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Based on review of the Governing Body Bylaws and Medical Staff Bylaws, physician credentialing files, and interview, the hospital failed to ensure the Governing Body appointed members of the medical staff after considering the recommendations of the existing members of the medical staff for four (Nurse Practitioner (NP) 1, Physician (Phys) 1, Phys2, Chief Medical Officer (CMO)) of six medical staff credentialing files reviewed for governing body appointment. This deficient practice had the potential to affect all patients receiving medical services at the hospital.

Findings include:

Review of the "Bylaws of [name of hospital board]," approved 01/31/24, indicated ". . . Responsibilities Of The Board - The activities, affairs, and property of the Corporation shall be managed, directed and controlled by the Board, except as otherwise provided in these By-Laws. The duties of the Board of Directors shall be to oversee the work and finances of the Corporation; to ensure that the work and finances of the Corporation are conducted in accordance with the Articles of Incorporation and the By-Laws; to appoint the officers; to approve an annual budget for the Corporation; and auditor's statements and to generally guide and direct the work of the Corporation in the performance of its purpose and mission. In exercising these responsibilities and managing the affairs of the Corporation, the Board, and the individual Directors thereof, are required to discharge their duties in good faith and with that degree of diligence, care, skill, and accountability which ordinarily prudent people would exercise under similar circumstances in like positions.

Review of the "Medical Staff Bylaws," dated 09/27/24, indicated ". . . The Chief of Staff reviews the application [for appointment or reappointment] for completeness and verifies the application materials. No action shall be taken on an application until all information required by these Bylaws is available and verified. The Chief of Staff then forwards the completed, reviewed application to the appropriate Department Chief, who reviews the application and makes a recommendation to the Medical Executive Committee The Medical Executive Committee reviews the application, and makes a recommendation, which is forwarded to the Board of Directors for final approval. . ."

Review of NP1's credentialing file indicated reappointment and privileges were approved by the MEC (Medical Executive Committee) on 12/12/24 and signed by the Governing Board President or Chair of the Board Credentialing Subcommittee on 12/17/24 without designation whether the reappointment was approved or denied (the line for "Approved" or "Denied" was not checked).

Review of Phys1's credentialing file indicated reappointment and privileges were approved by the MEC on 12/12/24 and signed by the Governing Board President or Chair of the Board Credentialing Subcommittee on 12/17/24 without designation whether approved or denied (the line for "Approved" or "Denied" was not checked).

Review of Phys2's credentialing file indicated reappointment and privileges were approved by the MEC (Medical Executive Committee) on 12/12/24 and signed by the Governing Board President or Chair of the Board Credentialing Subcommittee on 12/17/24 without designation whether the reappointment was approved or denied (the line for "Approved" or "Denied" was not checked).

Review of CMO's credentialing file indicated reappointment and privileges were approved by the MEC on 03/13/25 and signed by the Governing Board President or Chair of the Board Credentialing Subcommittee on 03/27/25 without designation whether approved or denied (the line for "Approved" or "Denied" was not checked).

During an interview on 05/09/25 at 1:30 PM, Chief Executive Officer (CEO) reviewed the above credentialing files and confirmed the designation of whether each was approved or denied was not documented. CEO stated the Chief of Staff or the Executive Medical Committee should check to see that all required documentation was complete.

Based on policy review, "Medical Staff Rules and Regulations" review, observation, patient medical record review, and interviews, the hospital failed to ensure the registered nurse (RN): 1. assured the telemetry monitor was set by the telemetry monitor technician to alert the physician to abnormal vital signs in accordance with physician orders for two (Patient (P) 10 and P13) of two patients with telemetry orders reviewed; 2. informed the physician when a diabetes teaching consult was not performed as ordered for one (P1) of one patient record reviewed with orders for a diabetic consult; 3. performed a CIWA (Clinical Institute Withdrawal Assessment of Alcohol Scale) assessment as ordered by the physician for one (P9) of one patient record reviewed with orders for a CIWA assessment from a sample of 30 patient and three supplemental patients; and 4. monitored the expiration dates of lab tubes on the nursing units so expired lab tubes were not available for use. These deficient practices had the potential to affect all patients receiving services at the hospital.

