HospitalInspections.org

Based on observation, policy review, record review and interview, the Governing Body failed to ensure the Chief Executive Officer (CEO) was responsible for management of the entire hospital, including accountability for the effective oversite of staff to comply with the requirements under 42 CFR 482.13 CoP: Patient's Rights, 42 CFR 482.42 CoP: Infection Prevention and Control and Antibiotic Stewardship and 42 CFR 482.23 CoP: Nursing Services.

The hospital failed to:
- Ensure the CEO was responsible for management of the entire hospital; (A-0057)
- Ensure the safety of all patients when they failed to recognize, intervene and investigate the neglect of one patient (#19) of one neglect event reviewed; (A-0145)
- Correctly transcribe, administer and monitor for side effects of a medication ordered for one patient (#19) of 11 medication event report reviewed; (A-0144)
- Ensure designated continuous telemetry (remote observation of a person's heart rhythm, using signals that are transmitted from the patient to a computer screen) observation for all telemetry monitored patients; (A-0144)
- Ensure expired medications and supplies were removed from one emergency crash cart (mobile cart which contains emergency medical supplies and medication) of one crash cart observed; (A-0144)
- Ensure temperature logs for the hospital's food storage freezers were accurately maintained for two of four freezers observed; (A-0144)
- Document the date opened and discard expired control solutions (a solution used to calibrate for glucometers (used to measure the amount of glucose [sugar] in your blood) on two of two patient care areas observed; (A-0144)
- Follow their internal policy for quality control of the centrifuge machine (a scientific instrument used to separate components of a blood sample); (A-0144)
- Ensure that staff were trained on a periodic basis in first aid related to restraints (any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely) for all nursing and provider staff; (A-0206)
- Recognize, investigate and follow their policies and procedures for medication administration when one current patient (#30) and two discharged patients (#32 and #41) of three medical records reviewed had 44 to 67 missed medication administrations; (A-0405)
- Perform hand hygiene (HH, washing hands with soap and water or alcohol-based hand sanitizer) and glove changes when providing care for eight patients (#5, #8, #9, #12, #13, #14, #16 and #18) of nine patients observed; (A-0749)
- Prepare a clean work surface prior to performing patient care for six current patients (#5, #8, #9, #13, #14 and #18) of nine patients observed; (A-0749)
- Sanitize equipment and ensure the use of clean/sterile (completely clean and free from germs) supplies for one current patient (#9) of one patient observed; (A-0749)
- Ensure visitors followed the hand hygiene and personal protective equipment (PPE) policies for one current isolated patient (#9) of one patient visitor observed; (A-0749)
- Remove an isolation mask prior to exiting one current isolation patient's room (#8) of two isolation patients observed; (A-0749)
- Follow the hospital's policy and procedures for single use patient care items for two current patients (#5 and #14) of two patients observed; (A-0749)
- Ensure a clean medication preparation area; (A-0749)
- Remove expired patient care supplies; (A-0749)
- Follow the hospital's policy and procedure for cleaning supplies storage;
- Follow the hospital's policy and procedure for the removal of expired food and labeling of food in two of three patient nutrition areas observed; (A-0749)
- Ensure clean kitchen surfaces; and (A-0749)
- Follow nationally recognized standards to maintain a sanitary environment. (A-0749)

These failures had the potential to adversely affect the quality of care and safety of all patients in the hospital.

The severity and cumulative effects of the systemic failures resulted in the hospital being out of compliance with 42 CFR 482.12 Condition of Participation (CoP): Governing Body.

Please refer to A-0057, A-0144, A-0145, A-0206, A-0405, and A-0749.

Based on observation, interview, record review and policy review, the hospital failed to:
- Ensure the safety of all patients when they failed to recognize, intervene and investigate the neglect of one patient (#19) of one neglect event reviewed; (A-0145)
- Correctly transcribe, administer and monitor for side effects of a medication ordered for one patient (#19) of 11 medication event report reviewed; (A-0144)
- Ensure designated continuous telemetry (remote observation of a person's heart rhythm, using signals that are transmitted from the patient to a computer screen) observation for all telemetry monitored patients; (A-0144)
- Ensure expired medications and supplies were removed from one emergency crash cart (mobile cart which contains emergency medical supplies and medication) of one crash cart observed; (A-0144)
- Ensure temperature logs for the hospital's food storage freezers were accurately maintained for two of four freezers observed; (A-0144)
- Document the date opened and discard expired control solutions (a solution used to calibrate glucometers machine used to measure the amount of glucose [sugar] in your blood) on two of two patient care areas observed; (A-0144)
- Follow their internal policy for quality control of the centrifuge machine (a scientific instrument used to separate components of a blood sample); (A-0144) and
- Ensure that staff were trained on a periodic basis in first aid related to restraints (any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely) for all nursing and provider staff. (A-0206)

The severity and cumulative effect of these practices had the potential to place all patients at risk for their health and safety, also known as an Immediate Jeopardy (IJ). As of 02/26/25, the hospital provided immediate action plans sufficient to remove the IJs when the hospital implemented corrective actions that included educating all current and oncoming nursing staff on telephone orders, medication administration, monitoring for medication side effects and the recognition and prevention of patient abuse and neglect.

This failed practice resulted in a systemic failure and noncompliance with 42 CFR 482.13 Condition of Participation (CoP): Patient's Rights.

Please refer to A-0144, A-0145 and A-0206.



49404

Based on interview, record review and policy review, the hospital failed to recognize, investigate and follow their policies and procedures for medication administration when one current patient (#30) and two discharged patients (#32 and #41) of three medical records reviewed had 44 to 67 missed medication administrations.

The severity and cumulative effect of these practices had the potential to place all patients at risk for their health and safety, also known as an Immediate Jeopardy (IJ). As of 02/26/25, the hospital provided an immediate action plan sufficient to remove the IJ when the hospital implemented corrective actions that included educating all current and oncoming nursing staff on medication administrations.

This failed practice resulted in a systemic failure and noncompliance with 42 CFR 482.23 Condition of Participation (CoP): Nursing Services.

Please refer to A-0405.

