HospitalInspections.org

The Condition of Participation is NOT met as evidenced by:


Based on observation, interview, and record review, the hospital's Governing Body (GB) failed to assume full legal responsibility for implementing, and monitoring policies governing the hospital's total operation, and provide oversight for quality health care in a safe environment as the following:


1. The hospital's GB failed to ensure the 2024 Infection Surveillance and Prevention plan was fully implemented including elements of the Antibiotic Stewardship Program, infection prevention practices were performed by staff including medical staff, instruments were sterilized correctly, there was hand hygiene surveillance and monitoring in the surgery department, negative pressure isolation rooms alarms were functioning and plant operations staff were able to demonstrate trouble shooting, and equipment was cleaned and stored to prevent cross-contamination. These failures resulted in the hospital not meeting the Condition of Participation (COP) for Infection Prevention Control and Antibiotic Stewardship. (Cross Reference A-0747)


2. The hospital's GB failed to ensure contaminated instrument were not use on patient's surgical procedure, autoclaves had routine maintenance, surgical instrument trays did not weight over 25 lbs, environmental services were provided appropriately, and surgical services were well organized and provided in accordance with acceptable standards of practice, policies, and procedures. These failures resulted in the hospital not meeting the Condition of Participation (COP) for Surgical Services. (Cross Reference A-0940)


The cumulative effects of these systemic problems resulted in the hospital's inability to ensure effective surgical services and infection prevention control and antibiotic stewardship system-wide programs in the provision of quality patient care in a safe environment.

The CONDITION OF PARTICIPATION is not met as evidenced by:


Based on observation, interview, and record review, the hospital failed to ensure Infection Control policies and procedures/ practices were followed for quality care when :


1. RN failed to perform hand hygiene (a term used for both hand washing using soap and water, and waterless or alcohol-based hand sanitizer) after direct patient in the Emergency Department (ED). [Cross-Reference A-0750]



2. RN provided direct patient care with artificial nails in the ED. [Cross-Reference A-0750]



3. An expired bottle of Enfamil (baby formula) was found available for patient use in the ED storage room. [Cross-Reference A-0750]


4. Hospital equipment was not stored according to policy and procedure (P&P) in the ED. [Cross-Reference A-0750]


5. Staff cleaned and disinfected the glucometer (device used to check blood sugar levels) as per P&P in ED. [Cross-Reference A-0750]


6. Alarms to the negative flow (a single-occupancy room that isolates patients with airborne infections) isolation rooms were not working in the ICU (Intensive Care Unit - provides specialized care for critical patients), ED, Telemetry (are of hospital where patients are continuously monitored) units. [Cross-Reference A-0750]


7. Plant operations staff were unable demonstrate how to turn on alarms when requested by RN in ICU, ED, and Telemetry units. [Cross-Reference A-0750]


8. General maintenance staff demonstrated vinometer use per guidelines. [Cross-Reference A-0750]


9. Patient 202 did not have a care plan for Infection Risk of Ventilator per P&P. [Cross-Reference A-0750]


10. Medical staff did not clean the Intravenous (IV) tubing hub (connection point on the end of a tubing where a syringe or another medical device can be attached to deliver medication directly into the patient's vein) prior to administering medication. [Cross-Reference A-0750]


11(a). RN did not perform hand hygiene after removal of gloves in the operating room (OR). [Cross-Reference A-0750]


11(b). Medical Staff did not perform hand hygiene after removal of gloves in OR. [Cross-Reference A-0750]


12. RN used a dirty gauze to open medication vial in the OR. [Cross-Reference A-0750]


13. Medical staff did not perform hand hygiene prior to medication administration after picking up trash off floor in OR. [Cross-Reference A-0750]


14. Staff cleaned and disinfected the glucometer as per P&P in pre-op (area prior to surgical procedure) for gastrointestinal (relating to stomach or intestines) procedures. [Cross-Reference A-0750]


15. Two contaminated instruments were found, with white substances on them, one found during a surgical procedure and the second found prior to a surgical procedure. [Cross-Reference A-0750]


16. The infection preventionist (IP) develop and implement hand hygiene surveillance and monitoring in the surgery department including the operating rooms (ORs) to adhere to nationally recognized guidelines. [Cross-Reference A-0772]


17. Ensure the infection preventionists (IP) had oversight of the Infection Prevention program priorities to developed and document written priorities correctly, according to the risk assessment grid tool and based on risk scores. [Cross-Reference A-0773]


18. Ensure the IP created action plans for hand hygiene non-compliance per the infection control plan. [Cross-Reference A-0773]


19. Ensure issues discover by the infection preventionist (IP) in the sterile processing department (SPD) during an audit conducted on 10/24/23 and 5/31/24 were followed up to ensure issues were resolved. [Cross-Reference A-0776]


20. Ensure the IP audit for hand hygiene visual reminders in the emergency department (ED) as indicated by the 2024 Infection Surveillance and Prevention plan, Priority #1- Hand hygiene. [Cross-Reference A-0776]


21. Ensure the IP monitor the hand sanitizer dispensers auditing, performed by the EVS director, was effective to prevent healthcare associated infections (HAIs) and avoid cross-contamination. [Cross-Reference A-0776]


22. The infection preventionist (IP) failed to collaborate with the antibiotic stewardship program leader on the antibiotic stewardship priority. [Cross-Reference A-0777]


23. The antibiotic stewardship program leader failed to create and provide a formal statement to support for antibiotic stewardship. [Cross-Reference A-0779]


24. The antibiotic stewardship program leader failed to communicate to staff about stewardship activities. [Cross-Reference A-0780]


25. The antibiotic stewardship leader failed to provide antibiotic stewardship competency- based training to hospital staff including medical staff. [Cross-Reference A-0780]


The cumulative effects of these systemic problems resulted in the facility's inability to ensure effective system-wide programs in providing quality health care in infection control prevention and control as well as in antibiotic stewardship programs.

The CONDITION OF PARTICIPATION is not met when:



Based on observation, interview, and record review, the hospital failed to ensure surgical services policies and procedures/ practices, protocols were followed for quality care when :


1. Open syringe of saline flush left at bedside.

2. Surgical care plans not followed.

3. a) Daily, weekly, and monthly routine maintenance were not done on Instrument Washers prior to December 2024.

3. b) Daily and weekly routine maintenance were not done on Autoclaves (a sterilizer machine that uses steam under pressure to kill harmful bacteria, viruses, fungi, and spores on instruments that are placed inside a pressure vessel) prior to December 2024.

4. Surgical instrument trays weighed over 25 lbs.

5. A physician assistant (PA) had long fingernails, with red nail polish, while scrubbing into a surgical case.

6. Environmental Services (EVS) logs for terminal cleaning were incomplete for the operating rooms (OR's).

7. Environmental Services (EVS) Terminal Cleaning Policy doesn't follow the facility practice.

8. The 24-hour updated H&P had the wrong date for Patient 100.

9. a) Not following pain management policy and procedure (P&P) for Patient 103.

9. b) Not following pain management policy and procedure (P&P) for Patient 105.

9. c) Not following pain management policy and procedure (P&P) for Patient 106.

10. Pain assessment not done per policy and procedure for Patient 301, Patient 303, Patient 304, and Patient 305.

11. A contaminated instrument was used on Patient 300 during surgery.

12. The 24-hour updated H&P had incomplete dates for Patient 300, Patient 301, Patient 302, and Patient 304.

13. Care plans were not initiated for Patient 304, Patient 305, and Patient 306.

[Cross-Reference A-0951]

The cumulative effects of these systemic problems resulted in the facility's inability to ensure effective system-wide programs in providing quality health care in the surgical services.

Based on observation, interview, and record review, the facility failed to maintain infection control practices and processes when:


1. RN failed to perform hand hygiene (a term used for both hand washing using soap and water, and waterless or alcohol-based hand sanitizer) after direct patient in the Emergency Department (ED).
2. RN provided direct patient care with artificial nails in the ED.
3. An expired bottle of Enfamil (baby formula) was found available for patient use in the ED storage room.
4. Hospital equipment was not stored according to policy and procedure (P&P) in the ED.
5. Staff cleaned and disinfected the glucometer (device used to check blood sugar levels) as per P&P in ED.
6. Alarms to the negative flow (a single-occupancy room that isolates patients with airborne infections) isolation rooms were not working in the ICU (Intensive Care Unit - provides specialized care for critical patients), ED, Telemetry (are of hospital where patients are continuously monitored) units.
7. Plant operations staff were unable demonstrate how to turn on alarms when requested by RN in ICU, ED, and Telemetry units.
8. General maintenance staff demonstrated vinometer use per guidelines.
9. Patient 202 did not have a care plan for Infection Risk of Ventilator per P&P.
10. Medical staff did not clean the Intravenous (IV) tubing hub (connection point on the end of a tubing where a syringe or another medical device can be attached to deliver medication directly into the patient's vein) prior to administering medication.
11(a). RN did not perform hand hygiene after removal of gloves in the operating room (OR).
11(b). Medical Staff did not perform hand hygiene after removal of gloves in OR.
12. RN used a dirty gauze to open medication vial in the OR.
13. Medical staff did not perform hand hygiene prior to medication administration after picking up trash off floor in OR.
14. Staff cleaned and disinfected the glucometer as per P&P in pre-op (area prior to surgical procedure) for gastrointestinal (relating to stomach or intestines) procedures.
15. Two contaminated instruments were found, with white substances on them, one found during a surgical procedure and the second found prior to a surgical procedure.


