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Based on interview and record review Licensed Nurses (LNs) failed to develop individualized care plans for three of 31 patients (Patients 5, 27, and 14) when:

1. LNs did not develop an individualized care plan for Patient (Pt) 5's chief complaint (CC- the primary reason why a patient seeks medical attention) of "fatigue (extreme tiredness resulting from mental or physical effort or illness)" in accordance with hospital policy and procedure (P&P) titled "Plan of Care and Patient Education- Interdisciplinary" dated 1/15/25.

2. LNs did not develop an individualized care plan for Pt 27's airway despite the chief complaint of "shortness of breath" and the presence of a stoma (surgically created opening) in his neck due to a laryngectomy (voice box removal).

3. LNs did not develop an individualized care plan for Pt 14's plan of birth, a vaginal birth after cesarean (VBAC).

These failures had the potential for inconsistent delivery of care for Pt 5, 27, and 14, and had the potential for not receiving nursing care to reflect their individual needs and goals which could negatively affect patient well-being.

Findings:

1. During a review of Pt 5's electronic medical record (EMR- digital versions of patients' paper charts, storing demographics, medical history, medications, diagnoses, immunizations, and test results in one secure system for a single practice or hospital) on 12/4/25 at 11:23 a.m., of Pt 5s "History and Physical (H&P- a comprehensive patient assessment by a healthcare provider)" the document indicated Pt 5 is a 68-year-old admitted to the hospital as an inpatient on 12/2/25 after coming to the Emergency Department (ED) for "fatigue."

During a review of Pt 5's EMR on 12/2/25 at 11:30 a.m., of Pt 5's "H&P" the document indicated Pt 5 presented to the Emergency Department (ED- a hospital facility providing immediate, 24/7 care for severe injuries and acute illnesses) "history of obesity, adrenal insufficiency (the glands, located above the kidneys, don't produce enough vital hormones, mainly cortisol, and sometimes aldosterone, leading to fatigue), chronic orthostatic hypotension (when your blood pressure drops significantly and suddenly when you stand up from sitting or lying down, causing dizziness, lightheadedness, blurred vision, or fainting) and cirrhosis (severe scarring of the liver due to long-term damage from various conditions) decompensated by esophageal varices (swollen, fragile blood vessels in the esophagus (food pipe)) and recurrent episodes of hepatic encephalopathy (the damaged liver can't filter toxins [harmful or dangerous to health or life] (mainly ammonia) from the blood) who presents with abdominal pain and nausea. Patient reports that she was in her usual state of health until today. In the morning, she started to have left lower quadrant [stomach] pain, constant and burning in nature. Throughout the rest of the day patient became very tired, sleeping through most of the day. Family was concerned her ammonia (too much ammonia in the blood, which is toxic to the brain) was high and brought her in for evaluation. In ED, patient was found to have colitis (inflammation of the large intestine (colon) that causes symptoms like abdominal pain, cramping, diarrhea (often bloody), and urgency to have a bowel movement) with shock (a life-threatening medical condition where the body's tissues and organs don't get enough oxygen-rich blood, leading to cellular dysfunction and potential organ failure) requiring norepi[nephrine-medication to raise blood pressure], HBS (undefined acronym) was consulted for admission..."

During a review of Pt 5's EMR the "Plan of Care" dated 12/2/25 indicated, the "Problem: Adult Inpatient Care Plan" and "Fall/Injury Risk..." being the only identified and documented patient problems for nursing intervention and monitoring.

During a concurrent interview and record review on 12/2/25 at 11:34 a.m., with the Quality Nurse Consultant (QNC), Pt 5's EMR indicated, a care plan (CP- a comprehensive document that outlines the individualized care and treatment a patient will receive from a healthcare team. It serves as a roadmap for nurses and other healthcare providers to ensure consistent, coordinated, and evidence-based care) for Pt 5's admission diagnosis had not been initiated. QNC stated it is expected that nurses will initiate a patient specific CP, update it once per shift, and complete CPs in accordance with hospital policy. QNC stated CPs should be patient-specific and that Pt 5's CP did not include a focus or plan for the management of Pt 5's chief complaint of fatigue.

2. During a concurrent interview and record review on 12/3/25 at 1:30 p.m. with Clinical Nurse Specialist (CNS) 1, ANM 5, Pt 27's "H&P", dated 11/30/25, and "Care Plan", dated 12/1/25 were reviewed. The "H&P" indicated Pt 27 arrived at the hospital on 11/30/25 with complaint of shortness of breath. Pt 27 had a past medical history (PMH) of stage four (cancer has spread from original site to distant parts of body making it advanced) voice box cancer with lung metastasis (secondary growth), after laryngectomy (voice box removal). Pt 27 was admitted to the hospital as an inpatient on 11/30/25 for kidney failure. The "Care Plan" indicated, Pt 27 had a care plan to address issues for confusion, falls, infection, comfort, and restraints. ANM 5 stated, LNs should have addressed Pt 27's airway in the care plan, since he had problems with his airway. ANM 5 stated care plans were supposed to be patient specific and individualized. ANM 5 stated the purpose of the care plan was to progress the patient towards their goals to discharge the patient safely.

3. During a concurrent interview and record review with the Assistant Nurse Manager of OB (ANM 1) (Obstetrics - pertaining to pregnant women) on 12/3/25 at 9:30 a.m., the Electronic Medical Record (EMR) for Pt 14 was opened and reviewed. The document titled, "OB Admission History and Physical" dated 12/2/25 at 7:04 a.m. indicated Pt 14 was a 30 year old woman who had a cesarean section delivery (infant delivered surgically through the abdomen) and wished to attempt to deliver her second child vaginally. The Patient assessment indicated, "Active Hospital Problems: Supervision of High Risk Pregnancy, hx (history) of cesarean section ..." The ANM 1, who stated she is also the Clinical Educator for the OB department, stated Pt 14 came in already in labor with a plan to do a VBAC (Vaginal birth after Cesarean) and stated VBACs are considered high risk deliveries. The document titled, "Plan of Care," which the ANM 1 stated was the Care Plan (CP-a document that outlines a patient's health conditions, treatments and other information to guide their care and ensure continuity) was initiated on 12/2/25 at 3:45 p.m. The CP included goals and plans for caring for Pt 14 after the baby was born, but did not include a plan for managing the high risk pregnancy prior to delivery. The ANM 1 stated the nurses should have created a Care Plan right after she was admitted to provide guidance and awareness of the high risk delivery.

During an interview on 12/5/25 at 2:50 p.m. with the Chief Nursing Executive (CNE), CNE stated it is her expectation that all patient CPs include the chief complaint. CNE stated fatigue (admitting diagnosis) should have been addressed in [Pt 5's] CP. The CNE stated Pt 27 should have had a care plan that addressed his difficulty breathing, and Pt 14 should have had an individualized care plan started soon after admission for her planned VBAC.