Based on observation, interview, and policy review, the hospital staff failed to:
- Perform hand hygiene (HH, washing hands with soap and water or alcohol-based hand sanitizer) and glove changes when providing care for eight patients (#5, #8, #9, #12, #13, #14, #16 and #18) of nine patients observed; (A-0749)
- Prepare a clean work surface prior to performing patient care for six current patients (#5, #8, #9, #13, #14 and #18) of nine patients observed; (A-0749)
- Sanitize equipment and ensure the use of clean/sterile (completely clean and free from germs) supplies for one current patient (#9) of one patient observed; (A-0749)
- Ensure visitors followed the hand hygiene and personal protective equipment (PPE, such as gloves, gowns, goggles, and masks) policies for one current isolated patient (#9) of one patient visitor observed; (A-0749)
- Remove an isolation mask prior to exiting one current isolation patient's room (#8) of two isolation patients observed; (A-0749)
- Follow the hospital's policy and procedures for single use patient care items for two current patients (#5 and #14) of two patients observed; (A-0749)
- Ensure a clean medication preparation area; (A-0749)
- Remove expired patient care supplies; (A-0749)
- Follow the hospital's policy and procedure for cleaning supplies storage;
- Follow the hospital's policy and procedure for the removal of expired food and labeling of food in two of three patient nutrition areas observed; (A-0749)
- Ensure clean kitchen surfaces; and; (A-0749)
- Follow nationally recognized standards to maintain a sanitary environment. (A-0749)

These failures had the potential to adversely affect the quality of care and safety of all patients in the hospital.
The severity and cumulative effects of the systemic failures resulted in the hospital being out of compliance with 42 CFR 482.42 Condition of Participation (CoP): Infection Prevention and Control and Antibiotic Stewardship.

Please refer to A-0749.



49404

Based on interview, policy review and record review, the Governing Body failed to ensure the Chief Executive Officer (CEO) was responsible for management of the entire hospital, including accountability for the effective oversite of staff to comply with the requirements under 42 CFR 482.13 Conditions of Participation (CoP): Patient's Rights, 42 CFR 482.23 CoP: Nursing Services, 42 CFR 482.41 and 42 CFR 482.42 CoP: Infection Prevention and Control and Antibiotic Stewardship.

These failures had the potential to affect the quality of care and safety of all patients.

Findings included:

Review of the hospital's document titled, "The Governing Board (Body) Bylaws," reviewed 01/2025, showed the authority and responsibility of the CEO included authority and accountability to the Board for all hospital operations and activities, and responsibility for overseeing the Medical Staff and organizational functions.

During an interview on 02/27/25 at 8:15 AM, Staff A, CEO, stated that as CEO she was responsible for full oversight of the hospital's operations.

Based on observation, interview and policy review, the hospital failed to:
- Correctly transcribe, administer and monitor for side effects of a medication ordered for one discharged patient (#19) of 11 medication event reports reviewed;
- Ensure designated continuous telemetry (remote observation of a person's heart rhythm, using signals that are transmitted from the patient to a computer screen) observation for all telemetry monitored patients;
- Ensure expired medications and supplies were removed from one emergency crash cart (mobile cart which contains emergency medical supplies and medication) of one crash cart observed;
- Ensure temperature logs for the hospital's food storage freezers were accurately maintained for two of four freezers observed;
- Document the date opened and to discard expired glucometer (machine used to measure the amount of glucose [sugar] in your blood) control solutions (a solution used to calibrate glucometers machine) on two of two glucometers observed; and
- Follow their internal policy for quality control of the centrifuge machine (a scientific instrument used to separate components of a blood sample).

Findings included:

Review of the hospital's policy titled, "Verbal and Telephone Orders," reviewed 01/2023, showed:
- Verbal orders are not allowed when the patient's chart is available;
- Both parties will pronounce numerical digits separately (saying for example, "one six" instead of "16");
- Both parties will express the doses of medication orders by the unit of weight; and
- The recipient will record each verbal order directly on an order sheet in the patient's chart, including phone or pager numbers in case it is necessary for follow-up questions.

Review of the hospital's document titled, "Incident Report," dated 10/05/24, related to Patient #19, showed:
- At 9:53 PM, the patient reported difficulty breathing to Staff W, Registered Nurse (RN), and the Respiratory Therapist (RT) was notified. The patient refused bi-level positive airway pressure (Bi-PAP, type of ventilator that is used to treat conditions in which a person is able to breathe on their own but needs assistance) because the mask "bothered her and made her restless."
- On 10/06/25 at 12:01 AM, an arterial blood gas (ABG's, a blood test that measures the amount of oxygen and carbon dioxide in the blood) was performed with critical results. The patient required BiPAP, it was placed and she began fighting and "ripped it off." The RT called the doctor to report the critical ABG results and requested a medication to help improve her compliance with the Bi-PAP. An order for 0.5 milligram (mg) of Intravenous (IV, in the vein) Ativan (a medication used to treat anxiety or sleep difficulty) was received by the RT. Staff W was notified of the order, but "walked away." Staff W forgot what the order was, returned to the room and stated, "was that five of Ativan" and the RT responded "yes." Staff W entered the five mg of Ativan order into the electronic medical record. There was no phone or pager number included in the order.
- At 12:15 AM, Staff W retrieved the five mgs of Ativan from the medication dispensing machine. Staff U, RN, hesitated to witness the dose override. Staff W was "aggressive" when questioned about the dose, but medication override was witnessed by Staff U.
- Ativan five mgs IV was administered to the patient.
- The Bi-PAP continued to alarm, and the patient struggled to maintain her oxygen saturation (measure of how much oxygen is in blood). Two nurses entered the room to assist the RT with the frequent alarms and the patient's apnea (temporary cessation of breathing, especially during sleep) episodes. When Staff W was questioned why the patient was lethargic, she responded she administered five mgs of IV Ativan.
- The provider was notified and "was shocked." An order was received for a medication to reverse the effects of the Ativan. The medication was administered and the patient became more alert, was able to speak.
- One hour later an ABG was repeated with critical results and the RT notified the provider.
- Later that morning the patient only awoke to vigorous stimuli for a short period of time and would drift back to sleep. The patient's primary provider was notified and a telephone order was received for additional medication to reverse the Ativan effects.
- The patient "finally" woke, refused bi-PAP and was alert. No injury or adverse outcome resulted and the supervisor was notified.

Review of Patient #19's medical record showed:
- On 10/01/24, a 53-year-old female was admitted to the hospital for respiratory failure (condition in which not enough oxygen passes from the lungs into the blood).
- On 10/06/24 at 12:05 AM, a telephone order was written by Staff W, RN, for Ativan five mgs IV.
- At 12:12 AM, a RT note indicated the physician was notified of a critical ABGs result and orders were received for Ativan 0.5 mg IV.
- At 12:20 AM, Staff W administered Ativan 5 mg IV.
- At 3:18 AM, she experienced frequent apnea episodes. The provider was called for medications to reverse the effects of the five mg of that was given. An order was received and confirmed with a read-back to the provider.
- At 3:23 AM, a provider note indicated the patient received five mg of Ativan instead of the 0.5 mg that was ordered.
- At 6:10 AM, Staff W, rejected the Ativan five mg IV order.
- At 6:48 AM, the patient was only responsive to vigorous stimuli for short periods and would drift off back to sleep. The provider was called for additional reversal medication.
- At 8:10 AM, the provider declined the Ativan five mg order.

