HospitalInspections.org

Based on the scope and severity of the deficiency related to Governing Body, the facility failed to substantially comply with this condition.

See Tag A-0083

Based on interview and document review, it was determined the facility failed to:

1. Maintain security and congruence of medical care by allowing staff members to share employee ID badges.

2. Remove untested dialysis machines from patient use and find safe alternatives for patient dialysis treatments during one (1) month in which monthly endotoxin microbial testing was not performed.

3. Adequately train, monitor, and provide corrective oversight to the staff member noted to demonstrate non-compliance with facility policies for medication administration, controlled medication wasting, and adherence to provider orders (eleven (11) occurrences of medication errors).

Based on the scope and severity of the deficiency related to Patient Rights, the facility failed to substantially comply with this condition.

See Tag A-0144

Based on observations, interviews, and document review, it was determined the facility failed to provide patient care in a safe setting by not maintaining five (5) emergency code carts as well as not storing oxygen tanks in a safe manner.

Based on the scope and severity of the deficiencies related to Quality Assurance and Performance Improvement (QAPI), the facility failed to substantially comply with this condition.

See Tag A-0273

Based on interviews and document review, it was determined that the facility's Quality Assurance and Performance Improvement (QAPI) program failed to:

collect and report all hospital-wide data-driven metrics for four (4) months (March 2022, April, 2022, November 2021 and December 2021), and

maintain quality metrics surrounding the root cause analysis and follow-up investigations into incident reports, adverse events, complaints, and grievances.

See Tag A-286

Based on interview and document review, it was determined that the facility's Quality Assurance and Performance Improvement (QAPI) program failed to take action aimed at performance improvement to ensure that improvements were sustained. Specifically, a Staff Member conducted medication administration errors on eleven (11) occasions.

See Tag A-308

Based on interview and record review, it was determined the facility's Quality Assurance and Performance Improvement (QAPI) program failed to reflect all hospital departments and services. Specifically, the QAPI program failed to collect data for the facility's dialysis program.

Based on the scope and severity of the deficiencies related to Nursing Services, the facility failed to substantially comply with this condition.

See Tag A-0398

Based on interviews and document review, it was determined the facility's nursing staff failed to:

follow the physicians order for ten (10) minute blood pressure checks and the administration of insulin for a decompensating patient (Patient #11),

conduct wound care as ordered for five (5) days for one (1) patient (Patient #4), and

remove a Peripherally Inserted Central Line Catheter (PICC) for one (1) patient prior to discharge.

See Tag A-0405

Based on interview and document review, it was determined that the facility's nursing staff failed to:

Ensure that nursing staff were adequately trained in the prevention of adverse medication events for eleven (11) documented errors in medication administration practices.

Based on the scope and severity of deficiencies related to Infection Prevention, the facility failed to substantially comply with this condition.

See Tag A-0749

Based on interview and document review, it was determined the facility's infection prevention program (IP) failed to employ methods to prevent and control the transmission of infectious diseases within the hospital. Specifically, the IP program failed to identify systemic infection control issues that spanned multiple hospital services (Food Services, Environmental services, Lab Services, Nursing Services, and Dialysis).


See Tag A-0776

Based on observations, interviews, and document review, it was determined the facility failed to ensure hospital-wide adherence to best practice guidelines for infection prevention and control. Specifically, the facility failed to:

ensure five (5) boxes of produce were stored and refrigerated appropriately to maintain sanitary and infection prevention guidelines,

ensure food delivery at the appropriate temperature to maintain sanitary and infection prevention guidelines,

ensure that lab specimens, equipment and soiled linens were stored appropriately, and

perform monthly endotoxin microbial testing of the dialysis water distribution system and dialysis machines in the dialysis unit for one (1) month, and provide patients with infection control safeguards following the lapse in testing.

Based on interview and document review, it was determined the facility failed to:

1. Maintain security and congruence of medical care by allowing staff members to share employee ID badges.

2. Remove untested dialysis machines from patient use and find safe alternatives for patient dialysis treatments during one (1) month in which monthly endotoxin microbial testing was not performed.

3. Adequately train, monitor, and provide corrective oversight to the staff member noted to demonstrate non-compliance with facility policies for medication administration, controlled medication wasting, and adherence to provider orders (eleven (11) occurrences of medication errors).

The findings include:

1. On 06/06/22 at 2:10 pm-Interview conducted with Staff Member #9 (night shift nursing supervisor). Staff Member #9 confirmed that they allowed several nurses on unit during night shift to utilize their badge for glucometer use on numerous occasions. Staff Member #9 did not provide names of all employees who permitted access to ID badge but stated that the Registered Nurse, (Staff Member #27) was one of them. Staff Member #9 stated that they knew the act was incongruent with facility practice but that Staff Member #27 needed to use the glucometer in order to check their patient's blood sugars, and that the employee did not yet have access. Staff Member #9 stated they made the issue known to the Chief Clinical Officer (CCO) at the time who allegedly stated it was acceptable practice until all clinical staff had glucometer badge access.

On 06/06/22 at 2:28 pm -Interview conducted with Staff Member #2 (interim CCO). Staff Member #2 stated that neither Staff Member #9 nor Staff Member #27 were disciplined for sharing of ID badges since they could not disprove the notion that the previous CCO had given them permission to do so. Staff Member #2 added that they were unable to interview the previous CCO regarding the sharing of ID badges since the CCO was not employed with facility at the time of the incident follow-up. Staff Member #2 stated that both employees were reeducated regarding the glucometer use.

Staff Member #2 confirmed to surveyor that such practice of the use of other's glucometer access was against the facility's standards of care. No information regarding inaccurate medical record documentation to include improper glucometer use was included in the adverse events log provided by the facility. Both Staff Member #2 and Staff Member #9 were unable to provide additional insight.