During a review of the hospital's P&P titled "Plan of Care and Patient Education- Interdisciplinary" dated 1/15/25, the P&P indicated, "... 1.0 Policy Statement 1.2 .1 Care is planned and provided in an interdisciplinary manner. The Patient Plan is developed by using a multi-dimensional approach to address the plans and goals for care, interventions and treatment, and services based on the patient's needs. 1.2 The Patient Plan is initiated within eight hours of admission to the hospital. 1.3 The Patient Plan is individualized and based on the specific patient needs identified during the initial admission assessment and ongoing assessments and reassessments throughout hospitalization. 1.4 Progress toward identified patient goals and appropriate interventions is reviewed each shift and communicated during each shift report and upon transfer to another unit or level of care. 1.5 Each discipline may add new problems to the Patient Plan, edit and resolve existing problems, and document the patient's progress towards goals... 2.0 Purpose 2.1 This policy provides guidelines for use of the Patient Plan and Patient Education activities within "hospital name" by members of the interdisciplinary team and describes the process for documenting the plan of care... 5.0 Procedure 5.2 Develop an individualized Patient Plan after collaborating with the patient and/or their representative, interdisciplinary team members, and review of pertinent patient information (e.g. PER, Notes, Doc Flowsheets, Patient Plan Progress Notes, and Event Log in Patient Plan). Review and update the Patient Plan every shift and as needed..."

During a review of a professional article from the American College of Obstetrics and Gynecology (ACOG) titled ACOG Practice Bulletin No. 205: Vaginal Birth After Cesarean Delivery retrieved from https://pubmed.ncbi.nlm.nih.gov/30681543/ the article indicated, "...Trial of labor after cesarean delivery (TOLAC) refers to a planned attempt to deliver vaginally by a woman who has had a previous cesarean delivery, regardless of the outcome. This method provides women who desire a vaginal delivery the possibility of achieving that goal-a vaginal birth after cesarean delivery (VBAC). In addition to fulfilling a patient's preference for vaginal delivery, at an individual level, VBAC is associated with decreased maternal morbidity and a decreased risk of complications in future pregnancies as well as a decrease in the overall cesarean delivery rate at the population level. However, although TOLAC is appropriate for many women, several factors increase the likelihood of a failed trial of labor, which in turn is associated with increased maternal and perinatal morbidity when compared with a successful trial of labor (ie, VBAC) and elective repeat cesarean delivery . Therefore, assessing the likelihood of VBAC as well as the individual risks is important when determining who is an appropriate candidate for TOLAC..."

Based on observation, interview and record review, the facility failed to ensure licensed nurses (LNs) followed the hospital's policies and procedures (P&P) for five of 31 sampled patients (Pts) (Pt 1, Pt 2, Pt 27, Pt 28, and Pt 31), when :

1. Staff failed to ensure the brakes of the patient hospital bed for one (1) of 31 sampled patients, (Pt 1), were locked in accordance with hospital policy and procedures (P&P) "Fall Prevention (Adult) [Area] Regional Policy" dated 10/15/25 and "Safe Patient Handling for Hospitals" dated 9/18/24.

This failure resulted in a fall with injury; suspicious for fracture (broken bone) of Pt 1's left hip/thigh, with the potential to contribute to a decline in medical condition up to and including death.

2. Licensed Nurses (LNs) did not follow the hospital's P&P titled, "Fall Prevention (Adult) [Area] Regional Policy", and the "[Brand Name and model] MedSurg [Medical Surgical] Bed Operations Manual", for one of two sampled high fall risk patients (Pt 2) when the bed alarm (a safety device with sensors that alerts nurses when a high-risk patient tries to get out of bed unassisted) an intervention instituted by LNs to prevent falls and injury was inaudible outside of Pt 2's room.

This failure allowed Pt 2 to get out of bed unassisted and fall to the floor without staff being alerted until someone in the hall heard him call for help.

3. LNs did not follow the hospital's P&P titled, "Pain Assessment and Management", for two of 31 (Pts 28 and 31) patients. LNs failed to reassess Pt 31 timely after pain medication and did not follow physician orders for Pt 28, who reported severe pain but received medication ordered for mild pain.

These failures placed Pt 28 and Pt 31 at risk for inadequate pain management and could negatively affect the physical, emotional, and psychosocial (the influence of both physical and social factors on an individual) well-being of the patients.

4.The cardiopulmonary resuscitation (CPR, a lifesaving procedure performed when the heart stops beating) Crash Cart (a wheeled container carrying medicine and equipment for use in emergency resuscitations) on 3 East Medical Surgical (MS) Unit was not checked daily according the hospital's P&P titled, "Adult/Pediatric Crash Cart Stocking and Pediatric Emergency Jump Bag [portable medical kit]", and the hospital document titled, "Adult Crash Cart Daily Checklist", when it was not checked on 12/1/25.

This failure placed patients at risk of not having their needs met during emergencies if the crash cart malfunctioned.

5. The hospital failed to ensure LNs documented accurately and completely for one of 21 sampled patients (Pt 27) by not using unapproved abbreviations, according to the hospital's P&P titled, "HIM [Health Information Management] Medical Record Documentation Requirements [Area] Regional Policy"

This failure had the potential to cause poor patient outcomes due to a lack of communication, medical errors, and delayed care.

Findings:

1. During a review of Pt 1's "Face Sheet (FS)", dated 1/17/25, the "FS" indicated, Pt 1's "...DOB (Date of Birth) 5/2/1950....Admit Date: 1/17/25... Admit Diagnosis: colon obstruction [when food, liquid, gas, or stool can't move through the large intestine, either partially or completely], htn [high blood pressure], hx [history of] colon cancer..."

During a review of Pt 1's History and Physical (H&P- an assessment from physician including medical history and exam) dated 1/18/25, the H&P indicated "... Chief Complaint: Abdominal [stomach] pain and constipation [unable to pass feces] in the setting of partial colectomy [a surgery to remove a diseased or damaged section of the colon] History of Present Illness: The patient is a 74-year-old with a history of hypertension, iron deficiency anemia [not enough healthy red blood cells to carry adequate oxygen to your body's tissue], hypothyroidism [a small butterfly-shaped gland in your neck, doesn't produce enough essential hormones that control your body's energy use], colon cancer status post partial colon resection [surgery to remove a diseased section of the colon] and presents to the emergency room with constipation for 5 days and bloating. CT [Computed Tomography, a sophisticated imaging test that uses X-rays and a computer to create detailed cross-sectional "slices" or 3D pictures of your bones, organs, soft tissues, and blood vessels] of the abdomen shows findings concerning for colonic obstruction... The ascending [first segment of large intestine] and transverse colon [middle section of large intestine] are significantly distended [swollen from the inside] and fluid-filled. The small bowel [area between stomach and large intestine] loops are distended and fluid-filled as well. There is [concern] for ileitis [inflammation of the ileum, the final section of the small intestine]. Trace [a very small quantity] ascites [the abnormal buildup of fluid in the peritoneal cavity, the space between the lining of the abdomen (peritoneum) and the abdominal organs, causing swelling and pressure in the belly] in the upper abdomen. Other findings as described. The patient will be admitted for care..."

During a review of Pt 1's "Fall" note dated 1/20/25 at 11:01 a.m., the note indicated "...Fall ...Location: Room. Description of event: Transporter, [name] Patient Care Aide [PCA], and writer entered room to help pull pt over to bed with "brand name" mat [transfer aide] from gurney. Pt slid halfway onto bed and then bed rolled out from underneath Pt 1 and Pt 1 slipped between bed and gurney. RN 4 stated the "Brand name" mattress was fully inflated and went with pt during fall. Pt slowly slid to floor with "brand name" mattress under her body, no injuries. Fall code called... Injury sustained: no apparent injury Level of Consciousness: gcs [Glasgow Coma Scale- a neurological scale used to assess a patient's level of consciousness after a brain injury or in cases of impaired consciousness 3 [deep coma], 15 [fully alert]) 15 (intact mentation] Pain: no..."