These failures had the potential to result in negative patient care outcomes, cross contamination of equipment, the potential to spread harmful microorganisms to patients and staff, potential to result in procedural and surgical site infections and result in an increased for hospital acquired infections and illness.



Findings:



1. During a concurrent observation and interview on 12/26/24 at 11:20 a.m. in ED with Manager of Emergency Department (EDM), Registered Nurse (RN) 4 did not perform hand hygiene after removal of gloves, after direct patient care. RN4 stated she should have used hand sanitizer after direct patient care and removal of gloves and confirmed that this was not done. EDM stated that RN4 should have sanitized after removal of gloves and confirmed RN4 did not perform hand hygiene per facility P&P.



During a review of the facility's P&P titled, "Hand Hygiene", dated 10/29/24, indicated, "C. Hand hygiene with alcohol-based hand sanitizer is indicated for routine decontamination when hands are not visibly dirty, particularly in the following clinical situations ... 5. Before and after direct patient contact; ... 8. After removing gloves ..."



2. During an observation on 12/26/24 at 11:30 in Triage #2, RN5 performed direct patient care with artificial fingernails.


During a concurrent interview and record review on 12/26/24 at 12:20 p.m. with EDM, the facility P&P titled, "Hand Hygiene", dated 10/29/24 was reviewed. The P&P indicated, " ... D. Natural fingernail tips must be trimmed to equal to or less than ¼ inch from the nail bed ... Artificial or acrylic fingernails are not allowed for staff who have direct contact with patients ..." EDM stated, that RN5 had artificial nails and acknowledged that per facility P&P RN should not have false nails.



3. During a concurrent observation and interview on 12/26/24 at 10:15 a.m. with EDM in the Supply Room of the ED, a 2-ounce bottle of ready to use Enfamil Infant Formula was found with expiration date December 1, 2024. EDM stated that the formula was expired by 3 weeks and should have been discarded.



During a review of the facility's P&P titled, "Purchasing and Receiving of Baby Formula and Products", dated 05/04/22, indicated,"A.6. Stores will check expiration dates on the unit and in Stores on a monthly basis. a. Expired items will be removed from rotation and logged prior to being disposed of."



4. During a concurrent observation and interview on 12/26/24 at 10:27 a.m. with EDM in the Supply Room of the ED, several IV Infusion pumps (device used to administer IV fluids and medications) were found on the floor next to the supply shelves, uncovered. EDM stated that the Infusion pumps are to be cleaned, covered and stored in a bin in the Supply Room. EDM acknowledged that they were not covered prior to storage and should have been per facility P&P.



During a concurrent interview and record review on 12/26/24 at 12:20 p.m. with EDM, the facility's P&P titled, "Equipment Cleaning and Monitoring of Non-Critical Devices", dated 03/03/25 was reviewed. The P&P indicated, " ... 4.a. Non-Critical Devices: Items that come in contact with intact skin. Examples ... IV pumps ... Requires low-level disinfection. These items can usually be disinfected where they are used ..." " ...D. All non-critical equipment will be cleaned and disinfected on a regular basis (see examples below), when visibly soiled and before equipment repair or service by biomed or other service technicians". "I.1. After a patient is discharged ... IV Poles, IV pumps, SCD machines, walker, and commodes left in the rooms are cleaned by EVS and left in room ... Any additional equipment found in the discharged patient room is cleaned by EVS, Bagged or tagged, and placed in the clean utility room ..." EDM stated, that per the P&P clean equipment should be cleaned after use and covered with bag when not stored in patient room.



5. During a concurrent observation and interview on 12/26/24 at 11:00 a.m. with RN6, RN6 demonstrated cleaning of the NOVA STATSTRIP accucheck meter and stated only one germicidal wipe is used to clean meter. EDM stated that RN6 failed to demonstrate the two-step process of cleaning AND disinfecting of the meter.



During a review of the facility's P&P titled, "Point of Care Testing NOVA STATSRIP Glucose Meter", dated 05/09/24, indicated, "MAINTENANCE B.1 ... the system is cleaned and disinfected after use on each patient. 2. Clean the meter ... Clean the meter with hospital approved germicidal bleach products ... c. Wipe the entire surface removing any blood or debris ... B.3. Disinfect the meter. a. Using a new, fresh germicidal bleach wipe, thoroughly wipe the surface of the meter (top, bottom, left, and right sides) a minimum of 3 times horizontally followed by 3 times vertically ensuring no fluid enters the port and electrical connector. Avoid the bar code scanner and electrical connector. b. Allow meter to stay wet for designated minutes on the germicidal container. c. Use additional wipes to assure continuous minute of wet contact time".



6. During a concurrent observation and interview on 12/27/24 at 09:30 a.m. with ICUM and general maintenance (GM) 1, ICUM stated that when a patient gets admitted needing reverse isolation (isolation for airborne diseases) the nursing staff would call general maintenance to come to the unit to turn on alarms. GM1 was asked to demonstrate how to turn alarms on in ICU negative pressure room 200 and 223. GM1 stated that no alarms were turned on prior to coming to the unit and stated that he did not know how to turn on the alarm to the room. The large sliding glass door to room 200 and 223 were open and no alarm was set off.



During an observation and interview on 12/27/24 at 12:20 p.m. with EDM in the ED, EDM stated that the ED has one negative pressure room and if they get a patient needing reverse isolation, they call general maintenance to test air flow turn on alarms prior to patient being placed in room. Demonstration of ED negative pressure room found no alarm was set off when door was opened.



During a concurrent observation and interview on 12/27/24 at 12:40 p.m. with Telemetry Nurse Manager (TNM) of Telemetry's negative pressure rooms 150 and 160 negative pressure rooms in unit, TNM stated the nursing staff would call general maintenance prior to placing a patient needing reverse isolation into the room to check for air flow and alarms. Demonstration of the door on room 150 and 160 found no alarm was set off when door was opened.



During an interview on 12/27/24 at 12:51 p.m. with DOPO, DOPO states that daily tests are completed on air flow to these rooms, but routine tests are not performed audible alarms. DOPO confirms that the alarms were not working on ICU room 200 and 223, ED negative pressure room and Telemetry rooms 150 and 160. DOPO states that "all arms should be on" and confirms that the alarms are not working on the rooms.



During a review of 2022 California Mechanical Cod, Part 4, 416.0 Alarms, "Airborne Infection Isolation Rooms and Protective Environment Rooms [OSHPD 1, 2, 3, 4 & 5]. 416.1 An alarm system which is based on static pressure control, volumetric control, or directional flow measurement shall be provided for each isolation room. The alarm system shall consist of a display monitor located on the corridor wall near the door to the room and a visual and audible alarm which annunciates at the room and at a nurses' station or other suitable location that will provide responsible surveillance.



7. During a concurrent observation and interview on 12/27/24 at 09:30 a.m. with ICUM and general maintenance (GM) 1, ICUM stated that when a patient gets admitted needing reverse isolation (isolation for airborne diseases) the nursing staff would call general maintenance to come to the unit to turn on alarms. GM1 was asked to demonstrate how to turn alarms on in ICU negative pressure room 200 and 223. GM1 stated that no alarms were turned on prior to coming to the unit and stated that he did not know how to turn on the alarm to the room.



During an observation and interview on 12/27/24 at 12:20 p.m. with EDM in the ED, EDM stated that the ED has one negative pressure room and if they get a patient needing reverse isolation, they call general maintenance to test air flow turn on alarms prior to patient being placed in room. Demonstration of ED negative pressure room found no alarm.



During a concurrent observation and interview on 12/27/24 at 12:40 p.m. with Telemetry Nurse Manager (TNM) of Telemetry's negative pressure rooms 150 and 160 negative pressure rooms in unit, TNM stated the nursing staff would call general maintenance prior to placing a patient needing reverse isolation into the room to check for air flow and alarms. Demonstration of the door on room 150 and 160 found no alarm.



During an interview on 12/27/24 at 12:51 p.m. with DOPO, DOPO states that daily tests are completed on air flow but not alarms. DOPO confirms that the alarms were not working on ICU room 200 and 223, ED negative pressure room and Telemetry rooms 150 and 160. DOPO states that "all arms should be on" and confirms that the alarms are not working on the rooms indicated.



During an interview on 01/02/24 at 4:00 p.m. with DOPO, DOPO stated that the alarms did not work on 12/27/25 in ICU, ED and Telemetry and stated the general maintenance staff needed to activate and increase the sensor volume. DOPO stated the "Wall monitor was set to off and adjusted to lowest sensitivity". DOPO confirmed that GM1 did not know how to turn on alarms.



During a review of 2022 California Mechanical Cod, Part 4, 416.0 Alarms, "Airborne Infection Isolation Rooms and Protective Environment Rooms [OSHPD 1, 2, 3, 4 & 5]. 416.1 An alarm system which is based on static pressure control, volumetric control, or directional flow measurement shall be provided for each isolation room. The alarm system shall consist of a display monitor located on the corridor wall near the door to the room and a visual and audible alarm ...



8. During a concurrent observation and interview on 12/27/24 at 09:30 a.m. with general maintenance (GM) 1, GM1 demonstrated the use of the vinometer (a device used to check the direction of air flow in an isolation room) by opening the door to the negative pressure room and placing the vinometer in the crack of the door. GM1 stated that he does not place the vinometer on the floor at the undercut of the door when checking air flow of Airborne Isolation Rooms.



During an interview on 12/27/24 at 10:00 a.m. with Director of Plan Operations (DOPO), DOPO stated that the facility recently obtained the new vinometer that was used today by GM1and that GM1 was trained on use 11/21/24. DOPO confirmed per guidlines, GM1 should have placed the device on the floor to obtain reading.