During an interview on 02/27/25 at 8:15 AM, Staff A, Chief Executive Officer (CEO), stated that telehealth (remote delivery of healthcare services while the health care provider is at a separate location, including exams and consultations, through video and telephone communication) providers were to write their own orders; telephone orders were unacceptable. A RT was not able to receive nursing orders. Any telephone order was to be confirmed with a readback. She expected nurses to observe for and be aware of potential medication side effects.

During an interview on 02/26/25 at 8:15 AM and 02/27/25 at 9:09 AM, Staff C, Director of Nursing (DON), stated that the telehealth providers had access to the patients' medical records and were to enter their own orders. Telephone orders were not acceptable. A RT was not able to receive nursing orders. There was a "standoff" between the primary nurse and the witnessing nurse in response to the high dose of Ativan override. The witnessing nurse was counseled for witnessing the incorrect medication dose. She expected staff to follow the policies and procedures for medication administration and telephone orders. She expected staff to observe for side effects of medications and staff to react to a patient's change in condition. Staff education was provided at a staff meeting in regard to incident reporting and telehealth providers entering their own orders. Staff not in attendance at the meeting were sent an electronic mail (email) message with a required read receipt. Not all staff reviewed the email as evidenced by the absence of read receipts. No additional staff education was provided regarding medication administration and monitoring for side effects of medications.

During an interview on 02/26/25 at 2:27 PM, Staff U, RN, stated that she felt "bullied" by Staff W, RN, when she was told to witness the Ativan five mgs override pull on the medication dispensing machine. She assisted with the administration of the reversal medications. It was not normal for a RT to receive nursing orders. If she had been the primary nurse, she would have called the provider to clarify the order. Staff U believed the patient was going to experience a code blue (emergency situation where a patient's heart or breathing has stopped, and staff quickly respond to attempt to restore the heartbeat or breathing).

During an interview on 02/26/25 at 3:20 PM, Staff V, RT, stated that the patient complained of shortness of breath and an ABG was performed. The ABG had critical results and she called the provider; a telephone order was received for Bi-PAP and Ativan 0.5 mg IV. She would not normally take an Ativan telephone order; she took it because the provider said to give it. She verbally informed Staff W, Primary RN, of the Ativan 0.5 mg order received from the provider. Staff W did not call the provider to clarify the order, she did not recognize the dose as "unusual." Staff W administered the medication and the patient became unarousable. She and the other nurses figured out the reason the patient was sedated after they reviewed the medication administration record. Another nurse called the provider and obtained a reversal medication telephone order. An hour later an ABG was performed resulting in critical results. She received no education in regard to telephone orders or medication administration.

Review of the hospital's policy titled, "Telemetry: Cardiac Monitoring," reviewed 01/2023, showed the nurse caring for the patient will be informed of any dysrhythmia (abnormal heartbeat).

Observation on 02/24/25 at 12:00 PM, with concurrent interview, in the Central Nurse Station, showed 19 current patients (#6, #7, #8, #9, #12, #13, #16, #18, #23, #29, #31, #33, #34, #35, #36, #37, #38, #39 and #40) on the telemetry monitor without designated staff present to observe the monitor. Staff E, Unit Secretary/Telemetry Monitor Technician (TMT), was talking on the telephone and looking at a computer screen with her back to the telemetry monitor. Staff E stated that she was the unit secretary and was also watching the telemetry monitors while the TMT was on her lunch break.

Review of the hospital's document titled, "General Incident Report," dated 09/24/24, showed:
- On 09/24/24 from 6:58 AM to 7:17 AM, Patient #3 was off of the telemetry monitor.
- At 7:18 AM, a staff member entered the room, observed the telemetry was not connected and reapplied the telemetry wire. Patient #3's heart rate (the number of times the heart beats within a certain time period, normal pulse/heartbeats for adults range from 60 to 100 per minute) was in the 20's.
- At 7:24 AM, the nurse and charge nurse were at the bedside and a code blue was initiated.
- At 7:41 AM, return of spontaneous circulation (ROSC, the resumption of a sustained heart rhythm after cardiac arrest) was achieved.
- Video surveillance review showed the TMT did not notify the nurse the patient was off of the telemetry monitor.

During an interview on 02/27/25 at 8:15 AM, Staff A, CEO, stated that the TMT breaks were to be covered with a designated staff member. She expected continuous focus on the telemetry monitors.

During an interview on 02/27/25 at 9:09 AM, Staff C, DON, stated that she expected continuous telemetry monitoring observation. If the Unit Secretary provided monitor observation during the TMT's break, she was to be removed from her unit secretary duties during that time. The RTs and nurses were able to provide telemetry monitoring coverage during breaks.

During an interview on 02/25/25 at 8:30 AM, Staff S, Risk Management Director/Infection Preventionist, stated that she expected a designated TMT at all times, including during staff breaks. The TMT was to only watch the telemetry monitors. The TMT was not to function simultaneously as the monitor technician and the unit secretary.

During an interview on 02/26/25 at 2:34 PM, Staff L, RN, stated that the event with Patient #3 occurred at shift change and no one noticed he was off of the telemetry monitor. She received a call over her walkie-talkie that assistance was needed in Patient #3's room. When she entered the room, she initiated Cardiopulmonary Resuscitation (CPR, emergency life-saving procedure performed when a person's breathing or heartbeat has stopped) and called for help. Normally nurses receive a call over their walkie-talkies with any telemetry concerns. The notification for Patient #3's telemetry concern was missed.

Review of the hospital's policy titled, "Crash Cart Checks," reviewed 03/2024, showed the emergency crash cart will be fully equipped and ready for use at all times through regularly scheduled equipment and supply checks. Pharmacy will perform monthly checks for drug expiration dates.

Observation on 02/24/25 at 11:30 AM, at the Central Nurses Station, showed a crash cart with:
- Two 1,000 milliliter (ml, unit of measure) bags of IV fluids which expired on 09/2024;
- Two calcium chloride (a mineral and medication used along with emergency medical treatment to treat life-threatening conditions) vials which expired on 12/2024;
- Seven epinephrine (a hormone and medication used along with emergency medical treatment to treat life-threatening conditions) vials which expired on 12/2024;
- Three atropine (an emergency medication used to treat a slow heart rate) vials which expired on 09/2024;
- Two lidocaine (an emergency medication used to treat a dysrhythmia) vials which expired 01/2025;
- Five blood tubes with expiration dates from 08/2016 to 12/2017; and
- No monthly log for expired medications and/or supplies inspections.

During an interview on 02/27/25 at 8:15 AM, Staff A, CEO, stated that expired medications and supplies were not to be available for use. She expected a log to be present to show the crash carts were inspected and ready for use. The expired medications in the crash cart were "really disappointing."

During an interview on 02/27/25 at 9:09 AM, Staff C, DON, stated that she expected no expired medications in the crash cart and a log to show the crash carts were inspected and ready for use.