Findings include:

1.Review of the hospital policy titled "Centralized Telemetry Monitoring of MSU [Medical/Surgical Unit] Patients," last revised 04/08/24, indicated ". . . Certified Telemetry Technicians (CTT) responsibilities: . . . 3. Continuously monitor the heart rates and rhythms of all patient on telemetry. 4. lnterpret and print rhythm strips at the beginning of each shift, every 4 hours (0800, 1200, 1600, 2000, 0000, and 0400 [8:00 AM, 12:00 PM, 4:00 PM, 8:00 PM, 12:00 AM, and 4:00 AM]), and with any rhythm changes. 5. Secure all printed strips to an EKG Rhythm Strip Sheet and placed in the telemetry binder. The EKG Rhythm Strip sheet must be completely filled out and signed. 6. Set default heart rate parameter settings: lower limit is 50 beats per minute and upper limit setting is 120 beats per minute. . . 9. Complete a narrative note in the EHR for rhythm changes and RN notifications. . ." The policy did not address the monitoring of blood pressure and the nurse's responsibility to review the rhythm strips every four hours when the strips were placed in the telemetry monitor's binder.

Observation on 05/06/25 at 2:20 PM in the room where the telemetry monitor technician monitors the rhythm of all patients ordered to be on telemetry revealed Telemetry Technician (Tele) 1 had P10 and P13 being monitored.

a.Review of P10's physician orders (shown to the surveyor by Tele1) on 05/06/25 at 2:20 PM revealed an order to call the physician for a blood pressure less than 100 diastolic, pulse less than 60, and pulse greater than 120. During the observation and interview, Tele1 stated the nurse was supposed to set the blood pressure and pulse parameters. Tele1 confirmed the telemetry monitor was not set to monitor the diastolic blood pressure.

Review of P10's electronic medical record (EMR) indicated an order located under the "Orders" tab by Physician (Phys) 1 on 05/06/25 at 8:03 AM for telemetry and continuous pulse oximetry and to call for systolic blood pressure less than 100, diastolic blood pressure greater than 120, pulse less than 60, and pulse greater than 120. Further review indicated an order by Phys1 on 05/06/25 at 11:32 AM to decrease the low heart rate alarm on the telemetry monitor to 40 beats per minute. Observation on 05/06/25 at 2:20 PM revealed the telemetry monitor was not set at these parameters.

b.Review of P13's physician orders (shown to the surveyor by Tele1) on 05/06/25 at 2:20 PM revealed physician orders for telemetry and continuous pulse oximetry and diastolic blood pressure less than 100, pulse less than 60 and greater than 120 with no parameters for the oxygen saturation. Observation revealed the telemetry monitor was set at systolic blood pressure high rate of 100 and low rate of 95.

During an interview on 05/06/25 at 2:40 PM, Tele1 stated he/she only notified the nurse if the oxygen and heart rate were not set according to the physician orders.

Review of P13's EMR under the "Orders" tab, indicated an order by Phys2 on 05/05/25 at 5:22 PM for temperature, pulse, respiration, and blood pressure check every eight hours and to call for systolic blood pressure less than 100, diastolic blood pressure greater than 120, pulse less than 60, and pulse greater than 120. Observation on 05/06/25 at 2:20 PM revealed the telemetry monitor was not set at these parameters.

During an interview on 05/09/25 at 12:37 PM with Tele1 and Acting Director of Nursing (ADON) present, Tele1 presented the manual kept by the telemetry technicians with the patient's monitor strips that were run at times according to hospital policy. Review indicated each strip was interpreted, signed by the telemetry technician, and the RN on the unit. The ADON stated the telemetry monitors were not set up to monitor patients' blood pressures. The ADON stated the monitors allow for blood pressure monitoring, but they had not begun to set it up as such, because they had not developed the policy for doing so yet.

2. Review of the "Medical Staff Rules and Regulations" dated 09/27/24 indicated ". . . Each consultation report should contain a written clinical assessment and recommendations by the consultant that reflects an examination of the patient and the patient's medical record. This report shall be made a part of the patient's record. . . Inpatient consultation reports shall be
completed on same day as the consultation requested. . ."

Review of P1's EMR physician order located under the "Orders" tab by Phys2 on 05/04/25 at 8:54 AM indicated an order for a consult on diabetic management teaching due to insulin noncompliance.

Review of P1's medical record indicated no documentation that a diabetic management teaching consult was performed.

