HospitalInspections.org

Based on observation, staff interview, and document review during the Life Safety portion of a Recertification Survey conducted on July 22, 2025, the surveyor finds that the facility failed to provide and maintain a safe environment for patients and staff.

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

Based on document review and interview, for 2 of 2 patients' (Pt. #19 and Pt. #20) clinical records reviewed regarding use of violent restraints, the hospital failed to complete a face-to-face evaluation within one hour after the initiation of the restraints.

Findings include:

1. On 7/22/2025, the hospital's policy titled, "Restraints-Protective Devices" (dated 9/01/2023) included, "...Definition: ...A. 2. a. Physical restraints may include ...locking limb restraints ...Method of Implementation: ...B. Behavioral Restraint: ...5. Within one hour of initial application, a behavioral restraint huddle/face-to-face assessment will occur to assess the patient's response to the intervention as well as evaluate potential factors contributing to the violent or self-destructive behavior ...".

2. On 7/22/2025, the clinical record for Pt. #19 was reviewed. On 5/17/2025, Pt. #19 presented to the hospital's ED (Emergency Department) via EMS (Emergency Medical Services) for a stated complaint of delirium (altered mental state of consciousness, episodes of confusion). The record included physician's orders for behavioral restraints on 05/17/2025 at 7:35 PM and again (renewal order) on 05/17/2025 at 10:04 PM. On 5/17/2025, Pt. #19 was placed in behavioral, violent restraints (four-point restraints) from 7:35 PM through 5/18/2025 at 1:13 AM (5 hours and 38 minutes). The clinical record lacked the required face to face evaluation within one hour after the initiation of restraint.

3. On 7/22/2025, the clinical record for Pt. #20 was reviewed. On 4/19/2025, Pt. #20 presented to the hospital's ED via EMS due to alcohol intoxication. On 4/19/2025, Pt. #20 was placed in behavioral, violent restraints from 9:00 PM through 10:00 PM (1 hour). The clinical record lacked the required face to face evaluation within one hour after the initiation of the restraint.

4. On 7/23/2025 at approximately 11:50 AM, findings were discussed with the ED Operations Leader (E #11). E #11 stated that a face-to-face must be conducted by a qualified practitioner within an hour after initial restraint application. E #11 reviewed Pt. #19's and Pt. #20's medical records and was unable to find a face-to-face assessment post restraint application.

Based on document review, observation and interview, for 1 of 1 cooler and 2 of 2 freezers in Food and Nutrition (FNS), the hospital failed to ensure that food was properly labeled when opened, as required per policy.

Findings Include:

1. The hospital's policy title, "How to Label a Food Item (7/26/2018)" was reviewed on 07/23/2025 and required, "What information do I include on the labels? Refrigerated/Frozen Food Label.... Product Name, Open/Production/Freeze Date."

2. During an observational tour of the FNS area on 07/23/2025 from 11:00 AM to 11:45 AM, the following was observed:
- At 11:10 AM, in the dairy cooler, an open container of soup was covered with saran wrap and was unlabeled.
- At 11:15 AM, in the meat freezer, a package of frozen chunk chicken was opened and unlabeled.
- At 11:17 AM, in the vegetable freezer, a large bags of peas, a large bag corn on the cob, and a bag of hash browns were opened and unlabeled.

3. During an interview on 7/23/2025 at 11:25 AM, the Director of FNS (E#12) stated, "All food items must be labeled with date of opening and content of package."

Based on observation, staff interview, and document review during the Life Safety portion of a Recertification Survey conducted on July 15, 2025, the surveyor finds that the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

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

Based on observation, document review, and interview, for 1 of 1 staff (E #3/CRNA/Certified Registered Nurse Anesthetist) observed, the hospital failed to ensure use of antiseptic technique when administering intravenous (IV) medications in the operating room (OR).

Findings include:

1. On 7/23/2025 between approximately 9:48 AM through 10:35 AM, an observational tour of the hospital's OR #2 was conducted. At approximately 10:20 AM and 10:25 AM, E #3 did not wipe Pt. #22's IV port (access for medications) with an antiseptic pad prior to administration of IV medications.

2. On 7/22/2025, the clinical record for Pt. #22 was reviewed. On 7/22/2025 at approximately 10:10 AM, Pt. #22 was brought to OR #2 for hernia repair. The clinical record indicated that E #3 administered IV anesthesia medications (fentanyl, versed, and ketamine) at 10:20 AM, 10:25 AM, and 10:30 AM, respectively.

3. On 7/22/2025, the hospital's policy titled, "Safe injection Practices" (7/2024) was reviewed and indicated, "Purpose: To prevent the exposure of patients... to communicable diseases... Method of Implementation. 1. Safe Injection... Intravenous Practices. a. Use antiseptic technique to avoid contamination of sterile injection equipment..."

4. On 7/22/2025 at approximately 10:35 AM, findings were discussed with E #2 (Director Surgical Services). E #2 stated that the intravenous port should be wiped with an alcohol antiseptic prior to administering medications to prevent potential cross-contamination.

Based on document review, observation and interview, for 3 of 3 (E#6, E#7 and E#8) staff observed in the laboratory, the hospital failed to ensure staff wore gloves, removed gloves, and performed hand hygiene as required per policy.

Findings include:

1. The hospital's policy titled, "Hand Hygiene (10/2024)" was reviewed on 7/22/2025 and required, "Gloves shall be worn when exposure to blood. ... When to de-germ hands [wash] ... After touching patient care equipment or environmental surfaces. ... After removing gloves."

2. During an observational tour of the laboratory on 7/22/2025 from 1:00 PM to 1:50 PM the following was observed:
- At 1:20 PM, E#6 (chemistry technician) had gloves on, touched full blood tubes, placed tubes in the clean blood spinner, returned to the clean blood tube holder and began process again with different full blood tubes. E#6 never removed gloves between tasks or performed hand hygiene.
- At 1:25 PM, E#7 (generalist technician) took a blood sample from the work station , placed the tube in the clean refrigerator and returned to the work station with other blood tube samples and began process over again. E#7 had on gloves, never changed gloves between tasks or performed hand hygiene.
- At 1:30 PM, E#8 (blood bank technician) took a blood bag out of the refrigerator to dispense to provider. E#8 did not wear gloves while handling blood product or perform hand hygiene after dispensing blood.

3. During an interview on 7/22/2025 at 1:35 PM, the Director of Laboratory (E#5) stated, "Gloves need to be changed between tasks of clean and dirty or when moving onto the next specimen. Staff must always wear gloves when handling blood bags."