During an interview on 02/24/25 at 12:10, Staff F, Pharmacy Director, stated that the pharmacy staff were responsible for performing monthly checks of the crash cart to ensure the medications and supplies were not expired. There were no crash cart logs to show inspections of medication and supplies were completed.

Review of the hospital's policy titled, "Refrigerator Temperatures," reviewed 01/2023, showed refrigerator and freezer temperatures will be monitored and recorded on the appropriate logs each day. The acceptable range of temperatures was 0 to -10° Fahrenheit for freezers and 36 to 41° F for refrigerators. Staff should notify the appropriate personnel if the temperature is out of range.

Review of the hospital's policy titled, "Storage of Food Items," reviewed 01/2022, showed each refrigerator and freezer must be equipped with an accurate thermometer. Temperatures shall be recorded daily for each refrigerator or freezer. If the temperatures are above 41°F for refrigerators or 0°F for freezers facility management will be notified.

Observation on 02/25/25 at 11:20 AM, in the hospital's nutrition room, showed one chest freezer did not have a thermometer.

Review of the hospital's document titled, "Freezer Temperature Chart," dated 11/2024, 12/2024, 01/2025 and 02/2025, showed all daily freezer temperatures were 0° F.

During an interview on 02/25/25 at 12:15 PM, Staff R, Dietician, stated that she was responsible for oversight of patient food preparation. She expected each freezer and refrigerator to have a thermometer and expected the recorded temperatures to fluctuate.

During an interview on 02/27/25 at 9:10 AM, Staff C, CNO, stated that she was unaware that a freezer was missing a thermometer and expected all freezers to have one. She expected recorded freezer temperatures to vary if accurately recorded.

Review of the hospital's policy titled, "Point of Care Testing," reviewed 01/2025, showed glucometer control solutions are labeled with the date opened and expiration date. Expired reagents should be immediately discarded.

Observation on 02/25/25 at 8:30 AM, in the West Nurse Station, showed one open glucometer control solution without an open date.

Observation on 02/25/25 at 9:00 AM, in the Laboratory, showed one expired glucometer control solution and two open glucometer control solutions without open dates.

During an interview on 02/25/25 at 8:30 AM with Staff S, Risk Management Director/Infection Preventionist, stated that all control solutions were to be dated with the date they were opened and expired 90 days after opening. Expired control solutions were to be discarded.

Interview on 02/27/25 at 9:09 AM, Staff C, DON, stated that she expected all control solutions to be dated when opened. Any expired control solutions were to be discarded.

Review of the hospital policy titled, "Quality Control (QC) Guidelines," reviewed 01/2023, showed the purpose of the control program is to realistically assess the laboratory's usual performance in relation to that of other laboratories. To identify significant problems as they arise and to document that the problems are solved. To be effective, one individual should be assigned the responsibility of maintaining and reviewing the laboratories quality control records. The date and initials of the person performing the test are recorded along with the test result for each level of control.

Review of the hospital's document titled, "Centrifuge Maintenance - Centrifuge Identification 10698," dated 2024, showed a space for daily centrifuge QCs. No QC was performed on 14 of 61 days.

Review of the hospital's document titled, "Centrifuge Maintenance - Centrifuge Identification 10698," dated 2025, showed a single line drawn through 01/04/25 through 01/31/25 and 02/05/25 through 02/28/25. There were no documented initials of the person performing the test.

During an interview on 02/25/25 at 9:00 AM, Staff S, Risk Management Director/Infection Preventionist, stated that ABGs and blood glucose (sugar that circulates in the blood and when too high or too low can be detrimental to a person's health) checks with the glucometers were the only testing performed in hospital. The RT's performed ABGs and the nurses performed blood sugar checks, there was no laboratory personnel. She was responsible for the oversite of the laboratory. The QCs were to be completed daily. She was responsible for the centrifuge daily testing, but she did not work on the weekends. The task was not delegated in her absence. She agreed a single line drawn on the QC log did not show the QCs were performed daily.
During an interview on 02/27/25 at 8:15 AM, Staff A, CEO, stated that she expected the centrifuge QCs to be completed every day, including the weekends. It was unacceptable for a line to be drawn through the dates of the QC log, she expected daily initials.

During an interview on 02/27/25 at 9:09 AM, Staff C, DON, stated that she expected the centrifuge QC to be performed every day with initials. She agreed she was unable to determine if the QCs were performed every day with a single line drawn through the dates on the QC log.








49404

A-0145

Based on interview, record review and policy review, the hospital failed to ensure the safety of all patients when they failed to recognize, intervene and investigate the neglect of one patient (#19) of one neglect event reviewed.

Findings included:

Review of the hospital's document titled, "Incident Report," dated 10/05/24, related to Patient #19, showed:
- At 9:53 PM, the patient reported difficulty breathing to Staff W, Registered Nurse (RN), and the Respiratory Therapist (RT) was notified. The patient refused bi-level positive airway pressure (Bi-PAP, type of ventilator that is used to treat conditions in which a person is able to breathe on their own but needs assistance) because the mask "bothered her and made her restless."
- On 10/06/25 at 12:01 AM, an arterial blood gas (ABG's, a blood test that measures the amount of oxygen and carbon dioxide in the blood) was performed with critical results. The patient required BiPAP, it was placed and she began fighting and "ripped it off." The RT called the doctor to report the critical ABG results and requested a medication to help improve her compliance with the Bi-PAP. An order for 0.5 milligram (mg) of Intravenous (IV, in the vein) Ativan (a medication used to treat anxiety or sleep difficulty) was received by the RT. Staff W was notified of the order, but "walked away." Staff W forgot what the order was, returned to the room and stated, "was that five of Ativan" and the RT responded "yes." Staff W entered the five mg of Ativan order into the electronic medical record. There was no phone or pager number included in the order.
- At 12:15 AM, Staff W retrieved the five mgs of Ativan from the medication dispensing machine. Staff U, RN, hesitated to witness the dose override. Staff W was "aggressive" when questioned about the dose, but medication override was witnessed by Staff U.
- Ativan five mgs IV was administered to the patient.
- The Bi-PAP continued to alarm, and the patient struggled to maintain her oxygen saturation (measure of how much oxygen is in blood). Two nurses entered the room to assist the RT with the frequent alarms and the patient's apnea (temporary cessation of breathing, especially during sleep) episodes. When Staff W was questioned why the patient was lethargic, she responded she administered five mgs of IV Ativan.
- The provider was notified and "was shocked." An order was received for a medication to reverse the effects of the Ativan. The medication was administered and the patient became more alert, was able to speak.
- One hour later an ABG was repeated with critical results and the RT notified the provider.
- Later that morning the patient only awoke to vigorous stimuli for a short period of time and would drift back to sleep. The patient's primary provider was notified and a telephone order was received for additional medication to reverse the Ativan effects.
- The patient "finally" woke, refused bi-PAP and was alert. No injury or adverse outcome resulted and the supervisor was notified.