During an interview on 05/08/25 at 11:17 AM, RN6 confirmed there was no documentation in P1's medical record that a diabetic management teaching consult was performed.

3. Review of P9's EMR "Orders" tab indicated an order by Phys3 on 05/05/25 at 5:05 AM for "CIWA PROTOCOL / MSU [medical/surgical unit] 1. Do vitals 2. Determine Flowchart . . . CIWA Assessment using Clinical Indicator Withdrawal Assessment . . . CIWA score < [less than] 8
a. Continue Ciwa [sic] scoring and vital signs q4h x 48hr, then q6h x 24hr
b. No alcohol-related medication treatments required
CIWA score 8-15
a. Continue Ciwa [sic] scoring and vital signs q1h [every one hour] b. If score is 8 or greater after 4 hr x 48 hr [four hours times 48 hours] then q6h x 24hr [every six hours times 24 hours] b. No alcohol related medication treatments required CIWA score 8-15 a. Continue Ciwa [sic] scoring and vital signs q1h [every one hour] b. If score is 8 or greater after 4 hrs [hours] with medications given per orders, call MD [medical doctor] to discuss patient transfer to ICU [intensive care unit] c. For alcohol related medication treatments - see med [medication] orders"

Review of P9's EMR located under the "Notes" tab indicated P9's CIWA assessment on 05/05/25 at 3:10 AM had a score of 6. Further review indicated P9's assessment and vital signs were not documented in accordance with Phys3's orders.

During an interview on 05/08/25 at 2:45 PM, RN6 confirmed P9's CIWA assessment and vital signs were not documented as ordered by Phys3.

4. Observation on 05/06/25 at 11:00 AM on the pediatric unit revealed a lab cart with 14 lavender pediatric micro containers that expired on 04/30/23, two green vacuettes that expired on 03/06/25, and four orange vacutainers that expired on 04/30/25. Further observation on 05/06/25 at 11:15 AM on the pediatric unit revealed the third drawer of the crash cart had two green microtainers that expired 11/30/24 and two lavender microtainers that expired 04/30/25. These lab supplies were available to be used by the nursing staff.

During an interview on 05/06/25 at 11:15 AM, RN1 stated the supply technician was responsible for checking expiration dates of lab supplies in the supply room. RN1 stated once the lab supplies were placed on the nursing unit, it was the responsibility of the nurses and certified nursing assistants to check for expiration dates.

Based on policy review, patient medical record review, and interview, the hospital failed to ensure the patient's nursing care plan reflected the patient's goals and the nursing care to be provided to meet the patient's needs for five (Patient (P) 1, P7, P16, P17, and P18) of 16 patient records reviewed for the nursing care plan from a sample of 30 patients and three supplemental patients. This deficient practice had the potential for unidentified and unmet care needs and goals important to the patients.

Findings include:

Review of the hospital policy titled "Patient Care Plans for Inpatient Units," effective 09/09/22, indicated ". . . B. Each patient's nursing care is individualized based on identified patient care needs and patient care standards and is consistent with the therapies of other disciplines. C. Evaluation shall include assessing the patient's individualized care needs, patient's health status/ conditioning and patient's response to interventions. . ." The policy did not address goals in relation to the nursing care to be provided to meet the patient's needs.

Review of the hospital policy titled "ACU [Adolescent Care Unit] Nursing Care Plan," effective 04/08/25, indicated ". . . The individualized nursing care plan includes: a. Nursing assessment to identify patient's needs by collecting subjective and objective data from the patient, family/legal guardian, and/or from the ACU clinical team when necessary. b. Patient's individualized existing and/or potential nursing diagnoses. c. Short-term and long-term (when necessary) nursing goals with measurable outcome through planning. D. Implementation of nursing interventions to meet planned goals. . ."

1.Review of P1's electronic medical record (EMR) under the "Notes" tab indicated P1 was admitted on 05/04/25 at 9:23 AM with diagnoses of diabetic ketoacidosis, type II diabetes mellitus, and personality disorder. Review of P1's nursing care plan located under the "Notes" tab developed on 05/04/25 at 10:40 AM indicated the problems identified included electrolyte imbalance risk, hyperglycemia risk, anxiety, and pain. Review indicated goals for electrolyte imbalance was "The patient will maintain electrolyte levels within normal parameters." The goal for hyperglycemia risk was "The patient will maintain appropriate glucose levels." The goal for pain was "The patient will identify factors that relieve pain. The patient will verbalize or demonstrate relief from pain." There was no documentation that the nursing care plan goals were written as measurable goals that reflected the nursing care to be provided to meet the patient's needs.