During a review of Pt 1's "Physician Note" dated 1/20/25, the note indicated "...Patient had a witnessed fall during transfer from bed to gurney. No obvious injuries, pain in the left hip with movement of left leg/hip. Will check X-ray to rule out any occult [not easily seen] fractures..."

During a review of Pt 1's "Radiology Order" dated 1/20/25, the "Radiology Order" indicated, "...Order: XR LEFT HIP...Frequency: One Time...Reason for Exam: fall rule out fracture..."

During a concurrent interview and record review on 12/3/25 at 1:49 p.m. with the Quality and Safety Improvement Consultant (QSIC), the QSIC stated Pt 1's fall was reported to Risk Management on 1/20/25. The QSIC stated the hospital conducted a "Comprehensive System Analysis (CSA-an in depth investigation after an event to determine cause)" on 2/11/25 which resulted in staff education and training sessions in person, daily safety huddles at shift change, and completion of computer-based modules focused on safe patient handling, communication and clarification of staff roles and responsibilities. The QSIC stated education was "rolled out" to staff 3/5/25 with a complete by date of 6/5/25.

During an interview on 12/4/25 at 2:00 p.m., with Registered Nurse (RN) 4, RN 4 stated she recalled the event and explained she assumed care of Pt 1 while Pt 1's primary RN went on a lunch break. RN 4 stated in report she learned Pt 1 was away from the unit expected return from CT was soon. RN 4 stated she responded to Pt 1's room upon her return from CT and found Patient Transport Aide (PTA) 1 had positioned the beds to help Pt 1's transfer and was positioned at Pt 1's left. RN 4 stated Pt 1, a bariatric (relates to the medical field of treating obesity) patient required at least 3 persons to transfer Pt 1 safely. RN 4 stated Patient Care Aide (PCA) 1 brought in a "brand name" inflatable transfer mattress pump into the room and started inflating the mattress. RN 4 stated she was positioned at the foot of the gurney and bed. RN 4 stated PCA was positioned at the right of Pt 1's hospital bed side. RN 4 stated upon transferring Pt 1 was halfway onto the hospital bed from the gurney when she observed the beds moving away from one another creating a "crack" at the center of the two beds and Pt 1 slid down to the floor. RN 4 stated Pt 1 landed once on the inflated mat hitting her left arm, bounced hitting her head on the second impact. RN 4 stated Pt 1 denied pain on assessment. RN 6 stated she called a "Code F" which is an overhead page alerting others that a patient has fallen and staff may need extra help. RN 4 stated she later learned that the wheels on the hospital bed had not been locked prior to transfer. RN 4 stated it is the team's responsibility to ensure all wheels are locked to ensure safe patient transfer and this was not the case with this event. RN 4 stated, "We should have made sure the wheels were locked before moving the patient."

During an interview on 12/5/25 at 9:30 a.m., with PTA 1, PTA 1 stated she was transporting Pt 1 by gurney from CT to her in patient room on 1/20/25. PTA 1 stated she positioned the gurney next to the hospital bed. PTA 1 stated she recalled locking the gurney but leaving the hospital bed unlocked. PTA 1 stated due to the room configuration, the third staffer would have to move the bed to make room to position themselves between the hospital bed and the restroom door. PTA stated Pt 1 slid between the beds while the hospital bed moved away from the gurney falling to the floor. PTA 1 stated the team should have made sure to lock all wheels before moving Pt 1. PTA 1 stated "closed looped" communication could have been better and now makes sure to pause and ask if all wheels are locked when transferring patients.

During an interview on 12/5/25 at 2:50 p.m., with the Chief Nursing Executive (CNE), the CNE stated it is her expectation that staff follow hospital P&P and manufacturer instructions for use (IFUs) [inflatable mattress and pump]. CNE stated patient locking the wheels and proper patient positioning may have prevented the event.

During a review of the hospital's P&P titled, "Safe Patient Handling for Hospitals", dated 9/18/24, the P&P indicated "... Policy Statement: "hospital system" supports a culture of safety that protects members, patients, visitors, and staff in "hospital system" Hospitals' general acute care hospitals. Purpose: The purpose of this policy is to provide guidance to ensure consistent safe patient handling and mobilization practices in "hospital system" general acute care hospitals in compliance with federal, state, and local regulations. Scope/Coverage: This policy applies to all employees who are employed by the following entities (collectively referred to as "hospital system")... 5.2.6 Employees are responsible for: Complying with the requirements stated herein, also including: 5.2.6.1 Working safely and following established safe patient handling policy and procedures..."

These findings represent past noncompliance with regulatory requirements. There was sufficient evidence the facility corrected the noncompliance as of 3/28/25 and there were no other occurrences of the same deficient practice at the time of the survey the facility was in substantial compliance with this regulatory requirement and therefore does not require a plan of correction.

2. During a concurrent interview and record review on 12/4/25 at 9:20 a.m. with Nurse Manager (NM) 1, NM 1 opened Pt 2's Electronic Medical Record (EMR- a digital version of a patient's medical history, including diagnoses, medications, tests, allergies, immunizations, and treatment plans) for review. Pt 2's document titled, "H&P", dated, 8/29/25, indicated, Pt 2 arrived in the emergency department (ED) with complaint of right hip pain after a fall when getting out of bed reaching for his walker. The "H&P" indicated Pt 2 had a past medical history (PMH) of atrial fibrillation (irregular heartbeat) on diabigatran (medicine to prevent blood clots), severe obesity (excessive body fat), and multiple myeloma (rare blood cancer affecting cells in the spongy tissue inside bones, weakens bones). The document titled, "XRAY [a picture of the bones and other parts inside of the body] RIGHT FEMUR (bone of the upper thigh)", dated 8/29/25, indicated, Pt 2 had a severely displaced (separates) comminuted (shatters) intertrochanteric (bumpy parts of the top of the thigh bone) fracture (broken or cracked bone) of the right femur. NM 1 stated Pt 2 was admitted as an inpatient on 8/29/25 at 10:48 a.m. for right hip surgery. NM 1 stated Pt 2 was moved to the MS unit on 8/29/25 at 12:51 p.m.

During a concurrent interview and record review on 12/4/25 at 9:40 a.m. with NM 1, NM 1 opened Pt 2's EMR for review. The document titled, "Assessments", dated 8/31/25 indicated RN 1 assigned a Schmid Fall Risk Scale score (a clinical tool in healthcare for evaluating a patient's risk of falling, higher score is a greater risk) of three. NM 1 stated a three indicated a high risk of falling. The document titled, "Safety Interventions", dated 8/31/25, were reviewed. The document included, headers titled, "patient safety", "patient rounds", and "precautions" The documents titled "Precautions, and Patient Safety" indicated, LNs had placed Pt 2 under fall precautions, and a bed alarm was on and set. NM 1 stated fall precautions meant Pt 2 had nonskid shoes or slippers when out of bed, nurses completed safety rounds, and he had supervised activity when out of bed. The document titled "Assessments", dated 8/31/25 indicated RN 1 completed a nursing assessment at 4 p.m. and 8 p.m. RN 2 documented Pt 2's GCS score 15 out of 15. NM 1 stated Pt 2 had no change in mental status from previous LN assessments. The document titled, "Nursing Note," dated 8/31/25 at 10:44 p.m., (late entry) indicated, at approximately 8:38 p.m. RN 1 found Pt 2 on the floor in a sitting position, with the bed alarm going off. RN 1 noted Pt 2 was awake and alert and able to answer questions. NM 1 stated Pt 2 did not have injuries related to the fall. NM 1 stated, she investigated the fall. NM 1 stated, prior to the fall Pt 2 was alert and oriented, and was behaving normally. NM 1stated Assistant Nurse Manager (ANM) 2 was moving another patient through the hall, heard the alarm by Pt 2's door, and found Pt 2 sitting on the floor. NM 1 stated through the results of their investigation discovered the bed alarm could be heard in the room but could not be heard at the nurse's station and overhead. NM 1 stated the bed was taken out of service, to ensure the bed was not malfunctioning, and discovered the bed was not connected to the call system.