Review of Patient #19's medical record showed:
- On 10/01/24, a 53-year-old female was admitted to the hospital for respiratory failure (condition in which not enough oxygen passes from the lungs into the blood).
- On 10/06/24 at 12:05 AM, a telephone order was written by Staff W, RN, for Ativan five mgs IV.
- At 12:12 AM, a RT note indicated the physician was notified of a critical ABGs result and orders were received for Ativan 0.5 mg IV.
- At 12:20 AM, Staff W administered Ativan 5 mg IV.
- At 3:18 AM, she experienced frequent apnea episodes. The provider was called for medications to reverse the effects of the five mg of that was given. An order was received and confirmed with a read-back to the provider.
- At 3:23 AM, a provider note indicated the patient received five mg of Ativan instead of the 0.5 mg that was ordered.
- At 6:10 AM, Staff W, rejected the Ativan five mg IV order.
- At 6:48 AM, the patient was only responsive to vigorous stimuli for short periods and would drift off back to sleep. The provider was called for additional reversal medication.
- At 8:10 AM, the provider declined the Ativan five mg order.

During an interview on 02/27/25 at 8:15 AM, Staff A, Chief Executive Officer (CEO), stated that she expected the immediate removal of staff with allegations of abuse and/or neglect. She expected all allegations of abuse and neglect to be investigated and all staff to be educated in response to any allegation of abuse and/or neglect. The hospital failed to recognize the event with Patient #19 as neglect.

During an interview on 02/26/25 at 8:15 AM and 02/27/25 at 9:09 AM, Staff C, Director of Nursing (DON), stated that she was notified at 3:00 AM of the events with Patient #19. She requested to speak with Staff W, RN, but she refused. She should have removed Staff W from patient care immediately, but she failed to recognize the event as neglectful at the time. Other nurses intervened with the patient. Staff W's contract was terminated, and her agency was notified of the event. The Department of Health and Senior Services (DHSS) was not notified of Staff W's neglectful act. The provider who directed the RT to stop calling was also removed from his agency. There was no investigation into the neglect of Patient #19 and no staff education was provided in regard to the recognition and prevention of abuse and neglect.

Interview on 02/25/25 at 2:03 PM, Staff S, Risk Management Director/Infection Preventionist, stated that she considered the event with Patient #19 to be neglectful, specifically in relation to the nurse's failure to notify the provider. No staff education was provided in regard to the recognition and prevention of abuse and neglect.

During an interview on 02/26/25 at 2:27 PM, Staff U, RN, stated that she felt "bullied" by Staff W, RN, when she was told to witness the Ativan five mgs override pull on the medication dispensing machine. She went to the patient's room to help with the reversal medications. Staff W "stayed at the end of the hallway and had little involvement with the patient." Staff U had to go find Staff W "several times" to ask for assistance because the RT was "in trouble" with the patient. Patient #19 decompensated and "Staff W walked out of the room." Staff U received no education in regard to the recognition and prevention of abuse and neglect.

During an interview on 02/26/25 at 3:20 PM, Staff V, RT, stated that Staff W was not involved with Patient #19's care when she decompensated. Staff V received no education in regard to the recognition and prevention of abuse and neglect.

Based on interview, record review and policy review, the hospital failed to ensure that staff were trained on a periodic basis in first aid related to restraints (any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely) for all nursing and provider staff.

This failure had the potential to result in serious injury or death to patients who required restraints in the hospital.

Findings included:

Although requested, the hospital failed to provide training requirements and completion logs for physicians and staff for related to restraint first aid.

During an interview on 02/27/25 at 8:15 AM, Staff A, Chief Executive Officer (CEO), stated that she was aware first aid training for patients in restraints was required.

During an interview on 02/27/25at 9:09 AM, Staff C, Director of Nursing (DON), stated that she was not aware first aid restraint training was required for staff and expected the training to be completed if required.

During an interview on 02/26/25 at 12:59 PM, Staff S, Risk Management Director/Infection Preventionist, stated that restraint first aid training was not provided to physicians or other staff members.

Based on interview, record review and policy review, the hospital failed to recognize, investigate and follow their policies and procedures for medication administration when one current patient (#30) and two discharged patients (#32 and #41) of three medical records reviewed had 44 to 67 missed medication administrations.

Findings included:

Review of the hospital's policy titled, "Clinical Practice Guidelines," reviewed 01/2023, showed the patient's medication will be documented with the appropriate time, route and dose by the nurse in the patient's medication administration record. When a medication is not given to the patient, it will be noted by the nurse with a brief explanation documented in the patient's medication administration record.

Review of the hospital's document titled, "Medication Administration Record Report," dated 01/01/25 through 01/31/25 showed:
- Patient #30 had 49 missed medication administrations on 01/01/25 through 01/29/25;
- Patient #32 had 44 missed medication administrations on 01/01/25 through 01/31/25; and
- Patient #41 had 67 missed medication administrations on 01/04/25 through 01/22/25.

During an interview on 02/27/25 at 8:15 AM, Staff A, Chief Executive Officer (CEO), stated that she expected medications were administered according to the hospital's policy and procedure.

During an interview on 02/26/25 at 8:15 AM, Staff C, Director of Nursing (DON), stated that missed medication administrations were not acceptable. She expected documentation in the medication administration record indicating why a medication was not given. She was not aware of the pattern for missed medication administrations, there was no auditing process in place for missed medication administrations. She had full oversight of nursing, and it was her responsibility to ensure medications were administered per the physician's orders.

During an interview on 02/26/25 at 9:09 AM, Staff F, Pharmacy Director, stated that he did not audit for missed medication administrations. He was surprised by the high number of missed medication administrations. He expected all medications to be scanned into the medication administration record. If a medication was not given, he expected documentation of the reason why.

Based on observation, interview and policy review, the hospital staff failed to:
- Perform hand hygiene (HH, washing hands with soap and water or alcohol-based hand sanitizer) and glove changes when providing care for eight patients (#5, #8, #9, #12, #13, #14, #16 and #18) of nine patients observed;
- Prepare a clean work surface prior to performing patient care for six current patients (#5, #8, #9, #13, #14 and #18) of nine patients observed;
- Sanitize equipment and ensure the use of clean/sterile (completely clean and free from germs) supplies for one current patient (#9) of one patient observed;
- Ensure visitors followed the hand hygiene and personal protective equipment (PPE, such as gloves, gowns, goggles, and masks) policies for one current isolated patient (#9) of one patient visitor observed;
- Remove an isolation mask prior to exiting one current isolation precautions patient's room (#8) of two isolation patients observed;
- Follow the hospital's policy and procedures for single use patient care items for two current patients (#5 and #14) of two patients observed;
- Ensure a clean medication preparation area;
- Remove expired patient care supplies;
- Follow the hospital's policy and procedure for cleaning supplies storage;
- Follow the hospital's policy and procedure for the removal of expired food and labeling of food in two of three patient nutrition areas observed;
- Ensure clean kitchen surfaces; and
- Follow nationally recognized standards to maintain a sanitary environment.