During a review of facility's document titled, "Regulatory Concepts: Airflow Checker Training ", dated 11/21/24, the Instructions on how to use, indicated in part, " ... place the Air Flow Checker flat on the floor and flush up against the undercut of the door of a pressurized space to observe the air flow direction. *Important Note: An undercut clearance of at least a ¼ inch is required to draw air into the Air Flow Checker and achieve a good reading ..."



During a review of facility's document titled, "Regulatory Concepts: Airflow Checker Training - Plant Ops", dated 11/21/24, the Air Flow Checker Training - Plant Ops signature page indicated, " ... check your negative and positive pressure dependent spaces for proper air flow direction such as Operating Rooms, Isolation Rooms, Soiled Utility Rooms, Labs, Construction Zones, and Clean Supply Rooms. This tool replaces the 'calibrated tissue test'." Signatures of those trained were listed on page including General Maintenance (GM1) was trained on 11/21/24.



9. During a concurrent interview and record review on 01/02/24 at 0900 with Manager of Clinical Information Systems (MCIS), Patient 202's Electronic Health Record (EHR), Care Plan, titled "Infection Risk of Ventilator - Associated Pneumonia MCP", dated 12/08/24 was reviewed. MCIS stated that Patient 202 had an order placed for a ventilator (a machine that breathes for a person) and the care plan for "Infection risk of ventilator" was not initiated until 48 hours later on 12/08/24. MCIS confirmed that the care plan indicated should have been initiated on 12/6/24.



During a review of facility's P&P titled, "Assessment of Patients - Interdisciplinary", dated 03/31/24, indicated in apart, "F.3. The intake Assessment information will be collected within 24 hours and will include: a. psychological and social status, b. Nutritional/Hydration screening, c. Functional/Environmental needs screening, d. Anticipated Discharge Planning needs, e. Initial anticipated educational needs, f. Pain History".





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10. During an observation on 12/26/24, at 11:54 a.m., in OR 1, an anesthesiologist (Anesth 1) administered medication through the IV tubing ports, without cleaning the ports, multiple times.
During a review of the facility's policy and procedure (P&P) titled, "Isolation: Standard and Transmission-Based Precautions" dated 7/27/22, indicated in part ... "Safe Injection Practices: i. Aseptic technique is used to avoid contamination of sterile injection equipment. Alcohol is used to disinfect all containers (i.e. vials, ampules, ports) of parenteral (intravenous-into the vein) medications prior to entry ..."



During an interview on 12/27/24, at 11:07 a.m., with the surgical services director (SSD), SSD acknowledged and verbalized Anesth 1 should be cleaning IV ports prior to administering any medications through the port.



11. a) During an observation on 12/26/24, at 10:44 a.m., in OR 1, a registered nurse (RN 1) was observed picking up trash, with gloved hands, from the OR floor, during the OR set up (before the next surgical case), and then removed the gloves. After removing the gloves, RN 1 did not perform hand hygiene.



11. b) During an observation on 12/26/24, at 11:50 a.m., in OR 1, an anesthesiologist (Anesth 1) administered spinal anesthesia to a patient (Patient 402) and wearing sterile gloves. After finishing the anesthesia procedure and removing the gloves, Anesth 1 did not perform hand hygiene.



During an interview on 12/27/24, at 11:04 a.m., with the surgical services director (SSD), SSD acknowledged and verbalized RN 1 and Anesth 1 both should have performed hand hygiene after removing the gloves.



During a review of the facility's policy and procedure (P&P) titled, "Hand Hygiene" dated 10/29/24, indicated in part ... "Hand hygiene with alcohol-based hand sanitizer is indicated for routine decontamination when hands are not visibly dirty, particularly in the following situations: 2. Before donning gloves ... 8. After removing gloves ..."



12. During a review of the facility's policy and procedure (P&P) titled, "Isolation: Standard and Transmission-Based Precautions" dated 7/27/22, indicated in part ... "Safe Injection Practices: i. Aseptic technique is used to avoid contamination of sterile injection equipment. Alcohol is used to disinfect all containers (i.e. vials, ampules, ports) of parenteral (intravenous-into the vein) medications prior to entry ..."



During an observation on 12/26/24, at 11:44 a.m., in OR 1, an anesthesiologist (Anesth 1) was preparing to administer spinal anesthesia to a patient (Patient 402). Anesth 1 was disinfecting Patient 402's back with skin preparation applicator sponges, then placing the used (dirty) applicator sponges back on the mayo stand away from the sterile kit. Anesth 1 then uses 4x4 gauze, from the sterile kit, to wipe off the skin prep from Patient 402's back. Anesth 1 then places the used 4x4 gauze next to the used (dirty) applicator sponges away from the sterile kit. A registered nurse (RN 1) was observed holding a glass medication ampule, then picked up the used 4x4 gauze (that had been used to wipe Patient 402's back), wrapped it around the neck of the glass ampule to break it open. After the medication ampule was open, RN 1 held the medication ampule while Anesth 1 withdrew the medication from the glass ampule.



During an interview on 12/27/24, at 11:09 a.m., with the surgical services director (SSD), SSD acknowledged and verbalized RN 1 should not have used the contaminated 4x4 gauze to open the glass medication ampule.




During a review of the facility's policy and procedure (P&P) titled, "Medication Administration" dated 9/8/22, indicated in part ... "Intradermal, subcutaneous, and intramuscular needle injection procedure: d. When breaking an ampule, wrap neck with alcohol wipe to protect fingers. Use a filter needle when administering the contents of an ampule ..."




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13. During an observation on 12/26/24, from 11:41 a.m. to 12:01 p.m., the anesthesiologist (Anesth 1), in the operating room during a procedure for one patient (Patient 402), Anesth 1 picked up trash off the floor and put on gloves without performing hand hygiene then gave Patient 402 medication.


During an interview on 12/27/24, at 10:42 a.m., with the surgical services director (SSD), the SSD confirmed anesthesiologists should perform hand hygiene before and after donning gloves, the anesthesiologist is not following the facility policy.


During a review of the facility's policy and procedure (P&P) titled, "Hand Hygiene", dated 10/29/24, the P&P indicated, "Hand hygiene with alcohol-based hand sanitizer is indicated ... before donning gloves ... after removing gloves ..."


14. During an observation and concurrent interview on 12/27/24, at 11:32 a.m., with the surgical services manager (SSM) and registered nurse (RN 3), in the pre-op for gastrointestinal procedures, RN 3 was asked to demonstrate and verbalize what is done with the glucometer between patients. RN 3 got one bleach wipe, wiped down the glucometer and placed it on a paper towel, got another wipe and wiped down the glucometer set a timer for four minutes and placed the glucometer in the docking station. RN 3 verbalized the timer is set for four minutes because we can't use it again until four minutes is up. Confirmed with SSM, this is not following the facility policy and procedure for cleaning/disinfecting the glucometer.



During a review of the facility's policy and procedure (P&P) titled, "Point of Care Testing Nova Statstrip Glucose Meter", dated 5/9/24, the P&P indicated, "Disinfect the meter ... allow meter to stay wet for designated minutes on the germicidal container ... use additional wipes to assure continuous minute of wet contact time ..."



During a review of the manufacturers instructions for use (MIFUs) titled, "Sani-Cloth Bleach Wipes", undated, the MIFUs indicated, "Allow surface to remain visibly wet for four minutes ... use additional wipes if needed to ensure continuous 4-minute wet contact time ... let air dry ..."



15. During a concurrent interview and record review on 12/27/24, at 10:43 a.m., with the surgical services director (SSD), the SSD stated we found two contaminated instruments, one on 10/24/24 and another on 11/19/24 after the instruments had been sterilized and prepared for use the two instruments had a white substance on them. SSD stated, the first contaminated instrument was found during a surgical procedure, the second instrument was found prior to the surgical procedure. Additionally, SSD stated when the second contaminated surgical instrument was found, on 11/19/24, the surgeon (MD 1) was notified, and MD 1 requested his surgeries scheduled for that day be canceled. SSD also stated, on the morning of 11/20/24 MD 2 called the facility and requested his surgeries to be canceled because of the contaminated instruments. Review of the surgical schedule for 11/20/24 indicated, Patient 306 was scheduled for surgery and it was canceled.




During a concurrent observation and interview on 12/6/24, at 2:36 p.m., with the sterile processing department lead technician (SPDLT), in the sterile processing department (in the dirty room), two Instrument Washers were observed. SPDLT verbalized the Instrument Washer Machine #1 [Steris Reliance 444] and the Instrument Washer Machine #2 [Amsco 7000] need to be check daily to make sure they are functioning properly before putting in a load of dirty instruments. SPDLT verbalized performing an indicator test and recording the results in a logbook. When asked if there was routine maintenance that needed to be performed on the Instrument Washers on a daily, weekly, and monthly schedule, SPDLT verbalized she was unsure and would have to refer to the manufacturer's instruction for use (MIFU's) manual. SPDLT further verbalized had just been hired at the facility a week ago and was unsure if the prior SPD supervisor had been documenting routine maintenance in a logbook.




During a review of the Manufacturer's Instructions for Use (MIFU's) for the Instrument Washer #1 [Steris Reliance 444] indicated ... "The sample preventative maintenance guide included in this section should be used as a guideline for determining the frequency of maintenance. This proves useful in helping ensure proper maintenance of your washer/disinfector. Maintenance procedures described in this section must be performed as required at the suggested frequency ... Daily Maintenance indicates to ... 1. Remove and clean bottom filters and wash chamber ...2. Remove riser valve and inspect for debris ...3. Check chemical containers ...4. Verify operation of vertical sliding doors ...5. Check Printer paper ...Weekly Maintenance indicates to ...1. Clean washer exterior ...2. Wash chamber interior ...3. Clean/wash chamber rotary spray arm ...4. Clean bottom rotary spray arm ...5. Clean bottom rotary spray arm accessories ...6. Perform the decontamination of the unit ...7. Clean building supply line strainers ...Monthly Maintenance indicates to ...Verify & lubricate peristaltic injection pump squeeze tubes ..."