Staff Member #2 provided the surveyor with the facility's glucometer use policy which revealed that the checking of patient's blood sugars by the use of a glucometer required the user-specific scanning of personal ID badge in order to document readings accurately. Additionally, the policy continued to say that once a blood sugar reading was obtained, it was automatically uploaded into the facility electronic medical record (EMR) under the scanned user's name.

The use of another staff member's ID badge for glucometer access would therefore create incorrect medical documentation by inaccurately reporting that the blood sugar of a patient was checked by Staff Member #9.


2. 05/05/22 at 12:28 pm- Staff Member #2 advised the surveyor during interview that the monthly endotoxin microbial testing of the dialysis water distribution system and dialysis machines was not performed for the month of December 2021. Staff Member #2 stated there was a vacancy in the dialysis manager position during this time, and that supplies for testing were unavailable until 12/31/21.

05/05/22 at 12:55 pm- Staff Member #1 (CEO) stated that Staff Member #14 (Corporate Dialysis Director) was serving as interim facility dialysis manager since November 2021 when the previous manager vacated the position. Staff Member #1 stated that Staff Member #14 had realized testing supplies were out of stock upon checking supply inventory, and had attempted to order the needed testing supplies soon after they were discovered to be out but that there "was a national shortage" of dialysis testing supplies at this time.

05/08/22 at 1:52 pm-Interview conducted with Staff Member #10 (Medical Director). Staff Member #10 informed surveyor that they were made aware that dialysis-testing supplies were not available in December 2021 due to the facility having difficulty with the supplier availability. Staff Member #10 admitted that dialysis machines were not removed from service per policy, and that ordered treatments continued to occur through 01/07/22 without testing.

05/08/22 at 2:58 pm-Interview conducted with Staff Member #11 (Dialysis Registered Nurse). Staff Member #11 confirmed that there was not a full-time designated dialysis manager since November 2021. Staff Member #11 stated they had discovered that the dialysis unit was out of testing supplies. Staff Member #11 stated they made Staff Member #14 aware by email that the facility needed to order supplies for monthly testing needs as soon as possible.

05/09/22 at 12:04 pm-Staff Member #14 stated that they became aware that they were out of supplies by notification from Staff Member #11. Staff Member #14 informed surveyor that the supplier was on backorder and out of testing supplies due to a national shortage. Staff Member #11 added that they had attempted to order the supplies from other sources causing further delay in supply acquisition. Staff Member #14 confirmed dialysis-testing supplies were not received until 12/31/22, and that dialysis endotoxin testing was not performed until 01/07/22 after scheduled patients were dialyzed.

The surveyor received the " Colony Count and Endotoxin Corrective Action Log " for 2021 from Staff Member #2 in the afternoon of 05/09/22. The log had an entry signed by Staff Member #14, which reads, " December samples were not collected. The necessary supplies needed were ordered but not delivered until 12/31/21 " .

The surveyor reviewed the dialysis-testing log for the month of January 2022, which confirmed the results of the endotoxin testing performed on 01/07/22 had colony counts within normal range.

The surveyor reviewed the facility policy titled, " Microbial Testing for Dialysis Machines " (with last review date of 12/18), which stated " all [hemo]dialysis machines in use including back up machines " require monthly testing to ensure endotoxin levels are within safe patient use. The policy continues to read that if sample cannot be obtained or are above safe use to " remove hemodialysis machine[s] from service " .

The surveyor requested all dialysis treatment information that occurred prior to the testing of dialysis equipment on 01/07/22. Staff Member #11 supplied the surveyor with the treatment flowsheet records, which occurred between 01/03/22 through 01/07/22 prior to endotoxin testing. The surveyor counted twelve (12) occasions in which dialysis treatments were performed on five (5) different patients on machines that were not tested.

05/09/22 at 1:45 pm-Interview conducted with Staff Member #18 (Nephrologist) who informed surveyor they were contracted with the facility, and was aware of lack of dialysis testing for December 2021. The surveyor informed Staff Member #18 that dialysis treatments were performed on five (5) different patients having no knowledge whether the dialysis equipment was safe for use. Staff Member #18 agreed that the event posed an unsafe situation in regards to infection control but was unsure what else could have been done. Staff Member #18 stated they were not aware whether facility procedures permitted dialysis treatments to be postponed, rescheduled or arranged for patients to be dialyzed at another facility.


3. In the afternoon of 05/05/22, the surveyor learned that (Staff Member #13) had eleven (11) documented adverse medication errors.

05/06/22 at 2:28 pm-During interview with Staff Member #2, the surveyor received confirmation that Staff Member #2 disciplined Staff Member #13 for medication administration practices inconsistent with facility policies. Staff Member #2 stated that the most recent " write-up " related to Staff Member #13 administering medications for more than one (1) patient at a time. Staff Member #2 confirmed with surveyor that all medications are required to be administered in accordance to the physician's orders, including administering, wasting (an established method to discard unused medication), and the documentation of all medications (charting - documenting in the medical record, med dispense - administering the medication).

The surveyor reviewed the personnel record of Staff Member #13 in the morning of 05/10/2022. Within the employee's file, documentation surrounding disciplinary action of the staff member was reviewed. The surveyor observed there were several entries pertaining to disciplinary actions of Staff Member #13 spanning from August 2021 through May 2022. Follow-up interventions for the staff member included providing additional education and training for safe medication practices.

05/09/22 at 11:42 am-The surveyor conducted interview with Staff Member #13 in the presence of Staff Member #2. The surveyor inquired about the documented medication errors; including the wasting of controlled medications. Staff Member #13 confirmed all listed medication events did occur, and expressed to the surveyor that they have received additional education from supervisor (Staff Member #9) as well as administration (Staff Member #2) in best medication administration practices.

