot held at temperature of 135 degrees Fahrenheit or above... Internal product temperatures will be checked using a calibrated stem thermometer at regular intervals as specified in HACCP or at a minimum of every two hours... Monitor temperature logs, and/or observe temperature..."

4. The hospital's policy titled, "Food Storage Temperatures" (revised 09/2024), was reviewed and required, "...Foods, which require cold storage will be held at a temperature below 41 degrees Fahrenheit..."

5. The Hospital's Food Safety Quality Reports from 01/01/2025 to 02/24/2025 were reviewed as follows:
- No food quality/temperatures logs were completed for 01/03/2025, 01/24/2025, 02/08/2025, 02/11/2025, 02/13/2025, and 02/23/2025.
- Times of meal service start were missing for lunch and/or dinner on 47 days between 01/01/2025 to 02/24/2025.
- Cook times and temperatures were not completed on 30 days between 01/01/2025 to 02/24/2025.
- Trayline Start and End Temperatures were either missing or documented out of range (i.e. at greater than 40 degrees Fahrenheit for cold food items) on 01/02/2025, 01/10/2025, 01/11/2025, 01/12/2025, 01/15/2025, 01/23/2025, 01/27/2025, 01/28/2025, 01/29/2025, 01/31/2025-02/05/2025, 02/07/2025, 02/12/2025, 02/14/2025, and 02/18/2025-02/22/2025.
- None of the logs indicated that appearance or taste quality were checked.

6. During a tour of the kitchen on 02/24/2025, the end meal (lunch) temperatures were documented on the log sheet at approximately 11:45 AM; however, the lunch trayline service had not yet been completed. The food remained in the warmers (available to serve) at least until 1:00 PM/end of tour.]

7. An interview was conducted with the Food Service Supervisor (E#27) on 02/24/2025, at approximately 11:30 AM. E#27 stated that the staff should be completing the temperature logs for each food item served and should document the times meal serve started and ended. E#27 stated that cold items should be kept at 40 degrees Fahrenheit or less. E#27 stated that the cook should be checking the taste and appearance of the food.

8. An interview was conducted with Cook (E#39) on 02/24/2025, at approximately 11:53 AM. E#39 stated that they are suppose to document the temperature of the food at the end of the trayline. E#39 stated that after the trayline is completed, they still hold the food in case of late trays. E#39 stated they can hold it for 2-3 hours. E#39 stated that E#39 takes the temperature of the food before preparing the late trays but does not document it.

9. An interview was conducted with the Director of Dietary Services (E#28) on 02/24/2025, at approximately 11:55 AM. E#28 stated that they do not keep the food more than 45 minutes to 1 hour after the trayline has ended.



51457

C. Based on document review, observation, and interview, it was determined that for dry and cold food stored in the kitchen, the Director of Dietary Services failed to ensure that expired/outdated food items were discarded and not available for use. This has the potential to affect all patients receiving oral diets.


dry and cold food items that were stored in the kitchen were readily available for patient use
Findings include:

1. The hospital's policy titled "Outdated Supplies" (revised on 9/2024) was reviewed and required "... Regular inventory audits are to be conducted to ensure that no supplies that are expired are kept in rotation. If any supplies are to be found expired is to be discarded immediately."

2. During a observational tour of the Dietary storage area, conducted 2/24/2025 at 11:57 AM, the following were observed in the coolers/refrigerators: 1 of 2 buckets of raw chicken expired on 02/16/2025, 1 small bag of tomatoes expired on 02/16/2025, 1 bag of diced potatoes expired on 02/19/2025, 11 packs of tortillas expired on 02/04/2025, 1 bag of cauflower expired on 02/19/2025, and 1 bucket of oranges expired on 02/16/2025. There was also green pepper, dated 2/24/2025 that was growing mold on it.

3. An interview was conducted with Food Store Room/Cook (E#34) on 02/24/2025 at approximately 12:05 PM. E#34 confirmed the food was expired and stated that the expired food should be discarded.


D. Based on document review, observation, and interview, it was determined 2 of 3 food items observed, the Director of Dietary Services failed to labels open food items.