During a review of the Manufacturer's Instructions for Use (MIFU's) for the Instrument Washer #2 [Amsco 7000] indicated ... "Regularly scheduled routine maintenance, as well as preventative maintenance, are required for safe and reliable operation of this equipment ... Daily Maintenance indicates to ...1. Check printer paper ...2. Check printer ink ...3. Clean debris screen in chamber ... Weekly Maintenance indicates to ...1. Inspect rotary arm assemblies for free movement and clogged holes ...2. Remove hard water deposits from interior of chamber ...3. Clean interior & exterior ...4. Clean water outlet connection in chamber ...5. Inspect rotary spray arm assemblies of manifold racks for free movement and clogged holes ... Monthly Maintenance indicates to ...1. Check door gaskets for wear and tear ...2. Clean each door gasket ...3. Verify date and time accurate ..."



During a concurrent interview and record review on 1/2/25, at 9:30 a.m., with the surgical services manager (SSM) and the sterile processing department manager (SPDM), the routine maintenance logs and MIFU's for the Instrument Washers (#1 & #2) were reviewed. The daily, weekly, and monthly maintenance logs had only been filled out for the month of December 2024 and the beginning of January 2025. SSM and SPDM both verbalized there was no other documentation for routine maintenance of the Instrument washers in a log or record. SSM and SPDM were both unclear as to what was being done prior to December 2024. SPDM verbalized had just been hired at the facility in December 2024. SSM and SPDM both acknowledged there was no documentation of routine maintenance being done prior to December and there should be.



During a concurrent observation and interview on 12/6/24, at 3:58 p.m., with the sterile processing department lead technician (SPDLT), in the sterile processing department (in the clean room), two Autoclaves were observed. SPDLT verbalized Autoclave #1 and Autoclave #2 need to be check daily to make sure they are functioning properly before putting in a load of surgical instruments to be sterilized. SPDLT verbalized performing a Bowie-Dick test to detect any air leaks and a biological test to detect any growing bacteria (or any microbes) and recording both the results in a logbook. When asked if there was routine maintenance that needed to be performed on the Autoclaves on a daily, weekly, and monthly schedule, SPDLT verbalized she was unsure and would have to refer to the manufacturer's instruction for use (MIFU's) manual.



During a review of the Manufacturer's Instructions for Use (MIFU's) for the Autoclaves (#1 & #2) indicated ... "Daily Maintenance indicates to ...1. Clean chamber drain strainers ...2. Clean chamber whenever soiled ...3. Check paper supply ...4. Check printer ink ... Weekly Maintenance indicates to ...1. Clean & Flush chamber drain ..."
There was no monthly routine maintenance.



During a concurrent interview and record review on 1/2/25, at 9:53 a.m., with the surgical services manager (SSM) and the sterile processing department manager (SPDM), the routine maintenance logs and the MIFU's for the Autoclaves (#1 & #2) were reviewed. The daily and weekly maintenance logs had only been filled out for the month of December 2024 and the beginning of January 2025. SSM and SPDM both verbalized there was no other documentation for routine maintenance of the Autoclaves in a log or record. SSM and SPDM were both unclear as to what was being done prior to December 2024. SSM and SPDM both acknowledged there was no documentation of routine maintenance being done prior to December and there should be.



According to AORN's (Association of perioperative Registered Nurses) book titled, "Guidelines for Perioperative Practice," copyright 2021, the guidance indicated, in part, "Instrument Cleaning: Cleaning Verification and Inspection ... Repeat the decontamination process if retained soil is seen ... inspect and evaluate items for cleanliness ... the absence of corrosion ... any other defects ... use of instruments that are not thoroughly cleaned, are damaged, or do not function correctly poses a risk to patients ... provide education and verify competency for specific knowledge and skills related to cleaning and care of surgical instruments including the following: location and understanding of manufacturers' IFU for the reusable surgical instrument or medical device, decontamination equipment (eg, washer-disinfectors, ultrasonic cleaners) ... process failure response protocols ... preventative maintenance requirements or recommendations are what the device manufacturer has determined are necessary to keep instruments and equipment in optimal working order is essential for patient and user safety ... maintain records of instrument, equipment, and other medical device maintenance and service ..."

Based on interview and record review the facility failed to ensure the infection preventionist (IP) develop and implement hand hygiene surveillance and monitoring in the surgery department including the operating rooms (ORs) to adhere to nationally recognized guidelines.


This failure resulted in the facility not conducting hand hygiene surveillance and monitoring in the surgery department and ORs which can potentially result in an increase of surgical site infections.


Finding:



According to the 2025 Association of periOperative Registered Nurses (AORN) guidelines. The Guideline for Hand Hygiene was approved by the AORN Guidelines Advisory Board and became effective as of June 15, 2022. The recommendations in the guideline are intended to be achievable and represent what is believed to be an optimal level of practice ... AORN recognizes the many diverse settings in which perioperative nurses practice; therefore, this guideline is adaptable to all areas where operative or other invasive procedures may be performed. This provides perioperative team members with evidence-based practice guidance for performing hand hygiene and surgical hand antisepsis to promote patient and personnel safety and reduce the risk for health care-associated infections, especially surgical site infections (SSIs). Hand hygiene is widely recognized as a primary method to prevent health care-associated infections and the transmission of pathogens in the health care setting ... Thus, the prevention of health care-associated infections is a priority for all health care personnel. Hand hygiene and surgical hand antisepsis are effective and cost-efficient ways to prevent and control infections in the perioperative setting ... Moderate-quality evidence has confirmed intraoperative transmission of Staphylococcus aureus from the hands of anesthesia providers, surgical attendings, surgical assistants, and circulating nurses to patients and environmental surfaces. Transient microorganisms are easier to remove by performing hand hygiene than are resident microorganisms, which are seated in the deeper layers of the skin. Surgical hand antisepsis aims to remove soil and transient microorganisms from the hands of perioperative team members and suppress the growth of resident microorganisms for the duration of the surgical procedure to reduce the risk that the patient will develop an SSI. Safe and effective surgical hand antiseptics rapidly and persistently remove transient microorganisms and suppress the growth of resident microorganisms with minimal skin and tissue irritation.
https://aornguidelines.org/guidelines/content?sectionid=173716124&view=book#180185009



According to Association for Professionals in Infection Control and Epidemiology (APIC) Guide to Hand Hygiene Programs for Infection Prevention. Hand hygiene is widely recognized as the most important measure to prevent the spread of infection. Despite evidence that improving hand hygiene reduces the risk of infection and improves patient outcomes, compliance with hand hygiene remains low. A key responsibility of the infection preventionist (IP) is to develop, implement, and monitor hand hygiene programs as a critical piece of broader infection prevention programs in healthcare settings. Hand hygiene monitoring can increase and sustain engagement, resulting in increased compliance and commitment to process improvement. Measurement of hand hygiene performance is important at the individual, unit (i.e. surgery OR) ...for organizations to perform internal and external benchmarking. The results of hand hygiene monitoring can be used to plan additional education and training opportunities, identify additional resources needed, and can contribute to organizational change. https://apic.org/wpcontent/uploads/2019/07/APIC_handhygiene.pdf



During a review of the hand hygiene data with the IP on 12/26/24 at 12:25 p.m., IP was asked if hand hygiene surveillance & monitoring was being conducted in the surgery department and ORs. IP stated, "We don't go into the OR to monitor hand hygiene." IP was asked how many surgical site infections (SSI) they have had. IP stated "From October of last year to this October we have had eleven (11) SSIs. IP was asked the rationale for not conducting hand hygiene surveillance in the surgery department. IP stated, "We just don't. I just know that we don't have to conduct hand hygiene surveillance in the ORs..." IP was asked to provide supporting documentation indicating the reason why they don't have to perform hand hygiene surveillance and monitoring in the surgery department.



During an interview with the director of quality (DOQ) on 12/26/24 at 4:28 p.m., the DOQ explained that according to Centers for Medicare Services (CMS) and the LeapFrog group hand hygiene surveillance and monitoring is not required in the surgery department including the ORs. Communicated to DOQ they need to provide supporting written documentation indicating that hand hygiene surveillance and monitoring does not have to be conducted in the surgery department including the ORs. Most nationally recognized guidelines promote hand hygiene surveillance and monitoring in the surgery department for which hospitals have to adhere to those guidelines. This hospital has adopted AORN guidelines for the surgical department.


During another interview with the IP, DOQ and infection prevention nurse (IPN) on 12/27/24 at 3:54 p.m., the DOQ reported again that according to CMS and the LeapFrog group hand hygiene surveillance is not require in the surgery department including the ORs. Communicated to DOQ, IP and IPN that if they are claiming hand hygiene is not required in the surgery department and ORs, that's fine, but to provide evidence or documentation supporting this.


The DOQ provided a document titled "2024 Leapfrog Hospital survey- Hand Hygiene Measure Specifications. This document addresses questions for hand hygiene reporting... However, this document does not support that hand hygiene is not required in the surgical department and ORs. The hospital administrative staff was not able to provide evidence supporting that hand hygiene surveillance is not required in the surgical department including the ORs.