During a review of the hospital document titled, "[Brand Name and model] MedSurg Bed Operations Manual", "undated", indicated, " ...The [Brand Name and model] MedSurg bed is equipped with a hospital grade plug for protection against electric shock hazard. It must be plugged directly into a properly grounded three prong receptacle [outlet]. Plug the optional interface cable into the 37-pin connector under the litter frame at the head end of the bed, into the "Patient Station", "Head Wall", "Docker Station" or equivalent (whichever applies). Test the interface cable to verify it is functioning properly. Additional Alarm Conditions ...If the operator would like to set the Awareness alarm to the Nurse Call Station, the "Status To N/C" must be turned "On" through the Advanced Options Menu in the Main Menu." ...The advanced menu items include: ...3. Awareness Alarm 4. Status To N/C ... Advanced options: the operator can choose between 10 exit alarms ...The operator can enable or disable an audible alarm for [bed type] Awareness alert states. ... If an audible alarm is required, the operator can set the Awareness alarm to "On" through the Advanced Options Menu in the Main Menu. ... If the operator would like to set the Awareness alarm to the Nurse Call Station, the "Status To N/C" must be turned "On" through the Advanced Options Menu in the Main Menu ..."

During an interview on 12/4/25 at 11:26 a.m. with ANM 2, ANM 2 stated she recalled Pt 2's fall on 8/31/25. ANM 2 stated she worked on the MS Unit as the Assistant Nurse Manager. ANM 2 stated that on 8/31/25 at approximately 8:30 p.m. she was moving another patient from one unit to another. ANM 2 was with three other individuals, moving the patient in the hallway outside Pt 2's hospital room and the door was partially open. ANM 2 stated she heard a bed alarm going off but didn't know which room but then realized the bed was going off in Pt 2's room. ANM 2 stated the pt said either help or help me, and she and Patient Care Technician (PCT) 1 went into the room while the third staff member took the other pt where they should go. ANM 2 stated Pt 2 appeared alert and oriented. ANM 2 stated the light was off in the room, but the patient's tablet screen was illuminating the room from the bed. ANM 2 stated Pt 2 was sitting on the floor but leaning on his left arm as though attempting to get up. ANM 2 reported that Pt 2 did not recall how he ended up on the floor. ANM 2 stated Pt 2 had not tried to get out of bed unassisted before. ANM 2 stated she did not hear the bed alarm until very close to the room, and the alarms were normally heard in the nurse's station and overhead.

During a telephone interview on 12/4/25 at 2:13 p.m. with PCT 1 with the Clinical Nursing Director (CND) in attendance, (Patient Care Technician (PCT) 1 stated she remembered Pt 2's fall on 8/31/25. PCT 1 stated she was assigned Pt 2 for her 3 p.m. to 11:30 p.m. shift on 8/31/25. PCT 1 stated she cleaned up Pt 2, picked up his dinner tray, and gave him his tablet when asked. PCT 1 stated nothing seemed abnormal, and he was not ambulatory (able to walk without assistance). PCT 1 stated that after her lunch around 8:30 p.m. she assisted ANM 2 in moving a patient, and when she was several doors from Pt 2's room she heard someone say, "help, or I need help". PCT 1 stated she let go of the other bed, went into Pt 2's room and turned on the light. PCT 1 saw Pt 2 sitting on the floor leaning to the left trying to get himself up. PCT 1 reported that Pt 2 indicated he was not injured. PCT 1 stated Pt 2's door was only opened a crack. PCT 1 stated she could not hear the bed alarm until she opened the door to Pt 2's room. When asked if the bed alarms were usually difficult to hear outside the rooms, PCT 1 stated sometimes they could be depending on how loud the unit was, but the bed alarms were supposed to be hooked up to the nursing station to get an alert. PCT 1 stated Pt 2's alarm was more difficult to hear since the door was almost fully closed.

During an interview on 12/4/25 at 2:42 p.m. with the QSIC, the QSIC stated the fall investigation determined Pt 2's bed was not hooked up to the call light system and should have been.

During an interview on 12/4/25 at 3 p.m. with RN 1, RN 1 stated she recalled Pt 2's fall on 8/31/25. RN 1 stated she was Pt 2's primary nurse on 8/31/25 and Pt 2 fell during her shift, she worked from 3 p.m. to 11:30 p.m. RN 1 stated when she started her shift she got report from the morning nurse the Pt 2 had a fall at home, and he had a hip fracture with surgical repair one day before. RN 1 stated during her assessment at 8 p.m. Pt 2 had GCS of 15 and was alert and oriented to person, place, time, and event. RN 1 stated Pt 2 asked for all his needs and had no side effects to the medications he was administered. RN 1 stated Pt 2 was a high fall risk but had not tried to get out of bed before his fall. RN 1 stated she could not hear the bed alarm before entering the room, but once in the room the bed alarm was audible. RN1 stated Pt 2 was sitting on the floor with legs outstretched, close to the bed, and no physical injuries were noted during the focused assessment. RN 1 stated Pt 2 did not hit his head. RN 1 stated Pt 2 told her he needed help and told her he did not know how he fell when asked.

During an interview on 12/5/25 at 3:20 p.m. with the CNE the CNE stated the bed alarms worked in two ways, audible and an alert in the nursing station. The CNE stated staff could hear the alarm but even at the highest volume it may not carry. The CNE stated during Pt 2's fall investigation the hospital discovered the hospital bed's alarm notifications system was not plugged into the wall to notify the nursing station, leaving only the audible alarm. The CNE stated staff should go through the room during their safety checks before patients arrive, and during handoff reports, to ensure all the equipment in the room was in working order. The CNE stated that the bed alarm had not properly alerted the nurses' station of a possible patient fall, which resulted from staff error. The CNE stated her expectation was for staff to check equipment to ensure patient safety.

During a review of the hospital's P&P titled, "Fall Prevention (Adult) [Area] Regional Policy", dated 10/15/25, was reviewed. The P&P indicated, " ...committed to maintaining patient safety by identifying patients at risk for falls and at high risk of injury from falls and implementing evidence-based interventions to prevent falls and injury. ...To provide evidence-based interventions [indicating an approach to medicine, education, and other disciplines that emphasizes the practical application of the findings of the best available current research] to protect the patient from injury related to falling ...a fall is a sudden, unintentional descent, with or without injury to the patient, that results in the patient coming to rest on the floor ..."

3. During a concurrent interview and record review on 12/3/25 at 3:31 p.m. with NM 5 and ANM 6, ANM 6 opened Pt 28's "EMR" for review. The document titled, "H&P" dated 11/28/25, indicated, Pt 28 arrived at the ED on 11/28/25 with complaint of headache and ears ringing for three days. The "H&P" indicated Pt 28 had a Computed Tomography (CT - medical imaging procedure using X-Rays and a computer to create detailed pictures inside the body) of the head with results indicating a large subdural hematoma with midline shift (SDH-a life-threatening condition where a collection of blood on the surface of the brain is large enough to push the brain past its natural center line). Pt 28 was admitted to the hospital as an inpatient on 11/28/25 for nontraumatic brain compression.