2.Review of P7's EMR under the "Notes" tab indicated P7 was admitted on 05/01/25 at 11:07 PM with diagnoses of urinary retention and urinary tract infection. Review of P7's nursing care plan developed on 05/01/25 at 11:16 PM indicated the problems identified were acute pain, infection risk, and knowledge deficiency. Review indicated goals for acute pain were "The patient and family (as appropriate) will identify factors that relieve pain. The patient will verbalize or demonstrate relief from pain." The goals for infection risk were "The patient will remain afebrile. The patient will have no sign of erythema or purulent drainage. The patient and family (as appropriate) will verbalize understanding the signs and symptoms of infection." The goal for knowledge deficiency was "The patient and family (as appropriate) will demonstrate knowledge retention related to lower urinary tract infection. The patient will demonstrate behaviors congruent with expressed knowledge." There was no documentation that the nursing care plan goals were written as measurable goals that reflected the nursing care to be provided to meet the patient's needs.

3.Review of P16's EMR under the "Notes" tab indicated P16 was admitted on 05/05/25 at 12:34 PM with diagnoses of major depressive disorder (MDD), generalized anxiety disorder, and alcohol use disorder. Review of P16's nursing care plan developed on 05/05/25 at 4:28 PM indicated the identified problems were altered social interaction, anxiety, coping impairment, impaired family dynamics, social isolation, and knowledge deficiency. Goals for altered social interaction indicated "The child will demonstrate positive changes in social interactions." The goal for coping impairment indicated "The child and family or caregiver (as appropriate) will identify appropriate coping behaviors. The child will develop appropriate coping behaviors. The child wi1l use appropriate coping behaviors." The goal for impaired family dynamics indicated "The child and family or caregiver (as appropriate) will verbalize problems and feelings. The child and family or caregiver (as appropriate) will demonstrate appropriate coping strategies." The goal for social isolation indicated "The chi1d will increase social interactions." The goal for knowledge deficiency indicated "The child and family or caregiver (as appropriate) will demonstrate knowledge retention related to depression. The child and family or caregiver (as appropriate) will demonstrate behaviors congruent with expressed knowledge. Review of the nursing goals indicated they were not written with measurable outcome in accordance with the ACU policy.

4.Review of P17's EMR under the "Notes" tab indicated P17 was admitted on 05/06/25 at 11:22 AM with diagnoses of ADHD (attention deficit hyperactive disorder), cannabis use disorder, and rule out MDD, generalized anxiety disorder, and PTSD (post-traumatic stress disorder). Review of P17's nursing care plan developed on 05/06/25 at 4:00 PM indicated identified problems included impulsivity, coping impairment, anxiety, and altered social interaction. Review of the goals for coping impairment indicated "The child and family or caregiver (as appropriate) will identify appropriate coping behaviors. The child will develop appropriate coping behaviors. The child wi1l use appropriate coping behaviors." The goal for altered social interaction indicated "The patient will demonstrate positive changes in social interactions." Review of the nursing goals indicated they were not written with measurable outcomes in accordance with the ACU policy.

5.Review of P18's EMR under the "Notes" tab indicated P18 was admitted on 05/06/25 at 10:53 AM with diagnoses of MDD and ADHD. Review of P18's nursing care plan developed on 05/06/25 at 8:21 PM indicated the identified problems included coping impairment, social isolation, suicide attempt risk, altered social interaction, impulsivity, anxiety. Review of the goal for coping impairment indicated "The child and family or caregiver (as appropriate) will identify appropriate coping behaviors. The child will develop appropriate coping behaviors. The child wi1l use appropriate coping behaviors." The goal for social isolation indicated "The chi1d will increase social interactions." The goal for altered social interaction indicated "The patient will demonstrate positive changes in social interactions." Review of the nursing goals indicated they were not written with measurable outcomes in accordance with the ACU policy.

During an interview on 05/08/25 at 9:53 AM with Chief Executive Officer (CEO), Chief Medical Officer (CMO), and Nurse Practitioner (NP) 1, NP1 stated he/she had reviewed the nursing care plans of the patients on the ACU. NP1 stated the nursing goals were not individualized and were not measurable.