Based on interview and record review the facility failed to:

1. Ensure the infection preventionists (IP) had oversight of the Infection Prevention program priorities to developed and document written priorities correctly, according to the risk assessment grid tool and based on risk scores.

2. Ensure the IP created action plans for hand hygiene non-compliance per the infection control plan.

These failures resulted in the antibiotic stewardship not being priority #1 in the Infection Prevention program plan and not having written action plans for hand hygiene non-compliance.

Findings:


1.During a concurrent review of the 2024 infection prevention risk assessment, the 2024 infection surveillance and prevention plan and interview with the infection prevention nurse (IPN) on 12/26/24 at 11:00 a.m., the IPN explained the 2024 Infection Prevention plan priorities are developed by utilizing the risk assessment scoring. The risk assessment score determines which issue or event will be prioritized in the Infection Prevention Program priorities as #1, #2, #3, #4, and #5 in the plan. The higher the risk score of an issue/event determines the priority level 1, 2, 3 and so forth.


According to the 2024 Infection Prevention Risk Assessment grid tool, the antibiotic stewardship had a risk score of nine (9). The MRSA bloodstream infections had a risk score of nine (9). These two issues/events had the highest risk score therefore the antibiotic stewardship should have been priority #1 in the plan.


Upon review of the 2024 Infection Prevention plan priorities, the plan indicated Priority #1 was hand hygiene. Priority #2 was MRSA blood infections. Priority #3 was device associated hospital acquired infections (HAIs). Priority #4 was antimicrobial stewardship.


During concurrent interview with the IPN on 12/26/24 at 11:00 a.m., the IPN was asked the rationale for the antimicrobial stewardship, with a risk score of nine (9), was not priority #1 in the IP plan. The IPN acknowledged and confirmed that based on the risk score, the antimicrobial stewardship should have been priority #1 in the IP plan, and it was not. IPN stated "I agree. In the plan, antimicrobial stewardship should have been priority #1 and not priority #4. The Infection Prevention plan priorities do not match the risk assessment grid issues/event based on the risk score. I don't know why hand hygiene was priority #1 ..."


The facility document titled "PLAN: 2024 Organization Wide-Infection Prevention and Risk Assessment", dated 4/30/24, indicated "The infection prevention and controlled risk assessment grid is a visual tool to develop infection prevention program priorities and stratify infection risks based on our geography, location in the community, and our patient population ... The risk assessment is based on risk score and priority and focus on infection prevention."


2.During a concurrent review of the 2024 Infection Surveillance and Prevention Plan and interview with the infection preventionists (IP) on 12/26/24 at 4:45 p.m., Priority #1 Hand Hygiene indicated one of the strategies or interventions was to create action plans for hand hygiene non- compliance. The IP was asked what the action plans for hand hygiene non-compliance were, to provide a copy of the action plans. The IP acknowledged and confirmed the hand hygiene interventions were not developed and implemented as indicated by the plan. IP stated "No, we don't have or have created written action plans for hand hygiene compliance."

Based on interview and record review the facility failed to:

1..Ensure issues discover by the infection preventionist (IP) in the sterile processing department (SPD) during an audit conducted on 10/24/23 and 5/31/24 were followed up to ensure issues were resolved.

2. Ensure the IP audit for hand hygiene visual reminders in the emergency department (ED) as indicated by the 2024 Infection Surveillance and Prevention plan, Priority #1- Hand hygiene.

3. Ensure the IP monitor the hand sanitizer dispensers auditing, performed by the EVS director, was effective to prevent healthcare associated infections (HAIs) and avoid cross-contamination.

These failures resulted in the SPD issues not being resolved, the ED not having enough hand hygiene visual reminders and had the potential of cross-contamination and promoting HAIs.


Findings:


1.During a concurrent review of the Infection Prevention Audit -SPD documents and interview with the IP and infection prevention nurse (IPN) on 12/26/24 at 12:25 p.m., the IP was asked if the IPs perform any type of monitoring, auditing or surveillance activities in the SPD and surgery department. IP indicated performing auditing in SPD in 2023 and 2024.


The report for the 2023 Infection Prevention Audit -SPD, dated 10/24/23 was reviewed with IP and (IPN). Audit indicated the following: #3 Vents have "some rust". #5 Walls and floor need repair. #31 Ceilings tiles have "stains" in the assembly/packing area. #32 Vents have rust in the assembly/packing area. #33 Walls & floors need repair. # 40 Instruments had residual tape residue. IP indicated the director of plant operations (DOPO) was responsible for the above issues #3 to #33. IP was responsible for the issue listed in #40 where instruments were observed having tape residue.


The Infection Prevention Audit -SPD, dated 5/31/24 was reviewed with IP and IPN. Audit indicated the following: #3 Vents have "some rust". #5 Walls and floor need repair.


During an interview with the IP on 12/27/24 at 10:43 a.m., the IP indicated not having documentation supporting that there was follow up regarding the instruments having tape residue. IP does not know what the outcome of this issue was whether if it was corrected or not. IP does not have any evidence or documentation supporting IP or anybody else took care of this issue.


During a concurrent review of the Infection Prevention Audit -SPD documents, dated 10/24/23 and 5/31/24 and interview with DOPO on 12/27/24 at 9:38 a.m., the DOPO was asked to provide documentation supporting the above issues #3-33 were corrected or resolved. DOPO explained to correct issues someone will have to have requested for facilities department to take care of the problems. Normally, a ticket is created in the facilities department, a technician is assigned to take care of the problem, the technician takes care of the problem and resolves or closes the ticket. Requested resolved tickets for the above items in the two audit reports.


During another interview with the DOPO on 12/27/24 at 3:31 p.m., the DOPO confirmed not having any supporting evidence or documentation the issues identified in the Infection Prevention Audit -SPD reports dated 10/23/24 and 5/31/24 were resolved. DOPO stated" No, I cannot find any work order in the facilities department indicating those issues #3 to #33 in the reports were taken care of or resolved."


2. During a concurrent review of the 2024 Infection Surveillance and Prevention Plan and interview with the IP on 12/26/24 at 4:50 p.m., Priority #1 Hand Hygiene indicated one of the strategies or interventions was to have visual reminders for hand hygiene. The IP explained hand hygiene visual reminders are signs posted in most frequented areas such as bathrooms, sinks, patient's room and throughout the entire hospital reminding staff, visitors, and everyone to wash their hands.


During a tour of the ED, accompanied by the IP, to observe the hand hygiene visual reminder signs and interview with the IP on 12/26/24 at 5:00 p.m., four out of four sinks were observed without a hand hygiene reminder sign posted in the vicinity. No hand hygiene reminder signs were observed posted inside patient's rooms. The IP acknowledged and confirmed there are not enough hand hygiene visual reminder signs posted in the ED. IP stated, "Yes, I agree we need to have more hand hygiene visuals near a sink and other areas in the ED. I agree we don't have enough reminders."


3. During a concurrent review of the 2024 Infection Surveillance and Prevention Plan and interview with the IP on 12/26/24 at 4:35 p.m., Priority #1 Hand Hygiene indicated one of the strategies or interventions was to ensure hand hygiene - alcohol base hand rub ABHR products ...are always available and accessible to all healthcare providers HCP. The IP reported the EVS director take care and monitors the hand hygiene ABHR sanitizers throughout the hospital.


During a concurrent review of the Hand Hygiene ...Sanitizer Volume Audit reports for first, second, third and fourth quarters in 2024 and interview with director of environmental services (DOEVS) on 12/27/24 at 11:15 a.m., the DOEVS reported sanitizer volume audits are being conducted in all the units of the hospital to ensure sanitizer dispensers are full for healthcare professionals to perform hand hygiene with ABHR products. The reports indicated the same sanitizer dispensers are being checked with the audits. In the medical surgical nursing unit (MSN 1) only 12 hand sanitizers are being checked over and over every quarter. According to the DOEVS, in MSN 1 there are more than 12 sanitizers dispensers which means some sanitizer dispensers are not being checked to see if they are full or empty during the audit process. If the sanitizer dispenser is empty, there is high probability that the healthcare professional is not performing hand hygiene.


According to the audit reports in the intensive care unit (ICU) only six sanitizer dispensers are being checked over and over. However, there are more than 6 sanitizers dispensers in the ICU. This means some sanitizer dispensers have not been checked to see if they are always full of sanitizer and accessible to healthcare professionals.


The DOEVS acknowledged and confirmed the current audit process is not being conducted correctly because not all the sanitizer dispensers are being checked in the units during the audit process. The DOEVS stated "Yes, I agree the same dispensers are being checked in the ICU, MSN 1, and the rest of the units in the hospital. I need to include all the sanitizer dispensers in the units during the audits. I need to list all the sanitizers in the units in the audit tool."

Based on observation, interview, and record review, the hospital failed to ensure surgical services were provided in a safe manner when surgical services policy and procedures for surgical protocols were not followed when:


1. Open syringe of saline flush left at bedside.


2. Surgical care plans not followed.


3. a) Daily, weekly, and monthly routine maintenance were not done on Instrument Washers prior to December 2024.


3. b) Daily and weekly routine maintenance were not done on Autoclaves (a sterilizer machine that uses steam under pressure to kill harmful bacteria, viruses, fungi, and spores on instruments that are placed inside a pressure vessel) prior to December 2024.

4. Surgical instrument trays weighed over 25 lbs.


5. A physician assistant (PA) had long fingernails, with red nail polish, while scrubbing into a surgical case.


6. Environmental Services (EVS) logs for terminal cleaning were incomplete for the operating rooms (OR's).


7. Environmental Services (EVS) Terminal Cleaning Policy doesn't follow the facility practice.


8. The 24-hour updated H&P had the wrong date for Patient 100.


9. a) Not following pain management policy and procedure (P&P) for Patient 103.