Findings include:

1. The hospital's policy titled, " Shelf Life for Open and Closed Items" (revised on 09/2024) was reviewed and required, "Label and date all open items with proper opening date as well as expiration date if items require. Insure (sic. ensure) all the items are placed in proper storage area."

2. During an observational tour of Dietary Services Unit, on 2/24/2024 at approximately 11:59 AM, 9 of 30 food items observed, including cucumbers, pineapples, lettuce, zucchini, bell peppers, cantaloupe, cauliflower, potatoes, and mushrooms, were not labeled with a use by date.

3. An interview was conducted with the Dietary Services Store Room/Cook (E#34), on 02/24/2025 at approximately 12:05 PM, E#34 stated that the food items should be dated and labeled with a use by date.

Based on document review, observation, and interview, it was determined that the hospital failed to ensure that documentation regarding incident, actions taken, follow-up, and resolution regarding the physical environment were maintained, as required.

1. On 2/24/2025 at approximately 1:30 PM, E #9 (Executive Director of Operations) provided an email, dated 12/8/2024. The email indicated, "From (E #10/Engineering), Sunday, December 8, 2024, 4:48 AM ... Made (boiler) rounds. #1 and #2 (boilers) online and #3. Made (building) rounds, got reports of water coming out of the nurses locker room (in) 3 South. Busted a coil and got another call, busted another coil in the room next door. Cleaned up space and talked to EVS (Enviromental Services) about sanitizing space. Put a pump in sump pit of C bank elevator. Cleaned up as much water as I could ..."

2. On 2/25/2025, the hospital's policy titled, "Safety Management Plan" (4/2021) was reviewed and included, "Policy ... Th safety program is designed to monitor and evaluate non-clinical safety issues in order to ensure a safe environment for patients, visitors and personnel ... Procedure ... Report and investigate all incidents of property damage ... The Risk Manager reviews all incident reports and appropriate actions are taken as incidents occur. A summary of these incidents is reported at each Safety Committee meeting and reviewed for any possible patterns or trends, and actions taken as appropriate ..."

3. On 2/25/2025 between approximately 10:00 AM through 10:40 AM, an observational tour of the 3 South was conducted. During the tour, Elevators Bay A and B were observed. One of the three cars (Car 1) in Elevator Bay A, and one of the three elevators (B6) in Bay B used for patients were not working. A work order was requested from E #9, none was provided.

4. On 2/25/2025 at approximately 9:50 AM, an interview was conducted with E #9 (Executive Director of Operations). E #9 stated, "There were several issues with steam heat. The hospital is boiler heated. The problem is that everything is so old, when it gets cold, some of the pipes and coils gets so cold and freeze. For the December 2024 incident, we have heating units that need significant repair. In this incident, the coil broke (in a mechanical room adjacent) to locker room in 3 South. Since the incident, that has not happened. However, there were situations when coil in other areas of the hospital would freeze and cause flooding." Requests were made from E #9 regarding the incident, actions taken, or resolution for the December 8, 2024, including logs regarding coils that caused flooding in the hospital were requested. However, none were provided.

5. On 2/25/2025 at 12:15, an interview was conducted with E #11 (Director of Quality). E #11 stated, "Risk reports to me. If there is a flooding incident in the hospital, there should be an incident report completed so we can follow-up." Requested any incident report regarding flooding in the hospital from E #11, however, none were provided.

6. On 2/25/2025 at approximately 2:40 PM, an interview was conducted with E #10 (Engineering). E #10 stated, "There was a flooding when a coil busted on the third floor. There was no incident report. We would enter incident of leaking or flooding in the log. There was a recent occurrence last week. A coiler busted that cause flooding on the first floor between MRI and the ER. As far as I know, the issue has not been resolved.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety code portion of the Full Survey Due to a Complaint conducted on 2/25-2/26/2025, the surveyors find that the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags.

A. Based on document review, observation, and interview, it was determined that for 1 of 2 (E #17), Patient Care Technician (PCT), observed performing blood glucose monitoring and disinfecting patient equipment, the hospital failed to ensure that isolation and infection control practices were adhered to, in accordance with policy.