During an interview on 05/09/25 at 12:37 PM, Acting Director of Nursing (ADON) offered no explanation for the nursing goals on the nursing care plans, not being measurable and not being reflective of the nursing care to be provided to meet the patient's needs.

Based on policy review, medical record review, review of controlled substance logs, and interviews, the hospital failed to ensure controlled substances were monitored in accordance with hospital policy. This deficient practice had the potential to affect all patients receiving services of the hospital.

Findings include:

During a tour of the surgical department on 05/06/25 at 10:00 AM, The binder labeled "Controlled Drugs" set on a cart. During review of the binder, the forms inside were titled "Controlled Drug Inventory Log" and read "All controls must be counted Q24H [every 24 hours]." The forms were dated, and the following was observed:
January 2025 was not signed off for Tuesday 01/07/25, Thursday 01/09/25, and Friday 01/10/25.
March 2025 was not signed off for Friday 02/14/25 and Tuesday 03/04/25.
April 2025 was not signed off for Friday 04/04/25, Thursday 04/10/25, Friday 04/11/25, Thursday 04/24/25, Friday 04/25/25, Monday 04/28/25, and Wednesday 04/30/25.

During an interview on 05/06/25 at 10:10 AM, Interim Nurse Executive (INE)1 was asked about the blanks on the forms. INE1 stated there should not be any blanks except on the weekends when no one is here. There should be two nurses that sign off on the count. INE1 stated there was an in service in January 2025 to remind staff to sign off on the forms.

Review of the hospital's policy titled, "OR Surgical Staff Scope of Responsibility" last revised on 05/05/25 revealed, "Purpose: Delineate the responsibilities of the staff. Policy: The provision of nursing services for all types of elective and emergency surgeries. Procedure: Lead Clinical /Charge Nurse: A professional nurse who plans, directs, coordinates, controls, administers, and evaluates care given to patients. The Charge nurse directly supervises and teaches members of the nursing team. Duries include. . .3. Ensure the daily narcotic count is completed and documented. . ."

Based on observation, interview, and policy review, the hospital failed to ensure medical records were stored in secure locations where they were protected from potential water damage if the sprinkler system became activated. This deficient practice had the potential to affect all stored paper records kept on shelving in the medical record department that were protected from fire by a sprinkler system.

Findings include:

Review of the hospital policy titled "Water Damage Policy," revised 07/28/09, indicated ". . . It is the policy of [name of hospital] to provide a contingency plan in the event records are damaged due to flood. Any type of damage is destructive. Water damage from flood or fire can be the most devastating. PURPOSE: To establish a written standard procedure for medical records department in the event records are damaged due to flood and/or fire sprinkler. Procedures: I. Determine what documentation should be rescued by using the retention requirements. II. Prioritize which records should be removed first in order to keep the hospital functioning. III. Records are to be removed within 48 hours of damage to prevent mold, mildew, and bacterial growth. IV. Depending on the degree of damage, the records can be restored by:
A. Air drying the records by placing absorbent material between each document and then fans are used for increased air circulation. B. Freezing the records and keeping them in cold storage. This process stops the deterioration of handwritten data on paper records.
C. Freeze drying is the quickest and most expensive method. Only for optimal preservation of original records that are totally irreplaceable. . ." Review of the policy indicated there was no method developed to keep the medical records from being exposed to the sprinkler system.

Observation on 05/09/25 at 9:10 AM revealed there was a five-inch stack of medical records that had not been scanned before being reviewed by the quality analysts. Further observation revealed 29 columns of a rolling shelving unit filled with medical records waiting to be purged and sent to the off-site storage facility. Observation revealed there was no protection between each column when rolled shut to protect the records if the sprinkler was activated.

During an interview on 05/09/25 at 9:30 AM with Director of Risk management (DRM), Chief Financial Officer (CFO), and Health Information Management Supervisor (HIMS) present, all in attendance confirmed more than 1000 patient records were not protected from potential water damage if the sprinkler system was activated.

Based on observations, policy review, and interviews, the food service director failed to ensure 1. kitchen equipment was maintained to ensure an acceptable level of safety and quality related to the three-compartment sink and documentation of the dishwasher temperature logs and 2. implementation of safe practices for food handling by having expired food items available for use in refrigerators on the patient care units. These deficient practices had the potential to affect all patients receiving services in the hospital.