These failures had the potential to adversely affect the quality of care and safety of all patients in the hospital.

Findings included:

Review of the hospital's policy titled, "Hand Hygiene," reviewed 02/2025, showed:
- All Landmark Hospital healthcare personnel will follow the Centers for Disease Control (CDC)/World Health Care (WHO) guidelines on hand hygiene and will be knowledgeable regarding hand washing procedures to comply with the procedures required.
- Hands must be cleansed by hand washing with soap and water or by hand asepsis with alcohol-based rubs before and after contact with all patients, after contact with the source of microorganisms (organisms, such as bacteria, too small for the naked eye) including body fluids and substances, mucous membranes, non-intact skin and inanimate objects that are likely to be contaminated and after removing gloves.
- Hand asepsis is achieved by hand washing or by use of an alcohol-based rub is recommended before and after patient contact.
- Gloves should be used as an adjunct to, not a substitute for hand washing.

Review of the hospital's policy titled, "Standard and Transmission Based Precautions," dated 09/2023, showed hand hygiene is performed before and after every patient contact, after every contact with the patient environment, and when gloves are removed.

Review of the hospital's undated document titled, "Corporate Compliance Landmark Hospital of Cape Girardeau," showed hands must be washed with soap and water or by hand asepsis with alcohol-based rubs before and after contact with a patient, after contact with any potential contaminated objects and before donning and after removing gloves.

Observation on 02/24/25 at 11:55 AM, on the East Unit, showed Staff B, Registered Nurse (RN), failed to perform hand hygiene and glove changes between removing a soiled wound dressing and applying a new dressing when providing care for Patient #5.

Observation on 02/24/25 at 3:05 PM, on the East Unit, showed Staff H, RN, failed to perform hand hygiene and glove changes during medication administration for Patient #5.

Observation on 02/24/25 at 12:35 PM, showed Staff G, RN, failed to perform hand hygiene prior to entering Patient #8's room. He was on contact precautions (precautions used to minimize the risk of infection spreading through touching an infected person or contaminated object). She dropped a percutaneous endoscopic gastrostomy (PEG, a tube inserted through a person's abdomen directly into the stomach to provide a means of feeding when oral intake is not possible) dressing package on the floor, picked up the package, failed to discard the package and perform glove changes and hand hygiene prior to cleaning the PEG site and applying the dropped dressing. She then placed the dirty washcloth used to clean the PEG tube in the dirty linen hamper and failed to remove her gloves and perform hand hygiene prior to performing urinary catheter (a small flexible tube inserted into the bladder to provide continuous urinary drainage) care. Staff G failed to remove her gloves and perform hand hygiene prior to assessing the peripherally inserted central catheter (PICC line, a flexible tube inserted into an arm, leg or neck vein to infuse fluids, blood products, and medications, or to withdraw blood for testing) dressing.

Observation on 02/24/25 at 1:00 PM, showed Staff D, RN, failed to remove her gloves and perform hand hygiene prior to exiting Patient #9's room to complete documentation on the workstation on wheels (WOW, a computer or supply and medication storage on a wheeled stand, that can be moved from patient to patient) keyboard. She failed to remove her gloves and perform hand hygiene prior to returning the patient's drink to the bedside table after performing care for Patient #9.

Observation on 02/24/25 at 3:15 PM, on the West Unit, showed Staff I, RN, failed to perform hand hygiene and glove changes between removing a soiled dressing and applying a new dressing when providing care for Patient #12.

Observation on 02/25/25 at 8:25 AM, on the West Unit, showed Staff I, RN, failed to change gloves and perform hand hygiene between removing a soiled dressing and applying a new dressing while caring for Patient #13.

Observation on 02/25/25 at 8:40 AM, on the East Unit, showed Staff M, Licensed Practical Nurse (LPN), failed to perform hand hygiene and glove changes between removing a soiled dressing and applying a new dressing. She also failed to perform hand hygiene between separate procedures when providing care for Patient #14.

Observation on 02/25/25 at 9:05 AM, on the West Unit, showed Staff N, LPN, failed to perform hand hygiene between glove changes during medication administration for Patient #16.

Observation on 02/25/25 at 10:10 AM, on the East Unit, showed Staff B, RN, failed to perform hand hygiene and glove changes between removing a soiled dressing and applying a new dressing when providing care for Patient #18.

During an interview on 02/27/25 at 8:15 AM, Staff A, Chief Executive Officer (CEO), stated that she expected hand hygiene to be performed according to policy, including when removing gloves and when moving from dirty to clean tasks. Dropped patient care items were to be discarded.

During an interview on 02/27/25 at 9:09 AM, Staff C, Director of Nursing (DON), stated that she expected hand hygiene and glove changes between procedures and when moving from a dirty area to a clean area. She expected a dropped supply to be discarded.

During an interview on 02/25/25 at 8:05 AM, Staff S, Infection Preventionist/Risk Management Director, stated that hand hygiene was to be completed before donning gloves and after glove removal. Staff were to perform glove changes and perform hand hygiene between patient care procedures. She expected a supply dropped on the floor to be discarded and not used for the patient.

Review of the hospital's policy titled, "Infection Prevention and Control," reviewed 03/2023, showed patient care equipment, including reusable items and durable medical equipment will be cleaned and disinfected in accordance with current CDC recommendations for disinfection. All surfaces in a patient room will be wiped down prior to setting medications on them or a barrier will be placed on the item/area.

Observation on 02/24/25 at 11:55 AM, on the East Unit, showed Staff B, RN, failed to create a clean barrier for dressing change supplies for Patient #5.

Observation on 02/24/25 at 12:35 PM, showed Staff G, RN, failed to create a clean barrier for patient care supplies for Patient #8.

Observation on 02/24/25 at 1:00 PM, showed Staff D, RN, failed to create a clean barrier for medication preparation for Patient #9.

Observation on 02/25/25 at 8:25 AM, on the West Unit, showed Staff I, RN, failed to create a clean barrier for dressing change supplies for Patient #13.

Observation on 02/25/25 at 8:40 AM, on the East Unit, showed Staff M, LPN, failed to create a clean barrier for dressing change supplies for Patient #14.

Observation on 02/25/25 at 10:10 AM, on the East Unit, showed Staff B, RN, failed to create a clean barrier for dressing change supplies for Patient #18.

During an interview on 02/25/25 at 8:15 AM, Staff A, CEO, stated that she expected a clean barrier for patient supplies and medications. Supplies placed directly on a patient's bedsheets did not meet her expectations.

During an interview on 02/25/25 at 9:09 AM, Staff C, DON, stated that she expected staff to create a clean barrier for patient care items.