05/09/22 at 12:23 pm-The surveyor interviewed Staff Member #19 (pharmacist) who confirmed with surveyor that Staff Member #13 has called them for instruction on how to waste controlled medications, including Fentanyl and Hydromorphone. Staff Member #19 added that pharmacy has documented discrepancies of Staff Member #13 inaccurately documenting medication as " given " when not administered. Staff Member #19 stated this was confirmed when instances of antibiotics were returned to pharmacy in same condition as dispensed.

The surveyor received confirmation by pharmacist that the following medication errors were made by Staff Member #13:

" [Staff Member #13] documented the waste with the nurse in Medhost but not the Pyxis." (Medhost is an electronic medical records managment system and Pyxis is an electronic managment system for medication)

On 4/3/2022, [Staff Member #13]: wasted 0.5 mg of Hydromorphone Carpuject 2mg/ml, but it was not documented as given to the patient, [Patient #3], on 4/3/2022.

On 3/3/2022, [Staff Member #13]: [Patient #9], was scheduled to receive iron sucrose 100 mg/NS 100 ml on 3/3/22 at 10:00 and documented as given at 9:48 pm on 3/3/2022. On 3/4/2022, [pharmacy tech] brought back the medication to the pharmacy; intact the same way pharmacy had sent it previously the day before.

On 2/13/2022, [Staff Member #13]: [Patient #1], Metronidazole 500 mg premix bag has been administered to the patient at 3 pm ...medication [returned to] pharmacy this morning, 3/14/2022. Checked med dispense and there was no Metronidazole IV premix bag dispersed during the time frame.

[Staff Member #13]: [Patient #10], charted zosyn 3.375 grams IV/NS 100 ml given to patient at 6:56 pm on 2/13/2022, along with Keppra 500 mg/NS 100 ml given at 10:15 on 2/13. Both these medication brought in to the pharmacy as not administered. Furthermore, these medications have not been dispensed from med dispense.

[Staff Member #13]: [Patient #12], charted zosyn 3.375 grams IV/NS 100 ml given to patient at 12:05 pm and 6 pm on 2/13/2022. Both these medication brought to the pharmacy this morning 2/14/2022. Upon further investigation medications have not been dispensed from med dispense either. "

Staff Member #19 stated during interview that the aforementioned medication events were inconsistent with the provider orders as well as facility medication policies.

Based on observations, interviews, and document review, it was determined the facility failed to provide patient care in a safe setting by not maintaining five (5) emergency code carts as well as not storing oxygen tanks in a safe manner.

The findings included:

05/04/22 at 4:12 pm-The surveyor conducted a facility-wide tour with Staff Member #1 and Staff Member #2 present.

Upon entering the third floor clean supply room, the surveyor counted sixteen (16) unemptied oxygen tanks in the front left corner of room. All sixteen (16) oxygen tanks were the smaller "E" style cylinder type tanks. The surveyor observed that greater than twelve (12) of them were stored unprotected, without the compressed air storage tank holder.

The surveyor inquired with both Staff Member #1 and Staff Member #2 regarding the facility oxygen storage procedures.

The surveyor received a copy of the "Medical Gas Storage Rooms" policy (with last review date of 01/22) in the afternoon of 05/05/22 from Staff Member #2. The surveyor confirmed with Staff Member #2 that policy addresses safe oxygen tank storage guidelines.

The policy reads, "To ensure that there is minimal risk to patients, visitors, and staff, precautions and strict procedures must be followed in the transportation and storage of compressed gas cylinders".
Under "Procedure" section of same policy reads, "An "E" cylinder contains about 25 cubic feet of oxygen and an "H" cylinder contains about 250 cubic feet. Therefore, "no more than 12 E cylinders, or one H and two E cylinders can be stored "unprotected" in a zone."

During a facility tour, the surveyor inquired with Staff Member #2 regarding the number of emergency code ("crash") carts (a cart prepositioned in the facility with life saving drugs and equipment to be used in an emergency) available throughout facility. Staff Member #2 stated there were a total of five (5) code carts available throughout the patient care areas, and were required to be "checked daily" by night shift nursing supervisors.

05/04/22 at 6:45 pm-The surveyor randomly inspected the "2 West" code cart with the assistance of Staff Member #31 (night-shift nursing supervisor). Upon inspection, the surveyor noticed there was not a pulse oximeter available on the code cart in order to assess for oxygen saturation (a pulse oximeter is a tool used to evaluate a patient's oxygen saturation, or namely, is the patient getting the proper amount of oxygen) . The surveyor received verbal confirmation from Staff Member #2 that assessing for oxygen saturation is a requirement during emergency code situations.

Staff Member #2 advised surveyor that all five (5) code carts throughout facility did not have pulse oximeters stocked on code carts. Staff Member #2 added, however, that pulse oximeters could be found throughout hospital but admitted that they were not readily available in code cart.

The surveyor requested the "Crash Cart Checklist" verification forms for all five (5) code carts for the past two (2) months, as well as the policy for the maintenance and checking of emergency code carts.

Staff Member #2 provided the surveyor with both aforementioned document types during the afternoon of 05/05/22.
A review of the "Crash Cart Checklist" reveals a required criterion for code cart checking is the presence of a pulse oximeter (SPO2), "SPO2 sensor-present and inspected". Review of the checklist showed the staff performing the checklists were writing, "N/A [not applicable]".

The surveyor also found that five (5) code checklists performed for the months of March and April 2022 were largely incomplete. The surveyor counted greater than thirty (30) occasions over the past two (2) months in which the code carts were not checked".