9. b) Not following pain management policy and procedure (P&P) for Patient 105.


9. c) Not following pain management policy and procedure (P&P) for Patient 106.


10. Pain assessment not done per policy and procedure for Patient 301, Patient 303, Patient 304, and Patient 305.


11. A contaminated instrument was used on Patient 300 during surgery.


12. The 24-hour updated H&P had incomplete dates for Patient 300, Patient 301, Patient 302, and Patient 304.


13. Care plans were not initiated for Patient 304, Patient 305, and Patient 306.


The hospital failed to ensure the surgical services department met the needs of the patients, had potential to compromise the health and safety of patients, and had potential to contribute to outbreaks of surgical site infections (and possible death) when not maintaing washers and autoclaves for cleaning, disinfecting, and sterilizing surgical instruments, and when contaminated instruments were used in a surgical case.


Findings:


1. During the tour of room 305 in 3 North with the telemetry nurse manager (TMN) and the clinical informatics nurse (CIN1) on 12/26/24 at 10:37 am. An opened 10cc syringe of normal saline flush is found on the bedside table. Patient N401 indicated a nurse had left it on the bed side table. The TMN acknowledged that the syringe should have not been left there.


The facility policy and procedure titled "Safe injection Practices", dated 3/29/24 indicates "Any injectable medical product with compromised or questionable sterility should be discarded".


2. During a concurrent record review and interview with the clinical informatics nurse (CIN1) on 12/27/24 at 10:50 am, patient N403 had a knee surgery. Care plan for the total knee replacement was initiated 12/26/24. There are 14 listed interventions in the care plan and only 3 interventions were being documented. CIN1 acknowledged it was not documented it is not done. CIN1 indicated the hospital does not have a policy for implementing care plan interventions.


During a concurrent record review and interview with the clinical informatics nurse on 12/27/24 at 11:20 am, patient N404 had a knee surgery. Care plan for total knee replacement was initiated 12/26/24. There are 17 interventions listed in the care plan, only 3 interventions were being documented. CIN1 acknowledged it was not done. Hospital does not have a policy for implementing care plan interventions.


39520

3. a) During a concurrent observation and interview on 12/6/24, at 2:36 p.m., with the sterile processing department lead technician (SPDLT), in the sterile processing department (in the dirty room), two Instrument Washers were observed. SPDLT verbalized the Instrument Washer Machine #1 [Steris Reliance 444] and the Instrument Washer Machine #2 [Amsco 7000] need to be check daily to make sure they are functioning properly before putting in a load of dirty instruments. SPDLT verbalized performing an indicator test and recording the results in a logbook. When asked if there was routine maintenance that needed to be performed on the Instrument Washers on a daily, weekly, and monthly schedule, SPDLT verbalized she was unsure and would have to refer to the manufacturer's instruction for use (MIFU's) manual. SPDLT further verbalized had just been hired at the facility a week ago and was unsure if the prior SPD supervisor had been documenting routine maintenance in a logbook.


During a review of the Manufacturer's Instructions for Use (MIFU's) for the Instrument Washer #1 [Steris Reliance 444] indicated ... "The sample preventative maintenance guide included in this section should be used as a guideline for determining the frequency of maintenance. This proves useful in helping ensure proper maintenance of your washer/disinfector. Maintenance procedures described in this section must be performed as required at the suggested frequency ... Daily Maintenance indicates to ... 1. Remove and clean bottom filters and wash chamber ...2. Remove riser valve and inspect for debris ...3. Check chemical containers ...4. Verify operation of vertical sliding doors ...5. Check Printer paper ...Weekly Maintenance indicates to ...1. Clean washer exterior ...2. Wash chamber interior ...3. Clean/wash chamber rotary spray arm ...4. Clean bottom rotary spray arm ...5. Clean bottom rotary spray arm accessories ...6. Perform the decontamination of the unit ...7. Clean building supply line strainers ...Monthly Maintenance indicates to ...Verify & lubricate peristaltic injection pump squeeze tubes ..."


During a review of the Manufacturer's Instructions for Use (MIFU's) for the Instrument Washer #2 [Amsco 7000] indicated ... "Regularly scheduled routine maintenance, as well as preventative maintenance, are required for safe and reliable operation of this equipment ... Daily Maintenance indicates to ...1. Check printer paper ...2. Check printer ink ...3. Clean debris screen in chamber ... Weekly Maintenance indicates to ...1. Inspect rotary arm assemblies for free movement and clogged holes ...2. Remove hard water deposits from interior of chamber ...3. Clean interior & exterior ...4. Clean water outlet connection in chamber ...5. Inspect rotary spray arm assemblies of manifold racks for free movement and clogged holes ... Monthly Maintenance indicates to ...1. Check door gaskets for wear and tear ...2. Clean each door gasket ...3. Verify date and time accurate ..."


During a concurrent interview and record review on 1/2/25, at 9:30 a.m., with the surgical services manager (SSM) and the sterile processing department manager (SPDM), the routine maintenance logs and MIFU's for the Instrument Washers (#1 & #2) were reviewed. The daily, weekly, and monthly maintenance logs had only been filled out for the month of December 2024 and the beginning of January 2025. SSM and SPDM both verbalized there was no other documentation for routine maintenance of the Instrument washers in a log or record. SSM and SPDM were both unclear as to what was being done prior to December 2024. SPDM verbalized had just been hired at the facility in December 2024. SSM and SPDM both acknowledged there was no documentation of routine maintenance being done prior to December and there should be.


3. b) During a concurrent observation and interview on 12/6/24, at 3:58 p.m., with the sterile processing department lead technician (SPDLT), in the sterile processing department (in the clean room), two Autoclaves were observed. SPDLT verbalized Autoclave #1 and Autoclave #2 need to be check daily to make sure they are functioning properly before putting in a load of surgical instruments to be sterilized. SPDLT verbalized performing a Bowie-Dick test to detect any air leaks and a biological test to detect any growing bacteria (or any microbes) and recording both the results in a logbook. When asked if there was routine maintenance that needed to be performed on the Autoclaves on a daily, weekly, and monthly schedule, SPDLT verbalized she was unsure and would have to refer to the manufacturer's instruction for use (MIFU's) manual.


During a review of the Manufacturer's Instructions for Use (MIFU's) for the Autoclaves (#1 & #2) indicated ... "Daily Maintenance indicates to ...1. Clean chamber drain strainers ...2. Clean chamber whenever soiled ...3. Check paper supply ...4. Check printer ink ... Weekly Maintenance indicates to ...1. Clean & Flush chamber drain ..."
There was no monthly routine maintenance.


During a concurrent interview and record review on 1/2/25, at 9:53 a.m., with the surgical services manager (SSM) and the sterile processing department manager (SPDM), the routine maintenance logs and the MIFU's for the Autoclaves (#1 & #2) were reviewed. The daily and weekly maintenance logs had only been filled out for the month of December 2024 and the beginning of January 2025. SSM and SPDM both verbalized there was no other documentation for routine maintenance of the Autoclaves in a log or record. SSM and SPDM were both unclear as to what was being done prior to December 2024. SSM and SPDM both acknowledged there was no documentation of routine maintenance being done prior to December and there should be.

4. During a concurrent observation and interview on 12/6/24, at 3:39 p.m., with the sterile processing department lead technician (SPDLT), in the sterile processing department (in the clean room) an orthopedic surgical instrument tray and a neurological spine surgical instrument tray were observed wrapped and ready to go into the autoclave (a machine that uses steam under pressure to kill harmful bacteria, viruses, fungi, and spores on items that are placed inside a pressure vessel) to be sterilized. When asked what the maximum amount a surgical instrument tray can weigh for proper sterilization, SPDLT verbalized 25 pounds is the weight limit. When asked if the orthopedic tray and the neurological spine tray had been weighed, SPDLT verbalized the trays had not been weighed. When asked to weigh each tray, SPDLT weighed the orthopedic tray on the instrument scale, and it weighed 25.8 pounds. The neurological spine tray was weighed next, and it weighed 29.8 pounds. SPDLT acknowledged both trays were too heavy weighing over the 25-pound weight limit.


When asked what happens when trays exceed the weigh limit, SPDLT verbalized would need to separate instruments out, to meet the weight criteria, before steam sterilization in the autoclave. SPDLT verbalized the process is to weigh the trays each day before being processed in the autoclave. SPDLT further verbalized had just been hired at the facility a week ago and the prior SPD supervisor had not been weighing the surgical instrument trays.


During a review of the facility's policy and procedure (P&P) titled, "Loaner Instrumentation, Acquisition and processing of" revised date 1/2/25, indicated in part ... "Per OSHA standard, all instrument trays will weigh 25 pounds or less ..."


5. During an observation on 12/26/24, at 12:20 p.m., prior to entering operating room (OR 1), a physician assistant (PA) was observed doing a surgical hand scrub at the scrub sink. PA was observed to have long fingernails with red fingernail polish.


During an interview on 12/27/24, at 11:10 a.m., with the surgical services director (SSD), SSD acknowledged and verbalized the PA and anyone who scrubs into surgical cases should not have long or artificial nails.