Findings include:

1. Review of the hospital's policy titled, "Guideline for Kitchen Sanitation" last revised 12/20/14, revealed, "Purpose: To prevent cross-contamination of all food preparation areas, serving line, dining areas and appliances shall be cleaned or sanitized after each use. Policy: The Hospital Food Services will make every effort to meet the safety and sanitation compliance of federal, state, and local laws and regulations. Procedures. . . t. Dish Machine Temperatures must be recorded at 7:00 a.m., 12:00 p.m., and 6:00 p.m. 12. Three-Compartment Sink. . .b. Temperatures shall be recorde on three- compartment sink temperatures record sheet during each refill. . ."

During a tour on 05/06/25 at 11:30 AM, review of the dishwasher indicated it was a high temperature dishwasher. Review of the "Dish Machine Temperature Chart" revealed temperatures were not recorded on 05/02/25 for 7:00 AM, and there were no recorded temperatures for 05/0125- 05/04/25 for 6:00 PM.

Also, during the tour, review of the "Three Compartment Sink Temperature Record was completed. There was a blank for an early check on 05/02/25.

During an interview on 05/06/25 at 11:45 AM, the Director of Nutritive Services (DNS) was asked about the blanks on the chart for the dish machine and the record for the three compartment sink. The DNS stated there should be no blanks on the two forms. They should be filled in completely.

2. Review of the hospital policy titled "Patient Meal Services, Diet Orders, and Tray Delivery," last revised 07/08/15, indicated ". . . Foods shall be rotated so that the oldest items are the first used. Date all opened items. If canned, put into a clean contained cover and date. Opened cartons shall be used before another is opened. . . Food Supplies a. Each morning the bulk nourishment forms will be inventoried by the FSW [food service worker] on MSU/PEDS [Medical Surgical Unit/Pediatrics], OB [Obstetrics] and ICU [Intensive Care Unit] inpatient wards and the outpatient clinic areas. The Food Service Worker will determine what supplies are below the par level and replenish these items. The bulk nourishment's [sic] are delivered [sic] 2:30 p.m. b. The FSW will check and rotate perishable items following the first-in/first-out system so that spoilage does not occur. All perishables must be discarded every three days. The foods items must be label [sic] & [and] dated. c. The perishable food items are discarded according to the expiration date or color codes. . ."

Observation on 05/06/25 at 10:30 AM revealed the inpatient refrigerator in the kitchen on the Medical/Surgical Unit had the following outdated food items available for use: one slice of bread with a use by date of 05/06/25 at 9:07 AM; a turkey sandwich with no cheese with a use by date of 05/06/25 at 8:17 AM; seven individual containers of Jello with a use by date of 05/06/25 at 8:03 AM.

During an interview on 05/06/25 at 10:40 AM with Inpatient Supervisor (InSup) and Dietary Technician (DT) 1 present, DT1 stated the dietary technician checks the par level between 7:00 AM and 7:30 AM and checks the refrigerator temperature. DT1 stated the scheduled time to replace the needed food items in the refrigerator is usually after lunch. InSup stated the dietary technician should have discarded the expired food items at the time the par level check was done.

Observation on 05/06/25 at 1:20 PM on the Adolescent Care Unit revealed the refrigerator used to keep patient nourishments had the following food items that were expired and available for use: five containers of Jello with a beyond use date of 05/06/25 at 8:07 AM; four cups labeled as 1% milk with a beyond use date of 05/05/25 at "end of day." Observation on 05/06/25 at 1:25 AM in the "ACU [Adolescent Care Unit] Healthy Cooking Class Activities Only" room revealed the refrigerator had an opened, undated bag of blue cornmeal and an undated and opened bag of chocolate chips available for use.

During an interview on 05/26/25 at 1:25 PM with Chief Executive Officer (CEO) and Acting Director of Nursing (ADON) present, CEO stated the expired food items should have been discarded, and the undated, opened bags of corn meal and chocolate chips should have been labeled with the dates each bag was opened.


25065

Based on observation, interviews, and policy review, the hospital failed to ensure appropriate hand hygiene/glove use, hand sanitizer units were maintained, and containers of Sani-Cloth (disinfectant wipes) were available for use. These deficient practices had the potential to increase transmission of bacteria and viruses.