During a concurrent interview and record review on 12/3/25 at 3:40 p.m. with NM 5 and ANM 6, Pt 28's, "Pain Assessment Flowsheet (PAF-where LNs document pain assessments)", and "Medication Administration Record (MAR- a record of drugs administered to a patient)", dated 12/1/25 were reviewed. The "PAF", indicated Pt 28 reported a pain score of nine (severe) out of 10 (worst) at 11:49 p.m., and LNs administered 650 milligrams (mg- a unit of measure) tablet of acetaminophen (a mild pain medication). ANM 6 stated the physician order for acetaminophen was written to be given as needed for mild pain (1-3). ANM 6 stated her expectation was for LNs to follow MD orders. ANM 6 stated LNs should document in the EMR when a patient preferred a milder pain medication than ordered.

During a concurrent interview and record review on 12/3/25 at 2:10 p.m. with the CND, ANM 5, and CNS 1, CNS 1 opened Pt 31's "EMR" for review. The document titled, "H&P", dated 12/1/25, indicated, Pt 31 arrived at the ED on 12/1/25 after a ground level fall and worsening right hip pain. The "H&P" indicated Pt 31 was admitted to the hospital as an inpatient on 12/1/25 for a surgical repair of an intertrochanteric fracture of a right femur with minimal lateral displacement of the distal fragment (lower part of the thigh bone shifted slightly outwards). The documents titled, "PAF", and "MAR", dated 12/1/25, were reviewed. The "PAF" indicated Pt 31 reported pain score of 7 (severe) at 6:52 p.m. The "MAR" indicated LNs administered an acetaminophen intravenous (IV medical technique that administers fluids, medications and nutrients directly into a person's vein through a plastic tube) solution 1,000 mg at 6:52 p.m. The "PAF" indicated Pt 31's pain reassessment was at 10 p.m. three hours and eight minutes later. CNS 1 stated LNs should have reassessed Pt 31's pain before 10 p.m. ANM 5 emphasized the importance of managing Pt 31's pain due to his injury. The CND expected nurses to document if the patient declined medication or chose to wait to see if pain relief improved over time.

During an interview on 12/5/25 at 3:10 p.m. with the CNE, the CNE stated her expectation was for LNs to listen to patients and assess, treat, and reassess patients for pain according to physician orders, and patient needs.

During a review of the hospital's P&P titled, "Pain Assessment and Management [Hospital Area] Regional Policy", dated 10/15/23, the P&P indicated, " ...Pain and Sedation Reassessment ...To evaluate the effectiveness and side effects of any pain intervention, reassess 60 minutes or less after administering analgesia or providing non-pharmacological intervention to treat pain, considering the peak action of the administered medication or intervention ..."

During a review of the hospital's P&P titled, "Medication Administration [Area] Regional Policy", 8/20/25, the P&P indicated, " ...Eight (8) Rights of Safe Medication Administration ... Right patient ...Right medication ...Right dose ...Right route ...Right time ...Right documentation ...Right reason (indication) ...Right response (patient response) ... Questioning and clarifying unclear, incomplete, or inappropriate orders. ... If the patient refuses a medication, the nurse should document on the MAR "patient refused" and notify the provider. ... The physician then can decide to reorder, modify or discontinue the medication and provide follow up orders as needed ..."

During a professional reference review titled, "Acute Pain Management Pearls: A Focused Review for the Hospital Clinician [health care professional]," dated 12/22/22, (found at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9818465/) indicated, "... Uncontrolled pain worsens patient outcomes ... Uncontrolled acute [sudden onset] pain triggers a complex neurohormonal cascade [a series of coordinated responses where hormones produced by neurons [make up brain and nervous system] that are released in succession to body responses] that is toxic [poisonous] to nearly every organ system, as evidenced by increased rates of renal [kidney] and gastrointestinal [stomach and intestine] dysfunction, infection, cardiopulmonary [heart and lungs] and thrombotic [blood clot] complications, impaired wound healing, adverse psychological [mental or emotional state of a person] effects, and poorer functional recovery and quality of life ... Acute pain management in hospitalized patients should therefore be a clinician [provider] and institutional [facility] priority as a key driver of patient outcomes..."

4. During a concurrent interview and record review on 12/2/25 at 11:07 a.m. with ANM 4, the 3 East MS Unit's, "Adult Crash Cart Daily Checklist (CCDC)", dated December 2025, was reviewed. The checklist had boxes to sign off when checking the defibrillator (a medical device that delivers an electric shock to the heart to reset its rhythm during a life-threatening heart rhythm), portable suction, airway mask (mask used during CPR), and the crash cart drawer plastic lock Identification (ID) numbers. The "CCDC" indicated, the crash cart checklist was blank on 12/1/25 indicating it had not been checked. ANM 4 stated the crash cart should be checked and signed off every day to ensure the equipment was present and in working order.

During an interview on 12/5/25 at 3:07 p.m. with the CNE, the CNE stated ensuring the crash carts were stocked and functioning correctly was a daily Assistant Nurse Manager activity. The CNE stated her expectation was for the crash carts to be checked and the log signed off daily, to ensure the cart was ready for use in case of emergency.

During a review of the hospital's P&P titled, "Adult/Pediatric Crash Cart Stocking and Pediatric Emergency Jump Bag", dated 6/18/25, the P&P indicated, " ... To establish a standardized procedure for the intake, cleaning, inventory, restocking, and distribution of adult and pediatric crash carts to ensure readiness for emergency use. ... All crash carts must be verified for functionality, completeness, and cleanliness ... It governs all SPD staff, pharmacy personnel, and nursing units involved in the turnover and management of crash carts. ... Restock bins and drawers per the approved crash cart content checklist. ... Confirm all items are within expiration. Items with the earliest expiration must be recorded on the exterior sticker. ... Suction unit must remain plugged in. ... Nursing: Responsible for timely return of used crash carts and retention of defibrillator, cables, and logbooks ..."

During a review of the professional reference titled "Audit of defibrillators at an urban public sector hospital", dated 8/17/18, the professional reference indicated, " ...Life-threatening emergencies are not limited to the emergency department. Any delay in intervention during an emergency often culminates [reach a climax] into a poor outcome. Early electrical defibrillation [a medical device that sends an electric shock to the heart to correct dangerously abnormal rhythms] is one of the most important interventions in patients with cardiac arrest [heart stops beating]. ... There is a need for ongoing training of hospital staff as well as the establishment of systems to prevent potential adverse [harmful] consequences resulting from device failure ..."