During a review of the facility's policy and procedure (P&P) titled, "Hand Hygiene" dated 10/29/24, indicated in part ... D. Natural fingernail tips must be trimmed to equal to or less than ¼ inch from the nail bed. Nail polish must not be chipped. Artificial or acrylic nails are not allowed for staff who have direct contact with patients. Studies have shown that chipped nail polish and artificial fingernails can harbor a significant number of microbes, despite hand hygiene with soap and water and/or alcohol-based hand sanitizer ...E. Any form of nail enhancement (UV, gel, shellac, dipped nails, and nails fixed with adhesive) should not be worn when performing scrub role ..."


6. During a concurrent interview and record review on 1/2/25, at 10:19 a.m., with the director of environmental services (DOEVS), the terminal cleaning logs for the operating rooms (OR's) dated 9/1/24 to 12/26/24 were reviewed. DOEVS verbalized terminal cleaning of the OR's are usually done on the second shift 2:30 p.m. to 11:30 p.m. DOEVS verbalized the cleaning checkoff list should be completed each day and documented on the terminal cleaning log. DOEVS verbalized after the OR's have been terminally cleaned the EVS technician will then set up the UV light robot (an automated machine that uses ultraviolet light to a room as an additional step to further disinfect surfaces and kill microorganisms that might have been missed during the standard cleaning process) and document the time it was used in the OR on the terminal cleaning log. DOEVS verbalized the final step of terminal cleaning of the OR's is the final inspection and verification by the EVS lead technician and or the EVS supervisor, and further verbalized is documented on the terminal cleaning log. The terminal cleaning logs from 9/1/24 to 10/8/24 had all the elements completed in the terminal cleaning logs. DOEVS verbalized the terminal cleaning logs changed format on 10/9/24. DOEVS acknowledged on the new terminal cleaning logs dated from 10/9/24 to 12/26/24, the EVS technicians were not documenting the time when the UV light robot had been used. Further review of the new terminal cleaning logs had several dates of missing documentation of the final inspection/verification performed by the EVS lead and/or EVS supervisor. DOEVS verbalized the ORs should have documentation of the final inspection of the OR's documented on the terminal cleaning logs and acknowledged they were incomplete.


7. During a review of the facility's policy and procedure (P&P) titled, "Environmental Cleaning in the perioperative Setting" dated 12/2/24, indicated in part ... "Terminal Cleaning: Done by EVS. Terminal cleaning of each operating and procedure room will be completed with low-linting, disposable microfiber cloth/mop dampened with an EPA-registered and facility- approved disinfecting agent once every twenty-four hours, regardless of whether the room was used ..."
There was no mention of using the UV light robot and/or the final inspection of the room.


During a concurrent interview and record review on 1/2/25, at 10:30 a.m., with the director of environmental services (DOEVS), the Terminal cleaning policy was reviewed. When asked about the UV light robot and the final inspection of the OR's verified by the EVS lead and or EVS supervisor, DOEVS verbalized these steps are to be done every time after the OR's are terminally cleaned. DOEVS confirmed this is our practice. When informed that the Terminal Cleaning Policy did not have the procedural steps of using the UV light robot and the final inspection of the OR's, by the EVS lead technician and or EVS supervisor, DOEVS acknowledged these steps should be outlined in their policy and verbalized this is our facility practice. DOEVS further acknowledged the policy should be updated to reflect the practice of terminal cleaning at the facility.


8. During a concurrent interview and record review on 1/2/25, at 3:09 p.m. with the clinical informatics nurse (CIN), Patient 100's medical record was reviewed. Patient 100's medical record indicated the patient was admitted for left total knee surgery on 10/18/24 at 6:09 a.m. Patient 100's 24-hour history and physical (H&P) update indicated Patient 100 had been examined and the H&P had been reviewed, there were no changes to Patient 100's condition, and was still a candidate for the planned procedure. The 24-hour H&P update was signed by the physician and dated 10/17/24 at 7:18 a.m. When asked if the 24-hour H&P update had the wrong date, CIN acknowledged the physician wrote the date 10/17/24 instead of 10/18/24. CIN verbalized the physician wrote the wrong date and further acknowledged the medical record was not accurate.


During a review of the facility's policy and procedure (P&P) titled, "Medical Record Content and Completeness" dated 12/28/22, indicated in part ... "Completeness: A. The medical record shall be considered complete when the required contents are in the EHR (electronic health record) and authenticated ...B. The medical record will be reviewed by HIM (health information management) associates upon discharge of the patient to ensure its completeness ...C. All entries in the medical record must be legible, dated, timed, and authenticated timely by the author. Signatures must include professional designation status ..."


9. a) During a review of the facility's policy and procedure (P&P) titled, "Admission-Pre-operative Tests/Guidelines" dated 8/19/24, indicated in part ... "iv. Pain management techniques-patients are educated to the 0-10 pain scale. Patients are educated that they will be asked to "rate" their pain using this scale. The RN (registered nurse) using the pain scale will document pain and response to medication on reassessment ..."


During a concurrent interview and record review on 1/3/25, at 9:36 a.m. with the clinical informatics nurse (CIN), Patient 103's medical record was reviewed. Patient 103's medical record indicated the patient was admitted for a fracture of the femur and had surgery on 11/24/24 at 1:05 p.m. Patient 103's medical record indicated Patient 103 was having pain, a 10/10, at 11:05 a.m. on 11/25/24 during occupational therapy (OT). Patient 103's medical record indicated the patient was premedicated with IV Tylenol (medication used to treat pain) at the start of the session. Patient 103's medication administration record (MAR) indicated IV Tylenol 1000 mg was given IV at 5:45 a.m. on 11/25/24. Further review of the MAR had no documentation of the administration IV Tylenol before the OT session. The MAR indicated the next dose of IV Tylenol 1000 mg was given at 6:28 p.m. CIN acknowledged there was no documentation in the MAR that IV Tylenol was given prior to the OT session and there should have been.


Further review of Patient 103's medical record indicted Patient 103 had to stop the OT session due to 10/10 left leg and knee pain when standing. After stopping the OT session, there was no documentation of a pain reassessment after the 10/10 pain on 11/25/24 at 11:05 a.m. CIN acknowledged there was no pain reassessment documented after the OT session had stopped and there should have been.


9. b) During a concurrent interview and record review on 1/3/25, at 10:45 a.m. with the clinical informatics nurse (CIN), Patient 105's medical record was reviewed. Patient 105's medical record indicated the patient was admitted for right total knee surgery on 12/3/24. The medical record indicated Patient 105's pain assessment on 12/5/24 at 1:30 p.m., indicated the patient had leg pain of 7/10. Patient 105's medication administration record (MAR) indicated Oxycodone 10 mg (a medication to relieve severe pain) was given at 1:30 p.m. Patient 105's medical record had no pain reassessment documented after Patient 105 received the Oxycodone. The next pain assessment that was documented in the medical record was at 3:47 p.m. (2 hours and 17 min later) and was documented a 3/10. CIN acknowledged there was no pain reassessment documented after the oxycodone and there should have been. CIN further acknowledged there should be pain assessments performed before and after a pain intervention.


9. c) During a concurrent interview and record review on 1/3/25, at 11:37 a.m. with the clinical informatics nurse (CIN), Patient 106's medical record was reviewed. Patient 106's medical record indicated the patient was admitted for hip fracture surgery on 12/14/24. The medical record indicated Patient 106's pain assessment on 12/17/24 at 3:11 a.m., indicated the patient had hip pain of 7/10. Patient 106's medication administration record (MAR) was reviewed and there was no documentation of any pain medication administration. Further review of Patient 106's medical record had no documentation of any pain intervention and no documentation of a pain reassessment. The next pain assessment was on 12/17/24 at 7:16 a.m. (4 hours and 5 mins later). CIN acknowledged there was no pain intervention documented and no pain reassessment documented for Patient 106 who had a 7/10 hip pain and there should have been.


During a review of the facility's policy and procedure (P&P) titled, "Pain Management" dated 12/8/24, indicated in part ... "Procedure: A. Initial/First Patient Assessment: 1. Screen patient for pain-is the patient in pain now?... 2. If yes to above, assess for the following, and document appropriately. Accept the patient's description of his/her: a. intensity/level of pain ...b. location of pain ...c. duration/frequency of pain ...d. quality of pain ...e. onset of pain ...f. aggravating/alleviating factors ...g. relief measures used/interventions ...B. Reassessment: 1. Pain reassessment will occur once per shift, after pain management interventions, and according to the patient's clinical condition ...2. Reassess pain within 30 minutes to 1 hour after pain medication administration ...3. Reassessment will include at least the following: a. intensity/level of pain (pain scale number) ... b. location ...c. sedation level when opioids are in use ...4. Document the reassessment ..."







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10. During a concurrent interview and record review on 1/2/25, from 3:18 p.m. until 4:18 p.m. with the surgical services manager (SSD), Patient 301's medical record was reviewed. Patient 301's medication administration record (MAR) indicated Morphine 2mg (a medication to relieve severe pain) was given at 12:47 p.m. on 10/25/24. Patient 301's medical record had no pain reassessment documented after Patient 301 received the Morphine. SSD acknowledged there was no pain reassessment documented after the Morphine and there should have been.


During a concurrent interview and record review on 1/3/25, from 9:23 a.m. until 11:30 a.m. with SSD, Patient 303's medical record was reviewed. Patient 303's MAR indicated Norco 5-325mg (a medication to relieve severe pain) was given at 5:43 p.m. on 11/06/24. Patient 303's medical record had no pain reassessment documented after Patient 303 received the Norco. SSD acknowledged there was no pain reassessment documented after the Norco and there should have been.