The surveyor addressed both code cart concerns with Staff Member #2 in the afternoon of 05/05/22. Staff Member #2 agreed that pulse oximeters should be present and readily available on all five code carts, and that the checklist verifications should be performed every day.

The surveyor reviewed the policy titled, "Emergency Medications and Code Cart" (with last review date of 01/22) in the evening of 05/05/22. The policy reads, "The code cart and/or emergency supply will be checked by nursing staff daily to insure the integrity of the cart, presence of all required equipment and supplies, and the proper functioning of all equipment. The inspection record ["Crash Cart Checklist"] will be completed by providing all required information".

Based on interviews and document review, it was determined that the facility's Quality Assurance and Performance Improvement (QAPI) program failed to:

collect and report all hospital-wide data-driven metrics for four (4) months (March 2022, April, 2022, November 2021 and December 2021), and

maintain quality metrics surrounding the root cause analysis and follow-up investigations into incident reports, adverse events, complaints, and grievances.

The findings include:

At the time of entrance conference conducted on 05/04/22 at 4:12 pm, the surveyor requested from Staff Member #1 (CEO) and Staff Member #2 (interim CCO) all Quality Analysis and Performance Improvement (QAPI) Meeting Minutes for the past 12 months.

The surveyor received all QAPI meeting minutes requested except for the months of March and April 2022. The surveyor informed Staff Member #1 regarding the need for both months QAPI minutes in the morning of 05/05/22.
The surveyor requested the information pertaining to the contribution of incident reports to QAPI by quality since March 2022.


The surveyor reviewed the facility organizational chart, and confirmed there was not a full-time designated dialysis manager responsible in contributing dialysis data to QAPI. Staff Member #2 stated that Staff Member #14 serves as the temporary dialysis manager from corporate.

05/09/22 at 12:04 pm-Interview conducted with Staff Member #14, who informed surveyor that, "We did not have QAPI for November 2021 nor December, 2021 due to not having a [dialysis manager]".

Staff Member #2 informed surveyor on 04/09/22 at 2:52 pm that certain quality metrics surrounding the root cause analysis and follow-up investigations into incident reports, adverse events, complaints, and grievances were never reported to QAPI. Staff Member #2 added this was because the whereabouts surrounding certain facility quality data have been "unknown" around the time of Staff Member #28's departure.

Staff Member #2 stated that it is unclear what happened with the facility-sensitive quality data metrics but stated that Staff Member #28 was ultimately responsible in contributing all quality data surrounding incident reports, adverse events, complaints, and grievances to QAPI.

Staff Member #2 also admitted to surveyor that dialysis data was not contributed to QAPI for the months of November 2021 and December 2021.

The surveyor confirmed with Staff Member #1 the information provided above to be true and accurate in the evening of 05/10/22.

Based on interview and document review, it was determined that the facility's Quality Assurance and Performance Improvement (QAPI) program failed to take action aimed at performance improvement to ensure that improvements were sustained. Specifically, a Staff Member conducted medication administration errors on eleven (11) occasions.

The findings include:

In the afternoon of 05/05/22, the surveyor learned that (Staff Member #13) had eleven (11) documented adverse medication errors.

05/06/22 at 2:28 pm-During interview with Staff Member #2, the surveyor received confirmation that Staff Member #2 disciplined Staff Member #13 for medication administration practices inconsistent with facility policies. Interview with Staff Member #2 along with personnel record review of Staff Member #13 revealed the "write-up" included the staff member administering medications for more than one (1) patient at a time, improper medication wasting practices, and the improper labeling of a blood culture sample. Staff Member #2 informed surveyor that facility policy and procedures dictate that all medications are required to be administered in accordance to the physician's orders (i.e. administration and wasting) as well as the acquisition and labeling of lab specimens.

05/09/22 at 11:42 am-The surveyor conducted interview with Staff Member #13 in the presence of Staff Member #2. The surveyor inquired about the documented medication errors; including the wasting of controlled medications mentioned in the complaint allegation. Staff Member #13 confirmed all listed medication events did occur, and expressed to the surveyor that they have received additional education from supervisor (Staff Member #9) as well as administration (Staff Member #2) in best medication administration practices.

The facility failed to provide sufficient Quality Assurance and Performance Improvement related documentation to demonstrate that identified issues were addressed. Staff Member #2 stated to surveyor that the whereabouts of documentation surrounding performance improvement, corrective actions, quality assurance since approximately August 2021 has been unknown following the previous Quality Director's departure.

Based on interview and record review, it was determined the facility's Quality Assurance and Performance Improvement (QAPI) program failed to reflect all hospital departments and services. Specifically, the QAPI program failed to collect data for the facility's dialysis program.

The findings include:

At the time of entrance conference conducted on 05/04/22 at 4:12 pm, the surveyor requested from Staff Member #1 (CEO) and Staff Member #2 (interim CCO) all Quality Assurance and Performance Improvement (QAPI) Meeting Minutes for the past 12 months.

The surveyor received all QAPI meeting minutes requested except for the months of March and April 2022. The surveyor informed Staff Member #1 regarding the need for both months QAPI minutes in the morning of 05/05/22.
The surveyor requested the information pertaining to the contribution of incident reports to QAPI by quality since March 2022.

The surveyor reviewed the facility organizational chart, and confirmed there was not a full-time designated dialysis manager responsible in contributing dialysis data to QAPI. Staff Member #2 stated that Staff Member #14 serves as the temporary dialysis manager from corporate.

05/09/22 at 12:04 pm-Interview conducted with Staff Member #14, who informed surveyor that, "We did not have QAPI for November 2021 nor December, 2021 due to not having a [dialysis manager]".