Findings include:

1.Review of the hospital policy titled "Hand Hygiene," last revised 06/14/23, indicated ". . . A. According to the CDC [Centers for Medicare and Medicaid Services] hand hygiene guidelines, employees should perform hand hygiene as follows: 1. When hands are visibly soiled with blood or other body fluids, wash hands with either a non-antimicrobial soap and water or an antimicrobial soap and water 2. If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all other clinical settings 3. Decontaminate hands before:
a. Having direct contact with patients b. Before donning sterile gloves with any procedure c. After contact with a patient's intact skin (e.g., [for example] when taking a pulse or blood pressure and lifting a patient) d. After contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings if hands are not visibly soiled e. If moving from a contaminated body site to a clean-body site during patient care f. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient g. After removing gloves h. Before eating and after using a restroom . . ."

Observation on 05/07/25 at 11:00 AM on the Medical/Surgical Unit with Chief Executive Officer (CEO) and Acting Director of Nurses (ADON) present revealed Registered Nurse (RN) 5 performed a glucose check for Patient (P) 11. Continuous observation revealed RN5 completed the fingerstick to obtain a blood sample. Observation revealed after performing the fingerstick, RN5 documented the results on note paper and used his/her pen without removing contaminated gloves and performing hand hygiene. Observation revealed RN5 donned a new set of gloves after performing hygiene to clean the glucometer (machine used to perform the glucose test). While wearing the same gloves, RN5 wiped the counter with a Sani-Cloth disinfectant wipe and placed the disinfected glucometer on the wiped counter. Observation revealed RN5, while wearing contaminated gloves (from disinfecting the glucometer), opened the drawer under the counter to place the container of test strips. RN5 then removed his/her gloves and performed hand hygiene.

During an interview on 05/07/25 at 11:15 AM, RN5 confirmed he/she did not remove his/her gloves after performing the glucose check before documenting the results. RN5 denied placing the container of strips in the drawer with contaminated gloves. RN5 stated he/she removed his/her gloves before placing the container of strips in the drawer. Observation revealed RN5 did not disinfect the container of strips before placing the container in the drawer.

During an interview on 05/07/25 at 11:30 AM with Chief Executive Officer (CEO) and Acting Director of Nurses (ADON), when the surveyor explained that observation revealed RN5 did not disinfect the container of test strips before placing the container in the drawer, both CEO and ADON agreed with the observation.

2.Review of the hospital policy titled "Patient Rooms (Terminal)," last revised 08/01/17, indicated ". . . After discharge or transfer, a patient room will be cleaned in the following manner: . . . Inspect and replenish all dispensers (soap, paper towels, and toilet tissue). . ."

Review of the hospital policy titled "Installation and Maintenance of Dispensers for Alcohol-based Hand Rub (ABHR)," last revised 03/21/25, indicated ". . . The dispensers should be maintained in accordance with manufacturer guidelines. . ."

Review of the hospital policy titled "Cleaning Nurses' Station," last revised 11/30/21, indicated ". . . The Environmental Services Department personnel will clean the Nurses' Stations on a daily basis . . . Damp dust counters, office furniture, cabinets, telephones, and receivers, etc., with a hospital-approved germicidal solution. . . Refill dispensers and supplies as necessary. . ."

Observation on 05/06/25 at 10:00 AM on the Medical/Surgical Unit revealed the hand sanitizer unit mounted on the wall outside Room 9 had no bag of sanitizer in the unit.

During an interview on 05/06/25 at 10:00 AM during the above observation, Registered Nurse (RN) 1, Charge Nurse, stated the sanitizer bag was removed, because the patient who was in Room 9 had a history of alcohol withdrawal. RN1 stated the patient had been discharged at 5:00 PM on 05/05/25. RN1 stated environmental services should have refilled the sanitizer unit when they cleaned the patient's room after discharge the previous day.

Observation on 05/06/25 at 11:08 AM on the Pediatric Unit revealed a container of Sani-Cloth wipes with an expiration of January 2025 was available for use on the counter of the nurse's station.

During an interview on 05/06/25 at 11:10 AM, RN4 stated staff is supposed to check the expiration date of the Sani-Cloth "when we bring it out" from the supply closet. When the surveyor asked if the expiration date was supposed to be checked before use after the container was brought out, RN4 stated "not that I'm aware of unfortunately."