5. During a concurrent interview and record review on 12/3/25 at 1:30 p.m. with Clinical Nurse Specialist (CNS) 1, ANM 5, NM 2, and the Clinical Nurse Director (CND), Pt 27's "H&P", dated 11/30/25, and "Glasgow Coma Scale", dated 12/1/25 and 12/2/25, were reviewed. The "H&P" indicated Pt 27 arrived at the hospital on 11/30/25 with complaint of shortness of breath. Pt 27 had a PMH of stage four (cancer has spread from original site to distant parts of body making it advanced) voice box cancer with lung metastasis (secondary growth), after laryngectomy (voice box removal). Pt 27 was admitted to the hospital as an inpatient on 11/30/25 for kidney failure. The document titled, "Glasgow Coma Scale", dated 12/1/25 at 11:32 p.m. and 12/2/25 at 2:46 a.m. were reviewed. On both assessments the LN had assessed Pt 27's "GCS" as 11, with the "Verbal response" scored as one, indicating none (no response), but had entered an abbreviation of "TC." When asked about the abbreviation, ANM 5, CNS 1, and the CND did not know its meaning. NM 2 stated if could possibly stand for tracheostomy collar (a soft strap that goes around the neck to secure a breathing tube) but did not know if "TC" was the approved abbreviation. The CND stated that the hospital had an approved list of abbreviations, and CNS 1 said LNs should not use unapproved abbreviations in medical records. ANM 5 emphasized the importance of avoiding unapproved abbreviations to ensure clarity in documentation.

During a review of the hospital's P&P titled, "HIM Medical Record Documentation Requirements [Area] Regional Policy, dated 8/21/24, indicated " ...Medical record documentation may contain approved abbreviations, acronyms and symbols as noted in the most current edition of Stedman's "Abbreviations, Acronyms & Symbols ..."

During a review of the hospital's document titled, "Steadman's Online Search Results tracheostomy Collar", "undated", the hospital document indicated, HHTC was the hospital approved abbreviation for high-humidity tracheostomy collar.

During a review of the professional reference titled, "Inappropriate Medical Abbreviations", dated 5/22/23, the professional reference indicated, " ... To prevent any misunderstanding and jeopardize patient safety, the Joint Commission now requires healthcare institutions to develop a list of approved and not approved medical abbreviations. In addition, there should be a system or an audit process to ensure that there is compliance. The healthcare institution must ensure that the medical abbreviation in the approved list is also not on the Do not use a list or vice versa. Further, if a medical abbreviation is permitted, then it can have only one universal meaning. For example, DOA can mean Date of Admission or Dead on Arrival. The Joint Commission also recommends that healthcare institutions not use abbr

Based on observation, interview, and record review the hospital failed to ensure medications were prepared and stored in accordance with the hospital's policy and procedures (P&P) titled, "Medication Storage", and "Medication Labeling", and accepted standards of practice, when one of eight sampled medication rooms had one 250 milliliter (mL-a unit of measurement) bag of 5% dextrose (a sterile sugar solution in water) intravenous (IV-intravenous - medical technique that administers fluids, medications and nutrients directly into a person's vein) solution laying on the counter unattended, without the protective overwrap and with a blank medication additive label (a special sticker, often bright and fluorescent, used in healthcare to clearly identify drugs added to IV bags or other solutions) attached.

This failure had the potential for patient harm including wrong drug administration, incorrect dosage (over/underdosing), adverse reactions, and infections from germs.

Findings:

During a concurrent observation and interview on 12/3/25 at 11:10 a.m. with Assistant Nurse Manager (ANM) 4, and the Clinical Nursing Director, during a tour of the hospital's Three East Medical Surgical (MS-area in hospital caring for patients with diverse medical and surgical conditions) Unit, the unit Medication Room was observed. One 250 milliliter (mL-a unit of measurement) bag of 5% dextrose (a sterile sugar solution in water) intravenous (IV-intravenous - medical technique that administers fluids, medications and nutrients directly into a person's vein) solution was found lying unattended on the counter with a blank medication additive label attached, and no protective overwrap. ANM 4 stated the bag should not be left on the counter with a blank additive label, or without the protective overwrap. ANM 4 stated LNs would not know what medications were added or when the fluid was unwrapped and should not be given to a patient. The CND directed the ANM to discard the fluids.

During a concurrent interview and record review on 12/5/25at 2:17 p.m. with the Infection Preventionist (IP), the photo taken 12/2/25, in the Three East MS Unit of the 250 mL bag of 5% dextrose IV fluids with a blank medication label found lying on the counter was reviewed. The IP stated that LNs should not leave IV fluids out of the package to avoid compromising sterility (free from germs). Additionally, IV fluids with a medication additive should not be left unattended due to potential medication compromise. Both actions pose patient safety concerns.

During a review of the hospital's P&P titled, "Medication Storage", dated 9/20/23, the P&P indicated " ...The purpose of this policy is to establish processes for appropriate medication storage, stocking and access. ... The IV solutions that are produced by manufacturers with an overwrap should be stored within the overwrap pouch. ...Medications that are contaminated, deteriorated, improperly labeled, illegibly labeled, recalled, outdated, or otherwise unusable shall not be kept in stock but shall be returned to the Inpatient Pharmacy ..."

During a review of the hospital's P&P titled, "Medication Labeling", dated 3/19/25, the P&P indicated, " ...Compounded Sterile Preparation (CSP): A preparation intended to be sterile that is created by combining, admixing, diluting [adding fluid], pulling, reconstituting [restoring something dried to its original state by adding liquid], repackaging or otherwise altering a drug product. ...Medications shall be properly labeled in compliance with the California State Board of Pharmacy and Federal agencies. ...At a minimum, all medications are labeled with the following ...Medication name, strength, dose, route ...Expiration date and time when expiration occurs in less than 24 hours. ...Date of preparation ... When preparing individualized medications for multiple specific patients or the person preparing the individualized medications is not the person Patient name. ... Patient location (room number). ... Direction for use or any applicable cautionary statement either on the label or attached as an auxiliary [additional] label ..."

During a review of the professional reference titled, "Reducing levels of medical device contamination through package redesign and opening technique", dated 11/7/18, the professional reference indicated, " ...Healthcare associated infections (HAIs), infections patients get while receiving medical treatment, have been categorized among the ten leading causes of morbidity and mortality in the United States. ... HAIs can be transmitted directly, from a single person to the patient, or indirectly, through an intermediate object or person. When medical devices serve as a vehicle for indirect transmission, the initial contamination tends to occur from a small number of micro-organisms that are transferred to the device, either from healthcare provider's hands or skin or other environmental sources ... packaging and aseptic technique both have the potential to play a role in contamination ..."

During a review of the professional reference titled, "Nursing Rights of Medication Administration", dated 9/4/23, (retrieved from https://www.ncbi.nlm.nih.gov/books/NBK560654/) the professional reference indicated, " ...Nurses have a unique role and responsibility in medication administration, in that they are frequently the final person to check to see that the medication is correctly prescribed and dispensed before administration. It is standard during nursing education to receive instruction on a guide to clinical medication administration and upholding patient safety known as the 'five rights' or 'five R's' of medication administration. These 'rights' came into being during an era in medicine in which the precedent was that an error committed by a provider was that provider's sole responsibility and patients did not have as much involvement in their own care. ... 'Right patient' ... 'Right drug' - ensuring that the medication to be administered is identical to the drug name that was prescribed. ... 'Right Route' - Medications can be given to patients in many different ways, all of which vary in the time it takes to absorb the chemical, time it takes for the drug to act, and potential side-effects based on the mode of administration. ... 'Right dose' - Incorrect dosage, conversion of units, and incorrect substance concentration are prevalent modalities [technique] of medication administration error. ... Patient safety and quality of care are essential components of nursing practice and priorities that demand consideration to enable the delivery of high-quality, patient-centered care, and overall well-being. Medical errors are unfortunately very common in clinical practice, and in addition to compromising a patient's personal safety, they can also be extremely costly for hospitals. ADEs [adverse drug events] qualify as unintended injuries or insults directly related to medical interventions involving a drug resulting in disability at discharge, death, or extended hospital stay that is the result of health care management rather than by the patient's underlying disease process

Based on observation, interview, and record review, the facility failed to maintain a clean and sanitary environment to avoid sources and transmission of infection when:

1. Two (2) of 39 ice machines (IMs) observed on the hospital's main campus were visibly soiled and were not maintained according to the manufacturer instructions for use (IFUs), and the Food and Drug (FDA) Federal Food Code guidelines.