Findings include:

1. The hospital's policy titled, "Blood Glucose Monitoring Point of Care Testing" (dated 1/2025), was reviewed and required, " ...Blood Glucose Testing: Cleaning: Clean the exterior of the meter with a low-level disinfectant cleaning cloth ..."

2. The hospital's policy titled, "Isolation Precautions: Contact or Contact Plus" (dated 1/21/2025), was reviewed and required, " ...Contact Plus precautions is used only when the organism requires soap and water hand wash and a surface disinfection with a hospital approved bleach product ..."

3. The hospital's "Contact Plus Isolation" signage, included, " ...After leaving this room: Clean all equipment with bleach!"

4. On 2/24/2025 at 10:45 AM, an observational tour of the 3 South/North Medical Surgical unit was conducted. During the tour, the following was observed:

-The PCT (E #17), was observed performing blood glucose monitoring on 3 patients (Pt #29, Pt #31, Pt #41), (Unit Manager/E#22) was present. E #17 was observed performing the blood glucose checks and failed to disinfect the glucose machines, following the testing. E #17 proceeded to the next patient's room without cleaning the machine.

- E #17 was observed leaving Pt #28's room with vital signs monitoring equipment. E #17 wiped down the equipment with wipes from a purple container. Pt #28's signage outside the room indicated that the patient was on Contact Plus Isolation precautions. Contact Plus Isolation requires disinfecting/cleaning with wipes from the blue container (contains bleach). E #17 did not use the proper wipes for cleaning equipment from Pt #28's room.

5. On 2/24/2025 at 11:25 AM, an interview was conducted with the Medical Surgical Unit Manager (E #22). E #22 stated that the blood glucose monitors should be cleaned after testing on each patient. E #22 stated that if a patient is on Contact Plus Isolation precautions, the staff need to clean with the wipes that contain bleach.

B. Based on document review, observation, and interview, it was determined that for 2 of 2 patients (Pt #27, Pt #28) reviewed for isolation, the hospital failed to ensure that isolation orders were properly placed, in accordance with policy.

Findings include:

1. The hospital's policy titled, "Isolation Precautions: Contact or Contact Plus" (dated 1/21/2025), was reviewed and required, " ...This policy defines situations in which contact or Contact Plus isolation would be implemented ...Order Contact or Contact Plus isolation. Isolation may be initiated by physician order or nursing order ...Contact or Contact Plus precautions are used for specified patients known or suspected to be infected or colonized ...Contact Plus precautions is used only when the organism requires soap and water hand wash and a surface disinfection with a hospital approved bleach product ..."

2. On 2/24/2025 at 10:45 AM, an observational tour of 3 South/North Medical Surgical unit was conducted. During the tour, 5 patient rooms were noted with isolation signs outside their doors.

3. The clinical records for 2 of 5 (Pt #27, Pt #28) patients on isolation were reviewed.

- Pt #27's isolation sign indicated that the patient was on Contact isolation. The physician orders included a "Standard Precautions" order, dated 2/22/25 (not Contact Precautions). Pt #27's lab results indicated that Pt #27, had a positive MRSA (bacterial infection), requiring a Contact Isolation order.
- Pt #28's isolation sign indicated that the patient was on Contact Plus isolation. The physician's orders included a "Contact Precaution" order, dated 2/17/25 (not Contact Plus). Pt #28 had a lab drawn to rule out C-difficile (bacteria in the colon), which requires Contact Plus isolation. According to the Infection Preventionist (E #6), Pt #28 has a history of Candida Auris (which also requires Contact Plus isolation).

4. On 2/25/2025 at 1:30 PM, an interview was conducted with the Infection Preventionist (E #6). E #6 stated that after review of Pt #27 and Pt #28's orders, E #6 acknowledged that the isolation orders were not entered as required for those particular organisms that the patients had. E #6 stated that in particular with Pt #28, the order for Contact Plus would require that the staff take additional precautions with cleaning equipment using bleach wipes.