Staff Member #2 informed surveyor on 04/09/22 at 2:52 pm that certain quality metrics surrounding the root cause analysis and follow-up investigations into incident reports, adverse events, complaints, and grievances were never reported to QAPI. Staff Member #2 added this was because the whereabouts surrounding certain facility quality data have been "unknown" around the time of Staff Member #28's departure.

Staff Member #2 stated that it is unclear what happened with the facility-sensitive quality data metrics but stated that Staff Member #28 was ultimately responsible in contributing all quality data surrounding incident reports, adverse events, complaints, and grievances to QAPI.

Staff Member #2 also admitted to surveyor that dialysis data was not contributed to QAPI for the months of November 2021 and December 2021.

The surveyor confirmed with Staff Member #1 the information provided above to be true and accurate in the evening of 05/10/22.

Based on interviews and document review, it was determined the facility's nursing staff failed to:

follow the physicians order for ten (10) minute blood pressure checks and the administration of insulin for a decompensating patient (Patient #11),

conduct wound care as ordered for five (5) days for one (1) patient (Patient #4), and

remove a Peripherally Inserted Central Line Catheter (PICC) for one (1) patient prior to discharge.

The findings include:

05/10/22 at 12:10 pm-The surveyor reviewed the medical record of Patient #11. Patient #11 had documentation of a rapid response call due to the patient declining. Review of the progress notes written by Staff Member #22 (bedside nurse) revealed that Patient #11 began declining in oxygen saturation with increased heart rate, and labored breathing at approximately 1:00 am on 01/13/22.

Physician progress note authored by Staff Member #21 (physician) on 01/13/22 at 5:44 am reads, " I was called around 1:12 am that patient HR [heart rate] is increased went to evaluate the patient but HR had resolved. Had another call in few hours that patient looks pale and her Hgb [Hemoglobin] was low...and has not been checked".

Same provider note continues to read," Nursing supervisor was not comfortable and continued to panic and disrupt patient care by calling "her nursing team ". MD ordered repeat set of vitals and BP [blood pressure] to be recycled every 10 minutes which was not done as bedside RN was pulled aside to print paperwork for possible transfer out ...500 cc bolus was given and BG [blood glucose] was checked showed 372 and insulin was ordered which again was not provided. "

The provider note continues to say that ten (10) minute vital signs and insulin were ordered but not administered per provider orders due to nursing supervisor (Staff Member #9) pulling nurse (Staff Member #22) out of room.

The surveyor confirmed with review of order set information that Staff Member #21 had ordered vital signs to be taken every 10 (ten) minutes and the administration of 5 (five) units of Regular Insulin on 01/13/22 at 4:18 am following rapid response event.

Staff Member #2 confirmed during medical record review that there was no documentation of vital signs occurring every ten minutes or insulin being administered as ordered by the physician.

05/06/22 at 2:10 pm-Interview with Staff Member #9 revealed rapid response event of Patient #11 had occurred and that vital signs and insulin were not followed as ordered by the physician. Staff Member #9 provided the surveyor with a written statement originally provided to the former CCO (Staff Member #29) on 01/15/22 at 12:24 pm. The documentation revealed that Staff Member #9 admitted to having a confrontation with the provider at the time of the rapid response call, and preventing the bedside nurse in abiding to the physician vital sign and insulin orders.


05/10/22 at 12:10 pm-The surveyor reviewed the medical record of Patient #4. The medical record reveals Patient #4 was admitted on 04/07/22 and was still an inpatient at the time of survey.

The wound care order placed by Staff Member #20 on 04/07/22 at 5:16 pm, reads, " L BKA [left below-the-knee amputation] - Cleanse with Dakin ' s [solution] and apply Dakin ' s moistened gauze secured with kerlix daily " .
The wound care nurse note of Staff Member #20 reveals that wound care came to assess and evaluate Patient #4 throughout inpatient stay, including on 04/07/22, 04/14/22, 04 /21/22, 04/28/22, and 05/02/22.

A review of the wound care interventions discovered the wound care for Patient #4's Left BKA was not being performed as ordered.. The surveyor confirmed during medical record review and interview with Staff Member #20 that the dressing was not changed on the BKA wound on 04/08/22, 04/09/22, 04/10/22, 04/12/22, and 04/13/22.

Staff Member #20 informed surveyor the responsibility of routine wound care falls within the primary bedside nurse as the wound care nurse provides a consulted specialty service for new or worsening wounds only.


05/10/22 at 12:10 pm-The surveyor reviewed the medical records of Patient #7.

The progress notes with the medial record of Patient #7 s revealed that Patient #7 had a Peripherally Inserted Central Line Catheter (PICC) line in place, and had requested discharge from facility on 04/20/22. The bedside nurse documented a call to the following provider, Staff Member #36 shortly after receiving patient ' s request. The medical record revealed Patient #7, bedside nurse, and provider all signed an " Against Medical Advice " discharge on 04/20/22 at 5:23 pm.

The surveyor conducted an interview with Staff Member #2 on 05/09/22 at 3:03 pm. Staff Member #2 stated that an " Against Medical Advice " (AMA) forms are used when a patient is requesting to leave facility prior to safe discharge. Staff Member #2 informed surveyor that all venous catheter lines should be removed whenever a patient leaves the hospital, including during an AMA event or standard discharge unless there is a provider order stating otherwise.

The surveyor confirmed with Staff Member #2 that there were no orders in the order set documentation within the medical records of Patient #7 indicating that the central line catheters had to stay in place.

Staff Member #2 provided the surveyor with facility policy titled, " Central Venous Access Device (CVAD), Peripherally Inserted Central Catheter (PICC), and Midline Selection, Insertion, Maintenance, Removal, and Documentation " (with last revision date of 01/22). The policy confirmed that unless otherwise stated, both Midline Central Lines and PICC Lines should be removed upon discharge " when deemed no longer necessary for the plan of care " . The same policy continues to read, " The clinical need for each midline, PICC, And CVAD is assessed on a daily basis " .