2. One (1) of 10 medication rooms observed on the hospital's main campus had a smudge of a reddish-brown substance on a cabinet, not in accordance with the Centers for Disease Control (CDC) guidelines and current standards of practice.

3. Registered Nurse (RN) 5 failed to follow the hospital Policy and Procedure (P&P) titled, "Hand Hygiene [Area] Regional Policy" for one of one sampled patient (Pt) Pt 31, when RN 5 did not change gloves, or perform hand hygiene (washing hands or using alcohol-based sanitizer) prior to or after hanging Pt 31's fresh frozen plasma (liquid part of blood) for transfusion (receiving blood or blood components into the vein through a plastic tube).

4. One of one medication rooms observed in the post-partum unit (unit where mothers and babies are cared for after birth) contained a bucket full of used oxygen saturation probes (devices used to make sure the patient is getting enough oxygen) was sitting on the counter where medications are prepared.

5. One of one medication rooms observed in the nursery had dirty, peeling stickers adhering to cabinets and supply bins.

These failures placed all patients and staff at risk for transmission of infections (an infectious agent is transferred from a reservoir to a susceptible host) and cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) and increased the potential for hospital acquired infections and illnesses.

Findings:

1.During a concurrent observation and interview on 12/2/25 at 10:09 a.m. with Nurse Manager (NM) 4, and during a tour of the hospital Critical Care Unit's (CCU- a specialized hospital department that provides care for patients with severe, life-threatening illnesses or injuries) nourishment room, the unit ice machine (IM) 1 was observed to have visible white-colored and textured stains/residue on the ice chute and water collection tray, and with dried splash marks on machine stainless steel surfaces. NM 4 stated the machine surfaces are cleaned daily by Environmental Services (EVS -cleaning) and the internal parts are managed by the Maintenance department staff. NM 4 stated the machine did not look like it had been wiped today and the residue on the chute (where the water and ice came out) and drip tray (where the water overflow fell) looked like hard water stains. NM 4 stated her expectation is that staff follow policy and procedure related to cleaning the IM to prevent cross contamination (the process by which germs, viruses, or other infectious agents are unintentionally transferred from one substance or object to another, with harmful effect) and patient, staff and/or visitor illness.

During a concurrent observation and interview on 12/2/25 at 10:20 a.m., with NM 2, during a tour of the hospital Four West Telemetry Unit's (a hospital floor where patients' heart activity is continuously monitored) nutrition room, we observed visible, white-colored and textured stains and residue on the ice chute and water collection tray, along with dried splash marks on the machine's stainless steel surfaces. NM 2 stated the buildup should not be on the ice machines and that EVS cleaned the outside of the machine daily.

During an interview on 12/5/25 at 10:52 a.m. with the Environmental Services Supervisor (ESS), the ESS saw a photo of 4 West Telemetry Unit's nutrition room's ice machine. The ESS explained that EVS staff were responsible for cleaning the ice machine's cover, chutes, and the grate and bin at the front that caught any overspill. The ESS noted that if there was any water scale (the dry white-color textured material) on the parts, the staff could scrub them, or the parts could be replaced. The ESS stated that ensuring the water scale was cleaned was important to prevent infection.

During an interview on 12/5/25 at 10:57 a.m. with the Chief Engineer (CE), the CE stated he supervised the Maintenance Department. The CE stated the ice machines were on a preventative maintenance (PM-a strategy to regularly inspect, service, and maintain equipment to prevent breakdown) schedule. The CE stated Maintenance cleaned and disinfected as well as replaced parts on the ice machines on a schedule. The CE stated there were quarterly cleanings completed, and every six months maintenance completed. The CE stated Maintenance had a PM computer system to let the staff know which machines were due for service. The CE stated staff could also enter a work order into the computer system if an ice machine needed attention before service was due.

During an interview on 12/5/25 at 10:57 a.m. with the Chief Engineer (CE), the CE stated he supervised the Maintenance Department. The CE stated the ice machines were on a preventative maintenance (PM-a strategy to regularly inspect, service, and maintain equipment to prevent breakdown) schedule. The CE stated Maintenance cleaned, disinfected, and replaced parts on the ice machines according to the schedule. The CE stated that they completed quarterly cleaning and maintenance every six months. The CE stated Maintenance used a PM computer system to notify staff which machines were due for service. The CE stated staff could enter a work order into the computer system if an ice machine needed attention before the scheduled service.

During an interview on 12/5/25 at 2:20 p.m. with the Infection Preventionist (IP), the IP stated that when the ice machines had water scale buildup, a biofilm (a thin, slimy film of bacteria [germ] that sticks to a surface) could form because the area was not able to be cleaned and disinfected (clean to destroy bacteria) properly. The IP stated EVS wiped the outside stainless steel and the outside parts daily. The IP stated Engineering had a routine schedule to change and sanitize the interior parts and the plastic surface. The IP stated, if the plastic surface appeared to need changing before the scheduled time, IP or staff would notify Maintenance of the need to change it.

According to the manufacturer's "[Brand Name], Installation and User's Manual for [type] Ice Maker- Dispensers", indicated " ... Maintenance and Cleaning ... There are five areas of maintenance: 1. Drip tray and drain system ... 3. Ice dispense bin ... It is important to keep the drip tray clean of trash. Remove any as soon as it is noticed. Pour hot water into the tray on a regular basis to keep the drain open. Over time the drip tray and cup rest may become coated with scale or dirt. It can be removed to be scrubbed at a wash sink. ...Twist dispenser chutes clockwise and pull down to remove. ...Wash out the drip tray and dispense chutes. Use ice machine scale remover if needed to dissolve scale ..." The ice machine is taken apart to clean and sanitize the interior parts. The Bin where the ice is held is cleaned with a scale remover and a clean cloth, then a sanitizing solution, before rinsing with clean water.

According to the Centers for Disease Control (CDC), undated, retrieved 12/12/2025 from https://www.cdc.gov/infection-control/hcp/environmental-control/appendix-c-water.html, "Microorganisms have a tendency to associate with, and stick to surfaces ... These adherent organisms can initiate and develop biofilms (a thin layer of bacteria that adheres to the surface) ..."

During a review of the Food and Drug Administration (FDA) Federal Food Code, dated 2022, 4-602.11 indicated, "...ice makers, and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms ..."

2. During a concurrent observation and interview on 12/2/25 at 10:23 a.m. with Assistant Nurse Manager (ANM) 3, during a tour of the hospital Four East Telemetry Unit's medication room, an adult finger sized smudge of a reddish-brown substance was identified at eye level on a cabinet near the handle. The cabinet held blood collection tubes (vacuum-sealed plastic tubes with color-coded rubber or plastic tops). ANM 3 stated the smudge should not be on the cabinet and staff should use the disinfectant (a chemical that kills or inactivates harmful germs) wipes to clean the area. ANM 3 stated the substance could cause an infection control issue for staff or patients.