C. Based on document review, observation, and interview, it was determined that for 1 of 1 Medical Surgical unit observed, the hospital failed to ensure that sharps were disposed of safely and secured, as required to prevent cross contamination and potential harm from needle sticks.

Finding include:

1. The hospital's policy titled, "Sharps Securement and Disposal Procedures" (dated 1/25), was reviewed, and required, "Purpose: To outline nursing responsibilities in the safe disposal and securing of sterile and contaminated sharp instruments ...Assess sharps containers for replacement daily. Sharps containers are replaced weekly. If container becomes full sooner, call EVS [Enviromental Services] department to replace. No contaminated sharps should be extended beyond the window of the container housing ..."

2. On 2/24/2025 at 10:45 AM, an observational tour of the 3 South/North Medical Surgical unit was conducted. During the tour, 5 of 5 occupied patient rooms were observed with the Unit Manager (E #22). The rooms contained puncture resistant containers used to secure sharp items (needles, sharp instruments, scalpels, etc.). All 5 of 5 containers, were full above the "fill line" and had needled exposed that extended out of the top of the container.

3. On 2/25/2025 at 1:35 PM, an interview was conducted with the Infection Preventionist (E #6). E #6 stated that sharp containers that have sharps past the "fill Line", pose an infection control risk. E #6 stated that when the sharps container is full beyond the "fill line" and more than 3/4 full, then the environmental services department should be called to replace the containers.

Based on document review and interview, it was determined that the hospital failed to demonstrate periodic assessment of the discharge planning process, including an internal audit of closed medical records and review of patients admitted within 30 days of previous admission were conducted. This potentially affect the discharge planning needs and outcomes for any patient in the hospital.

Findings include:

1. On 2/25/2025, the hospital's policy titled, 'Case Management Discharge Planning' (revised 1/27/2025) was reviewed and included, " ...V. Procedure: ...Assessment of Discharge Planning Process: Discharge planning process will be re-evaluated, minimally annually, by internal audit of closed medical records to review effectiveness of discharge plans for responsiveness to identified discharge needs, preventable readmission and other quality indicators ...Readmissions will be reviewed on a 30 day readmission interval ...".

2. On 2/25/2025, the hospital's '2024 Case Management Dashboard' document was reviewed and indicated that readmissions measures were provided per the Quality Department which included 'Medicare Readmission Rate' and Medicare #30 day Readmissions', however, no data was presented between September - December 2024.

3. On 2/25/2025, any documentation or data collected to indicate that the hospital conducted an internal audit of closed medical records and patients admitted within 30 days of previous admission was requested. No available documentation was provided.

4. On 2/25/2025 at approximately 9:55 AM, an interview with the Director of Social Work (E #12) was conducted. E #12 stated that monthly department and utilization meetings should be conducted and include metrics including readmissions, however, with the leadership turnover in the department, the review has not been conducted as it should.

5. On 2/25/2025 at approximately 10:50 AM, an interview with the Utilization Review Registered Nurse Case Manager (E #15) was conducted. E #15 stated that utilization review meetings had not focused on readmissions.

Based on document review and interview, it was determined that for 3 of 3 patients' (Pt. #27, Pt. #39, and Pt. #40) clinical records reviewed for discharge planning, the hospital failed to ensure that the discharge planning evaluation and plan was documented and discussed with the patient and or a patient representative.

Findings include:

1. On 2/26/2025, the hospital's policy titled, "Case Management Discharge Planning" (reviewed 11/2023) was reviewed and included, " ...I. Scope: Discharge Planning ...V. Procedure: ...Patient Rights & Responsibilities in Discharge Planning Process ...patient has the right to participate in the development and implementation of his/her plan of care ...patients or their representatives are actively involved in the discharge planning process ...the patient or his/her representative will be afforded the right to make informed decisions regarding his/her care and being involved in care planning and treatment ...".

2. On 2/26/2025, the clinical record for Pt. #27 was reviewed. On 1/07/2025, Pt. #27 was admitted due to shortness of breath and altered mental status. The clinical record indicated that Pt. #27 came from home (skilled nursing facility) and on 1/12/2025, Pt. #27 was discharged back home. The clinical record did not include notification and follow-up with the patient and or patient's representative regarding the plan and results of discharge planning evaluation.