During an interview on 02/25/25 at 8:05 AM, Staff S, Infection Preventionist Risk/Management Director, stated that she expected a clean barrier to be created prior to placing patient care supplies and/or medications. Placing patient care supplies on the patient's bed did not meet her expectations.

Review of the hospital's policy titled, "Standard and Transmission Based Precautions," dated 09/2023, showed medical equipment and instrument/devices must be cleaned and maintained according to the manufacturers' instructions to prevent patient-to-patient transmission of infectious agents. If patient care items must be shared, the items must be adequately disinfected prior to use on another patient.

Review of the hospital's undated document titled, "Corporate Compliance Landmark Hospital of Cape Girardeau," showed never use the computer keyboard while wearing gloves. If you do, you need to wipe down the keyboard immediately after you are done caring for the patient. Wipe down the scanning equipment between use.

Observation on 02/24/25 at 1:00 PM, showed staff D, RN, failed to clean the WOW and medication scanner prior to and after scanning medications for Patient #9, who was on contact precautions.

During an interview on 02/25/25 at 8:15 AM, Staff A, CEO, stated that the medication scanners were to be wiped prior to and after each use. She expected equipment to be cleaned after patient use.

During an interview on 02/25/25 at 9:09 AM, Staff C, DON, stated that she expected the medication scanner and WOW's to be cleaned after touched with dirty hands.

During an interview on 02/25/25 at 8:05 AM, Staff S, Infection Preventionist/Risk Management Director, stated that she expected the WOW to be cleaned after a nurse's touch if hand hygiene was not performed prior to contact with the WOW.

Review of the hospital's policy titled, "Standard and Transmission Based Precautions," dated 09/2023, showed visitors are provided education and asked to follow isolation precautions with strict hand hygiene and appropriate PPE upon entering and exiting the patient's room.

Observation on 02/24/25 at 1:00 PM, showed patient #8's visitor did not wear PPE or perform hand hygiene prior to exiting the patient's room. Staff G, RN, failed to provide visitor PPE and hand hygiene education. Patient #8 was on contact precautions.

During an interview on 02/25/25 at 8:15 AM, Staff A, CEO, stated that she expected staff to provide visitor education regarding PPE and hand hygiene.

During an interview on 02/25/25 at 9:09 AM, Staff C, DON, stated that she expected visitors to be educated on PPE and hand hygiene. Staff G, RN should have provided education to Patient #8's visitor.

Review of the hospital's policy titled, "Standard and Transmission Based Precautions," dated 09/2023, directed staff to dispose of mask upon leaving the patient's room.

Observation on 02/24/25 at 12:35 PM, showed staff G, RN, failed to remove her isolation mask prior to exiting Patient #8's room. Patient #8 was on contact isolation precautions.

During an interview on 02/25/25 at 8:05 AM, Staff S, Infection Preventionist/Risk Management Director, stated that isolation masks were to be removed when exiting an isolation precautions room.

During an interview on 02/25/25 at 8:15 AM, Staff A, CEO, stated that she expected staff to remove their mask when exiting an isolation room. If the staff member chose to wear a continuous mask, the mask was to be changed prior to exiting the isolations precautions patient's room.

During an interview on 02/25/25 at 9:09 AM, Staff C, DON, stated that she expected staff to remove their isolation mask when exiting an isolation room. If the staff member chose to wear a continuous mask, the isolation mask was to be changed prior to exiting the isolation precautions patient's room. The hospital had a staff educational opportunity for proper PPE use.

Review of the hospital's policy titled, "Infection Prevention and Control," reviewed 03/2023, showed single patient use items are cleaned and disinfected between uses by a single patient and disposed of after use (e.g., bedpans, urinals, pill splitters).

Review of the hospital's policy titled, "Infection Prevention and Control," reviewed 03/2023 showed single-use items are disposed of after a single use.

Observation on 02/25/25 at 8:40 AM, on the East Unit, showed a soiled suction cannister dated 12/20/24 in Patient #14's room. Patient #14 was admitted on 01/10/25.

Observation on 02/24/25 at 11:55 AM, on the East Unit, showed Staff B, RN, failed to use a clean measuring tape for each of his four wounds measured when performing wound care for Patient #5.

During an interview on 02/25/25 at 8:15 AM, Staff A, CEO, stated that it was unacceptable to reuse a suction cannister. She was "appalled" the nurse reused the suction cannister. She expected staff to use a different tape measure for each wound.

During an interview on 02/27/25 at 9:10 AM, Staff C, DON, stated that she expected disposable measuring tapes to be used to measure only one wound. Suction cannisters should be disposed of when patients are discharged and not reused. She expected staff to follow the hospital's policy and procedure for the cleaning of patient equipment.

During an interview on 02/25/25 at 8:05 AM and 9:30 AM, Staff S, Infection Preventionist/Risk Management Director, stated that she expected a different tape measure to be used for each patient wound. Staff were to follow the hospital's policy for single use items

During an interview on 02/25/25 at 2:05 PM, Staff B, RN, stated that she did use the same tape measure between wounds on the same patient and "had not thought about it, but it was a risk."

Review of the hospital's policy titled, "Standard and Transmission Based Precautions," dated 09/2023, directed staff to keep medication preparation areas clean.

Observation with concurrent interview on 02/25/25 at 9:15 AM, in the Pharmacy, showed an open loaf of bread, a kitchen knife and beef jerky on the counter next to medications. Staff F, Pharmacy Director, stated that the items were his lunch.

During an interview on 02/25/25 at 8:15 AM, Staff A, CEO, stated that it was unacceptable for the pharmacist to prepare his lunch and eat at the pharmacy counter.

During an interview on 02/25/25 at 9:09 AM, Staff C, DON, stated that Staff F, Pharmacy Director, was not to prepare his lunch and eat at the pharmacy counter.

Although requested the hospital failed to provide a policy for supply storage and expiration.

Observation on 02/25/25 at 9:45 AM, in the medication room, showed expired sterile surgical instruments, sterile gauze pads, port-a-cath (a small medical appliance installed beneath the skin in the chest region and connects the port to a vein and is used to administer medications and draw blood) needles, blood administration sets, sutures (a strand or thread used to sew skin and other body tissues together to close up a surgical incision or a tear), clear bandages, petroleum jelly-soaked bandage, syringes and sterile knives.

During an interview on 02/25/25 at 8:15 AM, Staff A, CEO, stated that maintenance performed the supply assessment. She planned to task them with the first in, first out process. She expected expired supplies were not to be available for patient use.

During an interview on 02/25/25 at 9:09 AM, Staff C, DON, stated that she expected expired supplies were removed from patient care areas.

Review of the hospital's policy titled, "Storage of Food Items," reviewed 01/2022, showed all cleaning supplies, soaps and detergents are stored separately from food supplies.