Staff Member #2 confirmed with surveyor that the intravenous central lines should have been removed by nursing staff prior at the time of discharge. Staff Member #2 informed surveyor that Patient #7 was required to return to the hospital for the removal of central lines.

Based on interview and document review, it was determined that the facility's nursing staff failed to:

Ensure that nursing staff were adequately trained in the prevention of adverse medication events for eleven (11) documented errors in medication administration practices.

The findings include:

In the afternoon of 05/05/22, the surveyor learned that (Staff Member #13) had eleven (11) documented adverse medication errors.

05/06/22 at 2:28 pm-During interview with Staff Member #2, the surveyor received confirmation that Staff Member #2 disciplined Staff Member #13 for medication administration practices inconsistent with facility policies. Staff Member #2 stated that the most recent " write-up " related to Staff Member #13 administering medications for more than one (1) patient at a time. Staff Member #2 confirmed with surveyor that all medications are required to be administered in accordance to the physician's orders, including administering, wasting, and the documentation of all medications.

Documentation surrounding disciplinary action of the staff member revealed there were entries spanning from August 2021 through May 2022. Disciplinary interventions of the staff member included additional education and mandatory medication training. The surveyor was unable to find any evidence indicating that the staff member was receiving ongoing evaluation following the documented education and training.

05/09/22 at 11:42 am-The surveyor conducted interview with Staff Member #13 in the presence of Staff Member #2. The surveyor inquired about the documented medication errors; including the wasting of controlled medications mentioned in the complaint allegation. Staff Member #13 confirmed all listed medication events did occur, and expressed to the surveyor that they have received additional education from supervisor (Staff Member #9) as well as administration (Staff Member #2) in best medication administration practices.

05/09/22 at 12:23 pm-The surveyor interviewed Staff Member #19 (pharmacist) who confirmed with surveyor that Staff Member #13 has called them for instruction on how to waste controlled medications, including Fentanyl and Hydromorphone. Staff Member #19 added that pharmacy has documented discrepancies of Staff Member #13 inaccurately documenting medication as " given " when not administered. Staff Member #19 stated this was confirmed when instances of antibiotics were returned to pharmacy in same condition as dispensed.

The surveyor received confirmation by pharmacist that the following medication errors were made by Staff Member #13:

" [Staff Member #13] documented the waste with the nurse in Med. Host but not the Pyxis.

On 4/3/2022, [Staff Member #13]: wasted 0.5 mg of Hydromorphone Carpuject 2mg/ml, but it was not documented as given to the patient, [Patient #3], on 4/3/2022.

On 3/3/2022, [Staff Member #13]: [Patient #9], was scheduled to receive iron sucrose 100 mg/NS 100 ml on 3/3/22 at 10:00 and documented as given at 9:48 pm on 3/3/2022. On 3/4/2022, [pharmacy tech] brought back the medication to the pharmacy; intact the same way pharmacy had sent it previously the day before.

On 2/13/2022, [Staff Member #13]: [Patient #1], Metronidazole 500 mg premix bag has been administered to the patient at 3 pm ...medication [returned to] pharmacy this morning, 3/14/2022. Checked med dispense and there was no Metronidazole IV premix bag dispersed during the time frame.

[Staff Member #13]: [Patient #10], charted zosyn 3.375 grams IV/NS 100 ml given to patient at 6:56 pm on 2/13/2022, along with Keppra 500 mg/NS 100 ml given at 10:15 on 2/13. Both these medication brought in to the pharmacy as not administered. Furthermore, these medications have not been dispensed from med dispense.

[Staff Member #13]: [Patient #12], charted zosyn 3.375 grams IV/NS 100 ml given to patient at 12:05 pm and 6 pm on 2/13/2022. Both these medication brought to the pharmacy this morning 2/14/2022. Upon further investigation medications have not been dispensed from med dispense either. "

Staff Member #19 stated during interview that the aforementioned medication events were inconsistent with the provider orders as well as facility medication policies.


05/10/22 at 12:10 pm-The surveyor reviewed the medical record of Patient #11. Patient #11 had documentation of a rapid response call due to the patient declining. Review of the progress notes written by Staff Member #22 (bedside nurse) reveal that Patient #11 began declining in oxygen saturation with increased heart rate, and labored breathing at approximately 1:00 am on 01/13/22.

Physician progress note authored by Staff Member #21 (physician) on 01/13/22 at 5:44 am reads, " I was called around 1:12 am that patient HR [heart rate] is increased went to evaluate the patient but HR had resolved. Had another call in few hours that patient looks pale and her Hgb [Hemoglobin] was low...and has not been checked".

Same provider note continues to read," Nursing supervisor was not comfortable and continued to panic and disrupt patient care by calling "her nursing team ". MD ordered repeat set of vitals and BP [blood pressure] to be recycled every 10 minutes which was not done as bedside RN was pulled aside to print paperwork for possible transfer out ...500 cc bolus was given and BG [blood glucose] was checked showed 372 and insulin was ordered which again was not provided. "

The provider note continues to say that ten (10) minute vital signs and insulin were ordered but not administered per provider orders due to nursing supervisor (Staff Member #9) pulling nurse (Staff Member #22) out of room.

The surveyor confirmed with review of order set information that Staff Member #21 had ordered vital signs to be taken every 10 (ten) minutes and the administration of 5 (five) units of Regular Insulin on 01/13/22 at 4:18 am following rapid response event.

Staff Member #2 confirmed during medical record review that there was no documentation of vital signs occurring every ten minutes or insulin being administered as ordered by the physician.