3. On 2/26/2025, the clinical record for Pt. #39 was reviewed. On 10/27/2024, Pt. #39 was admitted due to a seizure. The clinical record indicated that Pt. #39's initial discharge post facility need was a skilled nursing facility; however, on 11/01/2024, Pt. #39 was discharged home with home health. The clinical record did not include notification and follow-up with the patient and or representative regarding the plan and results of discharge planning re-evaluation.

4. On 2/26/2025, the clinical record for Pt. #40 was reviewed. On 11/03/2024, Pt. #40 was admitted due to altered mental status. The clinical record indicated that Pt. #40 came from home (skilled nursing facility) and initially would require a higher level of care facility prior to returning home. On 11/21/2024, Pt. #40 was discharged home. The clinical record did not include notification and follow-up with the patient's representative regarding the plan and results of discharge planning evaluation.

5. On 2/26/2025 at approximately 1:59 PM, an interview with the Registered Nurse Lead Case Manager (E #13) was conducted. E #13 reviewed patient's (Pt. #27, Pt. #39, and Pt. #40) clinical records and confirmed that the records did not include documentation that the patient and or representative were included throughout the discharge planning process as they should have been.

Based on document review, observation, and interview, it was determined that for 1 of 2 Registered Nurses (RN) (E #29), 1 of 1 CRNA (Certified Registered Nurse Anesthetist/E#31), and 1 of 2 Surgical Technicians (E #30) in Operating Room (OR) #5, the hospital failed to ensure adherence to the acceptable operating room attire while in the operating room, as required.

Findings include:

1. On 2/25/2025, the hospital's policy titled, "Proper Operating Room Attire" (Revised 8/2024) was reviewed and required, "...Head Covering - I.3.1 All head and facial hair should be covered within the Department of Surgery...I.6. Accessories...I.6.2. No jewelry will be worn in the OR..."

2. On 2/25/2025 between 9:10 AM and 10:40 AM, an observational tour of OR #5 was conducted. E #29, E #30, and E#31 had hair that was not confined in the surgical head covering and E#30 was observed wearing a necklace.

3. On 2/25/2025 at 1:28 PM, an interview was conducted with the Director of Surgical Services (E #5). E#5 stated that head covering should cover all head and facial hair. E#5 also stated that absolutely no jewelry of any kind is allowed to be worn within the surgery department.

Based on observation, document review, and interview, it was determined that for 1 of 1 ED (Emergency Department), the hospital failed to ensure the ED met the required registered nursing personnel.

Findings include:

1. On 2/24/2025 between 10:45 AM and 11:15 AM, an observational tour was conducted in the ED (Emergency Department). The staffing included one charge nurse, two additional nurses, one patient care technician, one unit secretary, and one ED physician. The staffing was short of one RN based on the staffing grid.

2. On 2/25/2025, the ED RN (Registered Nurse) staffing guideline (undated), provided by E #4 (Executive Director of Nursing) was reviewed. The guideline included the following staffing requirements: Day Shift (7:00 AM through 7:00 PM): Three RNs with one ED technician and one unit secretary; Mid-Day Shift (10:00 AM through 10:00 PM): Additional One RN; Night Shift (7:00 PM through 7:00 PM): Three RNs with one ED technician and one unit secretary.

3. On 2/25/2025, the ED staffing was reviewed with E #7 (ICU Manager/Clinical Coordinator). The review indicated the following:

- From 2/18/2025 through 2/24/2025: Short one RN from 7 PM through 7 AM on 2/23/2025, and one RN from 7 AM through 7 PM (2 of 21 12-hour shifts).

4. On 2/25/2025 at approximately 9:30 AM, E #4 (Executive Nursing Director) stated that appropriateness of staffing can be reviewed and validated with E #7 (Clinical Coordinator/ICU Manager). E #7 validated that the ED did not meet the staffing grid on the above dates.