Observation on 02/24/25 at 12:20 PM, in the patient nutrition room, showed stainless steel surface cleaner, oven cleaner, drain opener solution, septic tank maintenance solution, disinfectant spray, grill cleaner, dish soap, degreaser, a bag of towels, scouring brushes, hair bonnets, cooking utensils and hot/cold packs stored on the same cart in the same room as patient food. A food storage cart with grill bricks and a mop head in the same plastic container. Trash bags and an electric extension cord in the same plastic container. Wax paper, plastic wrap, label maker, labels, paper towels, food storage containers and cups in the same plastic container.

During an interview on 02/25/25 at 8:15 AM, Staff A, CEO, stated that she expected cleaning supplies were stored separately from patient care and food items.

During an interview on 02/25/25 at 9:09 AM, Staff C, DON, stated that she expected separate storage locations for cleaning supplies and patient care and food items.

During an interview on 02/25/25 at 8:05 AM, Staff S, Infection Preventionist/Risk Management Director, stated that cleaning supplies were not to be stored with food items.

Review of the hospital's policy titled, "Code Dating of Food," reviewed 01/2022, showed:
- The code dates of all food products will be reviewed on an ongoing basis to ensure there are no outdated products within the hospital's inventory;
- All food products will be marked with the date received and rotate stock following the "first in, first out" method of inventory control; and
- All dairy products are destroyed on the date listed on the carton.

Review of the hospital's policy titled, "Storage of Food Items," reviewed 01/2022, showed:
- Leftovers will be discarded after 72 hours;
- Fresh produce will maintain its freshness for at least five days under correct temperatures; and
- Any product that appears to be spoiled should be destroyed.

Observation on 02/24/25 at 1:55 PM, in the kitchen, showed undated butter and cooking oil below the counter, expired chili powder and sesame seeds and an opened, undated instant mashed potato container.

Observation on 02/24/25 at 1:55 PM, in the kitchen's refrigerator, showed expired milk, cheese, tortillas, lettuce, pasta salad and chicken salad.

Observation on 02/24/25 at 01:55 PM, in the kitchen's freezer, showed undated meat patties and chicken breasts in bags.

Observation on 02/24/25 at 12:20 PM, in the patient nutrition room, showed:
- Expired worcestershire sauce, boxes of salt, packets of chicken and beef broth, packets of ketchup, packets of ranch and honey mustard salad dressing and applesauce;
- Undated containers of soybean oil and chicken noodle soup;
- One container of vegetable oil with a date of 01/11/23 written on the cap, a preparation date of 01/20/24 without a use by date; and
- One metal tray with an open plastic bag of undated brown bananas and a dirty paper towel.

During an interview on 02/25/25 at 8:15 AM, Staff A, CEO, stated that she "absolutely" expected no expired food. All food was to be labeled according to the hospital's policy and procedure.

During an interview on 02/25/25 at 9:09 AM, Staff C, DON, stated that she expected all expired food was discarded.

During an interview on 02/25/25 at 8:05 AM, Staff S, Infection Preventionist/Risk Management Director, stated that expired and undated food did not meet her expectations.

Review of the hospital's policy titled, "Cleaning Schedule," revised 01/2022, showed kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent an accumulation of grime. All counters, shelves and equipment shall be kept clean.

Observation on 02/24/25 at 12:20 PM, in the patient nutrition room, showed a drawer dirty with food crumbs and a microwave plate.

Observation on 02/24/25 at 1:55 PM, in the kitchen, showed dirt on the counters, the grill, the grill hood, the oven and the warming tray.

During an interview on 02/25/25 at 8:15 AM, Staff A, CEO, stated that she expected the kitchen was clean. Staff R, Dietician, was new to the role. Environmental rounds were an opportunity for improvement and education.

During an interview on 02/27/25 at 9:10 AM, Staff C, DON, stated that the kitchen was an opportunity for improvement and should be kept clean.

During an interview on 02/25/25 at 12:15 PM, Staff R, Dietician, stated that she had oversight of the hospital's kitchen and visited it monthly. She was "not necessarily surprised" that it was dirty.

During an interview on 02/25/25 at 8:05 AM, Staff S, Infection Preventionist/Risk Management Director, stated that she was surprised to know the kitchen was dirty. The dietician performed monthly environmental rounds in the kitchen and those reports were reviewed at the Quality Assurance and Performance Improvement (QAPI, process for reporting and/or identifying adverse events, near misses or review of high risk, problem prone areas for patient safety) meetings. She did not round in the kitchen.

Review of the undated Associations of Professionals in Infection Control and Epidemiology (APIC) document titled, "Strategies to Mitigate Cross Contamination of Noncritical Medical Devices," showed preventing healthcare-associated infections (HAIs) requires a comprehensive infection prevention program that encompasses all potential reservoirs in the chain of infection including environmental surfaces, shared medical devices, and other fomites (inanimate objects or surfaces that can be contaminated with pathogens). The program must have clear guidance for the safe handling and storage of all equipment and basic items used in the delivery of healthcare.

Review of the hospital's policy titled, "Infection Prevention and Control," reviewed 03/2023, showed single patient-use items, such as pill splitters, are cleaned/disinfected between uses by a single patient and disposed of after discharge.

Although requested the hospital failed to provide a policy related to the labeling of solutions and
Environment of Care Rounding Logs.

Observation on 02/25/25 at 9:00 AM, in the East Nurse Station, showed a used and dirty pill splitter and two glass bottles without a label of an unknown liquid, patient care supplies, plastic ware, straws and plastic drinking cups in the same cabinet.

Observation with concurrent interview on 02/25/25 at 8:30 AM, in the West Nurse Station, showed:
- Alcohol wipes, straws, laboratory blood tubes, telemetry electrode tabs, plastic pouches for crushed medications, syringes, intravenous (IV, in the vein) sterile port caps, a staff phone and staff food in the same drawer;
- Three glass bottles without a label of an unknown liquid, single pack condiments and straws in the same cabinet;
- Staff S, Infection Preventionist/Risk Management Director, stated that staff and patient care items should not be stored together. Food items, eating/drinking utensils and unknown substances should not be stored together.

Observation and concurrent interview on 02/25/25 at 9:10 AM, in the Respiratory Department, showed;
- Tools, syringes, ventilator (a machine that supports breathing) valves and spray lubricant in the same drawer;
- A plastic bin with change, patient supplies and cleaning solutions together on the counter; and
- Staff S, Infection Preventionist/Risk Management Director, stated that the change, patient care supplies and cleaning supplies were not to be stored together.

During an interview on 02/25/25 at 8:15 AM, Staff A, CEO, stated that staff and patient care supplies were to be stored separately. She expected dirty/used items were not stored with clean items. Items with different purposes were to be stored separately, there were to be no "junk drawers."

During an interview on 02/25/25 at 9:09 AM, Staff C, DON, stated that she expected separate storage for different items. "Junk drawers," were not okay.




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