05/06/22 at 2:10 pm-Interview with Staff Member #9 revealed rapid response event of Patient #11 had occurred and that vital signs and insulin were not followed as ordered by the physician. Staff Member #9 provided the surveyor with a written statement originally provided to the former CCO (Staff Member #29) on 01/15/22 at 12:24 pm. The documentation revealed that Staff Member #9 admitted to having a confrontation with the provider at the time of the rapid response call, and preventing the bedside nurse in abiding to the physician vital sign and insulin orders.

Based on interview and document review, it was determined the facility's infection prevention program (IP) failed to employ methods to prevent and control the transmission of infectious diseases within the hospital. Specifically, the IP program failed to identify systemic infection control issues that spanned multiple hospital services (Food Services, Environmental services, Lab Services, Nursing Services, and Dialysis).

The finding include:

See Tag A-0776

Based on observations, interviews, and document review, it was determined the facility failed to ensure hospital-wide adherence to best practice guidelines for infection prevention and control. Specifically, the facility failed to:

1. Ensure five (5) boxes of produce were stored and refrigerated appropriate.

2. Ensure food delivery at the appropriate temperature.

3. Ensure that labs, equipment, and soiled linens were stored appropriately.

4. Perform monthly endotoxin microbial testing of the dialysis water distribution system and dialysis machines in the dialysis unit for one (1) month, and provide patients with infection control safeguards following the lapse in testing.

Based on observations, interviews, and document review, it was determined the facility failed to ensure hospital-wide adherence to best practice guidelines for infection prevention and control. Specifically, the facility failed to:

1. Ensure five (5) boxes of produce were stored and refrigerated appropriately.

2. Ensure food delivery at the appropriate temperature.

3. Ensure that labs, equipment, and soiled linens were stored appropriately.

4. Perform monthly endotoxin microbial testing of the dialysis water distribution system and dialysis machines in the dialysis unit for one (1) month, and provide patients with infection control safeguards following the lapse in testing.

The findings included:

1. 05/04/22 at 4:12 pm-The surveyor conducted a facility-wide tour with Staff Member #1 and Staff Member #2 present.

During tour of cafeteria, the surveyor observed a large uncovered box of potatoes on the floor propping open the door to the dry storage closet. The surveyor confirmed with Staff Member #1 that food containers could not be placed on floor.

Within the walk-in refrigerator, the surveyor observed several boxes of uncovered bins containing produce that were unwrapped and not labeled. More specifically, the surveyor counted four (4) boxes in total with the following details: box #1 contained celery and carrots, box #2 contained peppers, box #3 contained squash, and box #4 contained grapes. As mentioned, all four boxes were uncovered and unlabeled with no indication of expiration date.

05/05/22 at 2:56 pm-The surveyor conducted an interview with Staff Member #6 (Dietary Manager). The surveyor informed Staff Member #6 of the above concerns; Staff Member #6 confirmed that dietary policy does not permit for food to be placed on floor, nor for refrigerated food items such as produce to remain uncovered.

Staff Member #6 supplied the surveyor with facility policy titled, "Food Storage-Dry Goods" (with last revision date of 05/14), which read that all food must be stored "6 [six] inches above the floor on shelves, racks, dollies or other surfaces which facilitate thorough cleaning".

Staff Member #6 also provided facility policy titled, "Food Storage: Cold" (with last revision date of 05/14), which read, "that all food items are stored properly in covered containers, labeled and dated ...to prevent cross contamination".

2. 05/06/22 at 12:11 pm-The surveyor conducted an interview with Staff Member #7 (Dietician). Staff Member #7 stated that all prepared food items served by cafeteria require monthly " diet audit " . Staff Member #7 added that one criteria of the monthly audits require testing the temperature of various food items. Staff Member #7 stated to surveyor that all foods served " hot " must maintain temperature of at least 130 degrees Fahrenheit to maintain sanitary and infection prevention guidelines.

Staff Member #7 added that the audits performed in January and February of 2022 had failed in meeting that temperature criterion when patient food items contained within Styrofoam and plastic containers were randomly checked. Staff Member #7 provided the surveyor with the audits from January through March 2022, which corroborated the information provided by the dietician.


3. 05/04/22 at 7:05 pm-The surveyor entered the "2 East Soiled Utility Room" located on the second floor. The surveyor observed lab samples being stored within the soiled utility room. The surveyor observed the following laboratory equipment located within the soiled utility room: centrifuge, refrigerator, and open collection bag for storage of all non-refrigerated lab samples.

05/04/22 at 7:11 pm-The surveyor inspected the lab collection bag mounted on wall, which could not be covered, and observed that there was a blood laboratory sample on Patient #19.

The surveyor voiced concerns to both Staff Member #1 and Staff Member #2 regarding how facility could prevent the contamination and infection of collected lab specimens when the samples are uncovered, and reside within the soiled utility room.

The surveyor observed signage posted throughout second and third floor inpatient units, which read, "All collected labs go in 2 East Dirty Utility" room. The surveyor received confirmation by both Staff Member #1 and Staff Member #2 that all staff are advised to place all lab samples within the soiled utility room on "2 East".

In the morning of 05/05/22, the surveyor received the facility policy titled, "Soiled Linen" (with last review date of 03/22) from Staff Member #2. The policy confirmed that blue bags are to store only soiled linen, and in "always keeping soiled linen separate" from clean areas.

The facility policy titled, "Cleaning and Disinfection" (with last review date of 07/21) was received from Staff Member #2 by same time on 05/05/22. The policy reads, "Store all clean equipment/supplies off of the floor". The policy continues to state that all disinfected will be completely covered with a bag for "identifying" of clean equipment.

At approximately 6:00 pm, the surveyor observed two (2) enteral feeding pumps uncovered within the "2 West" clean supply room.