During a concurrent interview and record review on 12/5/25 at 10:54 a.m. with the ESS, The ESS reviewed a photo taken on 12/2/25, of the cabinet in the medication room of the Four East Telemetry Unit with a reddish-brown smudge. The ESS stated, "Looks like blood to me," when identifying the reddish-brown smudge on the cabinet. The ESS stated EVS only cleaned the floors and wiped the cabinets in the room, but all staff could have wiped the smudge off the cabinet for infection prevention.

During a concurrent interview and record review on 12/5/25 at 2:25 p.m. with the IP, the IP reviewed the photo taken on 12/2/25, of the cabinet in the medication room of the Four East Telemetry Unit with the reddish-brown smudge. The IP stated any staff should have cleaned the area, the smudge was an infection control issue and should not be left on the door of the medication room cabinet.

According to the CDC's "Recommendations for Disinfection and Sterilization in Healthcare Facilities, dated 12/7/23, the CDC recommends, " ...Cleaning and Disinfecting Environmental Surfaces in Healthcare Facilities ... Disinfect (or clean) environmental surfaces on a regular basis (e.g., daily, three times per week) and when surfaces are visibly soiled. ... Promptly clean and decontaminate spills of blood and other potentially infectious materials. Discard blood-contaminated items in compliance with federal regulations ..."

During a review of the professional article titled, "The role of the surface environment in healthcare associated infections", dated 8/26/13, the professional article indicated, " ...Hospital surfaces are frequently contaminated with important healthcare-associated pathogens [disease causing agents]. Contact with the contaminated environment by healthcare personnel is equally as likely as direct contact with a patient to lead to contamination of the healthcare provider's hands or gloves that may result in patient-to-patient transmission of hospital acquired pathogens. Improved cleaning and disinfection of room surfaces decreases the risk of healthcare-associated infections ..."

3. During an observation on 12/2/25 at 2:18 p.m. with RN 5, ANM 4, and Pt 31 in Pt 31's hospital room, Pt 31 was lying at a 30-degree angle with his eyes closed. Pt 31 agreed to the observation of his plasma transfusion unit. RN 5, wearing gloves, typed at the computer on wheels workstation, then crossed to Pt 31's bedside with soiled gloves to verify the plasma with ANM 4 and Pt 31. RN 5 scanned the plasma bag and Pt 31's wristband, then spiked, hung, and set the transfusion rate (how fast the blood product goes into the patient) with the same soiled gloves. After increasing the infusion rate, RN 5 removed her gloves but did not perform hand hygiene before resuming typing on the computer, missing six hand hygiene opportunities during the blood product infusion.

During an interview on 12/3/25 with NM 2, NM 2 stated RN 5 should have changed her gloves and performed hand hygiene prior to spiking the bag. NM 2 stated RN 5 should have performed hand hygiene after removal of the soiled gloves. NM 2 stated hand hygiene was infection prevention and protection against infection.

During an interview on 12/3/25 at 4 p.m. with RN 5, RN 5 stated she should have changed gloves and performed hand hygiene (washing hands with soap and water or using alcohol-based sanitizer) prior to spiking (inserting the tubing port into the bag) and hanging the blood products. RN 5 stated she should have then removed her gloves and again performed hand hygiene before typing on the computer. RN 5 stated hand hygiene was important to prevent infections in patients, especially since Pt 31 was going to surgery later in the afternoon.

During a review of the hospital P&P titled, "Hand Hygiene [Area] Regional Policy", dated 5/17/23, the P&P indicated, " ...The [Hospital name] region follows the World Health Organization (WHO) 5 Moments of Hand Hygiene ...Indications for hand hygiene include the WHO 5 Moments of Hand Hygiene and other instances as indicated below: ...Before or upon entry to patient's room; before patient contact or donning [putting on] personal protective equipment (PPE) ...Before performing clean and/or aseptic procedures ...After body fluid exposure/risk or after removal of PPE ...After contact with patient and patient's environment ...After or upon exiting the patient's room ...The preferred method of hand hygiene is waterless alcohol-based hand rub/sanitizer. ...Use of soap and water is required in the following situations: ...Hands are visibly soiled ..."

During a review of professional reference from the CDC titled, "Clinical Safety: Hand Hygiene for Healthcare Workers, dated 2/27/24, the professional reference indicated, " ... Hand hygiene protects both healthcare personnel and patients. Hand hygiene means cleaning your hands with Handwashing with water and soap (e.g., plain soap or with an antiseptic). Antiseptic hand rub (alcohol-based foam or gel hand sanitizer) ... Cleaning your hands reduces: The potential spread of deadly germs to patients. The spread of germs, including those resistant to antibiotics ... Know when to clean your hands ... Immediately before touching a patient ... Before performing an aseptic task such as placing an indwelling device or handling invasive medical devices ... Before moving from work on a soiled body site to a clean body site on the same patient ... After touching a patient or patient's surroundings ... After contact with blood, body fluids, or contaminated surfaces ... Immediately after glove removal ...".

4. During a concurrent observation and interview on 12/2/25 at 10:23 a.m. with Assistant Nurse Manager (ANM) 7, during a tour of the hospital's medication room in the post-partum unit, a bucket was observed to be sitting on the counter where medications are processed. The bucket was full of oxygen saturation probes. ANM 7 stated these were devices that have been used on patients, and that they are in the bucket waiting to be cleaned and reprocessed (Reprocessing - is a detailed multistep process to clean and then disinfect or sterilize reusable devices according to manufacturer's instructions for use) for reuse. ANM 7 stated the probes are not clean, and should not be in the medication room, which is considered a clean room.

During a concurrent interview and record review on 12/5/25 at 2:25 p.m. with the IP, the IP stated the medication room is not a safe place to store dirty items because of the risk of cross contamination.

During a review of hospital P&P titled, "Cleaning, Disinfection and Storage of Reusable, Medical Devices, NCAL Regional Policy dated 07/16/2025, the P&P indicated, "... 5.3 Dirty or contaminated equipment will be separated from equipment that is clean or sterile. ... 5.4 Reusable medical devices must be cleaned as soon as possible and at the point of use to remove all organic matter and other residue to reduce the development of biofilms and to reduce the possibility of contaminating the environment and blood and body fluid exposure to staff ..."

5. During a concurrent observation and interview on 12/2/25 at 11 a.m. with Assistant Nurse Manager (ANM) 7, during a tour of the hospital's medication room in the Nursery, the cabinets and storage bins were labeled with stickers that were peeling off and exposing the adhesive underneath. ANM 7 stated the peeling stickers could not be cleaned and needed to be replaced with stickers that can be disinfected.

During a concurrent interview and record review on 12/5/25 at 2:30 p.m. with the IP, the IP stated peeling stickers in any area of the hospital create a risk of spreading infection because sticky surfaces cannot be cleaned.

During an interview on 12/5/25 at 10:30 a.m. with the Area Safety Quality Officer (ASQO), the ASQO stated the hospital has a process for rounding on units to look for environmental safety concerns and they have identified the problem with peeling stickers during their environmental safety rounds. The ASQO stated their process is to refer their findings back to unit leadership. The ASQO stated, "We don't have a process for following up to make sure the items we find are corrected."

During a review of hospital P&P titled, Cleaning, Disinfection and Storage of Reusable, Medical Devices, NCAL Regional Policy dated 07/16/2025, the P&P indicated, "... 5.11 Storage areas, containers, racks, cabinets and shelves used to store clean equipment, and supplies must be cleaned regularly and must be free of dust and debris..."




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