During a concurrent interview and record review on 1/3/25, from 9:23 a.m. until 11:30 a.m. with SSD, Patient 304's medical record was reviewed. Patient 304's MAR indicated Percocet 5-325mg (a medication to relieve severe pain) was given at 3:12 a.m. on 11/14/24. Patient 304's medical record had no pain reassessment documented after Patient 304 received the Percocet. SSD acknowledged there was no pain reassessment documented after the Percocet and there should have been.


During a concurrent interview and record review on 1/3/25, from 9:23 a.m. until 11:30 a.m. with SSD, Patient 305's medical record was reviewed. Patient 305's MAR indicated Acetaminophen 650mg (a medication to relieve mild pain) was given at 3:37 a.m. on 12/6/24. Patient 305's medical record had no pain reassessment documented after Patient 305 received the Acetaminophen. SSD acknowledged there was no pain reassessment documented after the Acetaminophen and there should have been.


During a review of the facility's policy and procedure (P&P) titled, "Pain Management" dated 12/8/24, indicated in part ... "Procedure: A. Initial/First Patient Assessment: 1. Screen patient for pain-is the patient in pain now?... 2. If yes to above, assess for the following, and document appropriately. Accept the patient's description of his/her: a. intensity/level of pain ...b. location of pain ...c. duration/frequency of pain ...d. quality of pain ...e. onset of pain ...f. aggravating/alleviating factors ...g. relief measures used/interventions ...B. Reassessment: 1. Pain reassessment will occur once per shift, after pain management interventions, and according to the patient's clinical condition ...2. Reassess pain within 30 minutes to 1 hour after pain medication administration ...3. Reassessment will include at least the following: a. intensity/level of pain (pain scale number) ... b. location ...c. sedation level when opioids are in use ...4. Document the reassessment ..."



11. During an interview on 12/26/24, at 2:30 p.m., with the surgeon (MD 1), MD 1 stated I performed a total knee replacement on Patient 300 on 10/24/24, during the procedure an instrument called the "pants" was used, it holds the pins in place, the instrument had a white substance on it, I think it was cement. Additionally, MD 1 stated I didn't notice the instrument had a white substance on it until it was already in the patient, and at that point the patient was already contaminated. MD 1 was asked if the white substance was sterile and stated, "I don't know, I don't know what the protocol is." MD 1 was asked if the other instruments that were in the tray with the "pants" were contaminated and stated yes the would be. Asked MD 1 if he noticed the white substance on the "pants" could it and the other instruments in the tray be replaced and MD 1 stated, "I don't know what the protocol is." Asked MD 1 when MD 1 noticed the white substance on the "pants" and MD 1 stated, "I don't remember exactly when I noticed the cement on the instrument."


During an interview on 12/26/24, at 3:12 p.m., with the surgical services director (SSD), the SSD stated when I spoke to the scrub technician (ST 2), ST 2 told me that a new instrument was offered to MD 1 prior to it being placed in Patient 300, that ST 2 handed the instrument to MD 1 and MD 1 verbalized what is this white residue. Additionally, SSD stated the sterile processing department supervisor (SPDS) was called and offered MD 1 a new instrument and tray. Furthermore, SSD stated that MD 1 did have an opportunity to stop and get a whole new set up as we have back up trays that could have been used.


During an interview on 12/27/24, at 10:00 a.m., with registered nurse (RN 2), RN 2 stated I was the circulating nurse during Patient 300's surgery, I heard MD 1 say there is a white substance on this instrument and I heard ST 2 offering MD 1 to get a replacement instrument. Additionally RN 2 stated I called the charge nurse and SPDS, the SPDS came up and was outside the OR and heard the SPDS offer MD 1 a new instrument tray and MD 1 said no.


During a concurrent interview and record review on 12/27/24, at 10:43 a.m., with the SSD, the SSD stated we found two contaminated instruments, one on 10/24/24 and another on 11/19/24 after the instruments had been sterilized and prepared for use the two instruments had a white substance on them. SSD stated the first contaminated instrument was found during a surgical procedure.


During an interview on 12/27/24, at 11:50 a.m., with ST 2, ST 2 stated I was the scrub tech during Patient 300's surgery, that had the contaminated instrument it is called the "pants". ST 2 stated MD 1 said what is this white substance looks like cement. ST 2 stated I asked MD 1 do you want another new instrument and MD 1 did not respond. Additionally ST 2 stated RN 2 reported the contaminated instrument. Furthermore, ST 2 stated SPDS came up with a red bin to get contaminated tray and instrument and offered MD 1 a new instrument tray, this was the second opportunity to take contaminated instruments off the sterile field. Also ST 2 stated the surgical services manager (SSM) came up to the OR door and MD 1 stated he should have waited until all my cases were done to say anything now I'm delayed. ST 2 acknowledged that MD 1 had an opportunity to give back the contaminated instruments and change them out for new instruments before deciding to keep going with the case.


According to AORN's (Association of perioperative Registered Nurses) book titled, "Guidelines for Perioperative Practice," copyright 2021, the guidance indicated, in part, "Instrument Cleaning: Cleaning Verification and Inspection ... Repeat the decontamination process if retained soil is seen ... inspect and evaluate items for cleanliness ... the absence of corrosion ... any other defects ... use of instruments that are not thoroughly cleaned, are damaged, or do not function correctly poses a risk to patients ... provide education and verify competency for specific knowledge and skills related to cleaning and care of surgical instruments including the following: location and understanding of manufacturers' IFU for the reusable surgical instrument or medical device, decontamination equipment (eg, washer-disinfectors, ultrasonic cleaners) ... process failure response protocols ... preventative maintenance requirements or recommendations are what the device manufacturer has determined are necessary to keep instruments and equipment in optimal working order is essential for patient and user safety ... maintain records of instrument, equipment, and other medical device maintenance and service ..."

Based on interview and record review the infection preventionist (IP) failed to collaborate with the antibiotic stewardship program leader on the antibiotic stewardship priority.

This failure resulted in no communication and collaboration between the IP and the antibiotic stewardship pharmacist leading the antibiotic stewardship program.


Finding:


During a concurrent review of the 2024 Infection Surveillance and Prevention Plan, and interview with the infection prevention nurse IPN) on 12/26/24 at 11:19 a.m., the IPN was asked to explain the infection preventionists (IPs) collaboration in the antibiotic stewardship program since the antimicrobial (antibiotic) stewardship is one of the priorities in the infection prevention plan. The IPN stated "The antimicrobial stewardship is not something we do. The pharmacist does this. All I know is that it's chaired by the pharmacist. They collect data ... [IPs name] and I don't get involved with this, this belongs to the pharmacist."


During a concurrent review of the 2024 Infection Surveillance and Prevention plan and interview with the director of pharmacy (DOP) on 12/27/24 at 9:15 a.m., the plan's priority #4 antimicrobial (antibiotic) stewardship was discussed. DOP was asked about the collaboration between the IP and DOP regarding the antimicrobial stewardship priority. DOP stated "[IP's name] and I have not talked or collaborated about the antimicrobial stewardship priority. These strategies or interventions I have no idea what they are or where they came from."

Based on interview and record review the antibiotic stewardship program leader failed to create and provide a formal statement to support for antibiotic stewardship.

This failure resulted in the antibiotic stewardship program not having a formal support statement.


Finding:


During a concurrent review of the 2024 Infection Surveillance and Prevention plan and interview with the director of pharmacy (DOP) on 12/27/24 at 9:25 a.m., the plan's priority #4 antimicrobial (antibiotic) stewardship indicated one of the strategies and interventions was to provide a formal statement of support for antibiotic stewardship. The DOP was asked what this was and to provide evidence or documentation supporting that this was performed.


During another interview with the DOP on 12/27/24 at 10:45 a.m., the DOP confirmed not knowing what this was or meant and that this was not performed. DOP stated, "I have no idea what a formal statement for the antibiotics stewardship is or if this was done."

Based on interview and record review the antibiotic stewardship program leader failed to communicate to staff about stewardship activities.

This failure resulted in facility staff not being aware of the antibiotic stewardship program activities.


Finding:


During a concurrent review of the 2024 Infection Surveillance and Prevention plan and interview with the director of pharmacy (DOP) on 12/27/24 at 9:20 a.m., the plan's priority #4 antimicrobial (antibiotic) stewardship indicated one of the strategies and interventions was to communicate to staff about stewardship activities. The DOP confirmed leading the antibiotic stewardship program. DOP was asked to provide evidence or documentation supporting communication to staff about stewardship activities have occurred.


During another interview with the DOP on 12/27/24 at 12:00 p.m., the DOP acknowledged and confirmed the facility's staff have not been provided with any communication regarding antibiotic stewardship activities that have been occurring throughout the year.

Based on interview and record review the antibiotic stewardship leader failed to provide antibiotic stewardship competency- based training to hospital staff including medical staff.

This failure resulted in the hospital staff including medical staff not being trained on antibiotic stewardship activities.


Finding:


During a concurrent review of the 2024 Infection Surveillance and Prevention plan and interview with the director of pharmacy (DOP) on 12/27/24 at 12:15 p.m., the plan's priority #4 antimicrobial (antibiotic) stewardship indicated one of the strategies and interventions was provide opportunities for hospital staff training on antibiotic stewardship. The DOP was asked if hospital staff such as nursing, pharmacy technicians, and medical providers have been provided with antibiotic stewardship training. The DOP explained the hospital staff receive annual education including infection control and antibiotic stewardship education. The DOP was asked if this annual education that the staff receives is it specifically to the current or active antibiotic stewardship activities in the hospital or is its general education. The DOP stated "The antibiotic stewardship education that the hospital staff receive including the medical staff is general education. The hospital staff such as nursing and medical staff have not received training on current antibiotic stewardship activities specifically to this hospital."