The surveyor confirmed with Staff Member #1 that all equipment within the clean supply rooms should be disinfected and stored appropriately in "clean" condition. Staff Member #1 confirmed with surveyor that all components of stored machines should be covered/bagged without contact to the floor.

6:12 pm- The surveyor observed a pile of seemingly used linen is a blue dirty linen bag located within the second floor clean linen closet.

6:15 pm- The surveyor inquired with both Staff Member #1and Staff Member #2 as to whether the linen found within the blue linen bag was dirty. Staff Member #2 requested the unit PCT, Staff Member #30 (Certified Nursing Assistant), for surveyor interview.

Staff Member #30 was able to speak to the linen as they were actively working on unit, per Staff Member #2. Staff Member #30 confirmed during interview that the blue bag contained soiled/dirty linen, and not "reject linen" as initially speculated by Staff Member #1 and Staff Member #2.

05/05/22 at 2:11 pm-The surveyor conducted a telephone interview with Staff Member #4 (Vice President of Infection Prevention). The surveyor informed Staff Member #4 regarding the aforementioned infection control concerns. Staff Member #4 voiced understanding of concerns, and agreed that lab specimens may be more safely stored in an area other than the soiled utility room, such as a designated lab holding area.


4. 05/05/22 at 12:28 pm- Staff Member #2 advised the surveyor during the interview that the monthly endotoxin microbial testing of the dialysis water distribution system and dialysis machines was not performed for the month of December 2021. Staff Member #2 stated there was a vacancy in the dialysis manager position during this time, and that supplies for testing were unavailable until 12/31/21.

05/05/22 at 12:55 pm- Staff Member #1 (CEO) stated that Staff Member #14 (Corporate Dialysis Director) was serving as interim facility dialysis manager since November 2021 when the previous manager vacated the position. Staff Member #1 stated that Staff Member #14 had attempted to order the needed testing supplies soon after they were discovered to be out but that there " was a national shortage " of dialysis testing supplies at this time.

The surveyor requested interviews with Staff Member #14 (Corporate Dialysis Director), Medical Director (Staff Member #10), and the dialysis staff member who discovered that the supplies were out of stock (Staff Member #11).

05/08/22 at 1:52 pm-Interview conducted with Staff Member #10 (Medical Director). Staff Member #10 informed surveyor that they were made aware that dialysis-testing supplies were not done December 2021 due to the facility having difficulty with the supplier availability. Staff Member #10 admitted that dialysis machines were not removed from service per policy, and that ordered treatments continued to occur through 01/07/22 without testing.

Staff Member #10 added they also served as an Epidemiologist, and confirmed that such practice posed an infection control concern. Staff Member #10 added, however, that they were not aware of any adverse patient events having resulted from the lack of testing. Staff Member #10 stated that Staff Member #14 had completed a corrective action log in response to the December event.

05/08/22 at 2:58 pm-Interview conducted with Staff Member #11 (Dialysis Registered Nurse). Staff Member #11 confirmed that there was not a full-time designated dialysis manager since November 2021. Staff Member #11 stated they had discovered that the dialysis unit was out of testing supplies. Staff Member #11 stated they made Staff Member #14 aware by email that the facility needed to order supplies for monthly testing needs as soon as possible. Staff Member #11 was unable to provide the surveyor with the email sent to Staff Member #14. The date in which management was notified regarding the lack of supplies was therefore unable to be determined.

05/09/22 at 12:04 pm-Staff Member #14 stated that they became aware that they were out of supplies by notification from Staff Member #11.

Staff Member #14 informed surveyor that the supplier was on backorder and out of testing supplies due to a national shortage. Staff Member #11 added that they had attempted to order the supplies from other sources causing further delay in supply acquisition. Staff Member #14 confirmed dialysis-testing supplies were not received until 12/31/22, and that dialysis endotoxin testing was not performed until 01/07/22 after scheduled patients were dialyzed. The third party supplier shortage could not be authenticated by the surveyor outside of the facility materials manager reiterating the supplier shortage assertion provided by Staff Member #14. The surveyor was therefore unable to acquire evidence to validate the supplier "backorder" claim.

The surveyor received the " Colony Count and Endotoxin Corrective Action Log " for 2021 from Staff Member #2 in the afternoon of 05/09/22. The log has an entry signed by Staff Member #14, which reads, " December samples were not collected. The necessary supplies needed were ordered but not delivered until 12/31/21 " .

The surveyor reviewed the facility policy titled, " Microbial Testing for Dialysis Machines " (with last review date of 12/18), which state that " all [hemo]dialysis machines in use including back up machines " require monthly testing to ensure endotoxin levels are within safe patient use. The policy continues to read that if sample cannot be obtained or are above safe use to " remove hemodialysis machine[s] from service " .

The surveyor requested all dialysis treatment information that occurred prior to the testing of dialysis equipment on 01/07/22. Staff Member #11 supplied the surveyor with the treatment flowsheet records, which occurred between 01/03/22 through 01/07/22 prior to endotoxin testing. The surveyor counted twelve (12) occasions in which dialysis treatments were performed on five (5) different patients on machines that were not tested.

05/09/22 at 1:45 pm-Interview conducted with Staff Member #18 (Nephrologist) who informed surveyor they were contracted with the facility, and was aware of lack of dialysis testing for December 2021. The surveyor informed Staff Member #18 that dialysis treatments were performed on five (5) different patients having no knowledge whether the dialysis equipment was safe for use.

Staff Member #18 agreed that the event posed an unsafe situation in regards to infection control but was unsure what else could have been done. Staff Member #18 stated they were not aware whether facility procedures permitted dialysis treatments to be postponed, rescheduled or arranged for patients to be dialyzed at another facility.