HospitalInspections.org

Based on observation, interview, record review and policy review, the hospital failed:
- To provide a safe environment for patients when they did not respond with urgency to repair their malfunctioning call light system or provide adequate alternative communication devices for patient and staff to utilize in the interim (A-144);
- To ensure that Consent for Treatment and Important Message from Medicare (IM, information about a patient's right to appeal discharge) letters were supplied to two patients (#2 and #44) and/or their representative in a timely manner (A-144): and
- To safeguard the Protected Health Information (PHI, any information about health status, provision of health care, or payment for health care that can be linked to a specific individual) of their patients (A-147).
The hospital census was 21.

The severity and cumulative effect of this practice resulted in the overall noncompliance with 42 CFR 482.13 Condition of Participation: Patient's Rights, which resulted in a condition of Immediate Jeopardy (IJ).

As of 04/26/23, the hospital had provided an immediate action plan sufficient to remove the IJ when the hospital implemented the following actions:
- Provided immediate education prior to the start of their next shift, for all clinical staff regarding the expectation to carry handheld radios at all times;
- Provided direction for staff to ensure that all patients capable of using handheld bells had one immediately available and within reach, and to immediately replace any missing bells;
- Implemented a designated staff member to complete and document 15 minute safety checks on all patients to ensure that their needs are met; and
- Provided direction for staff members to physically remain in the hallways to ensure visibility of the call lights.

Based on observation, interview, record review and policy review, the hospital failed to:
- Ensure the Chief Clinical Officer (CCO) provided adequate oversight and supervision of nursing personnel, when the staff managing the wound care program were not properly trained or qualified in wound care management and treatment (A-0386);
-Ensure staff established and implemented an effective wound care and prevention program that prevented new or worsening wounds from occurring for two current patients (#6 and #15) and two discharged patient (#47 and #48) of four patients with wounds reviewed (A-0395);
- Ensure staff provided appropriate hygiene for six patients (#6, #14, #15, #17, #23, and #49) of six patients reviewed (A-0395);
- Ensure patients were appropriately turned and repositioned for four patients (#6, 44, 35, 43,) of four patients reviewed (A-0395) and
- Ensure staff follow the medication administration policies for two current patients (#6 and # 23) and three discharged patients (#29, #30, and #31) of 10 reviewed (A-405).

These failed practices resulted in a systemic failure and noncompliance with 42 CFR 482.23 Condition of Participation: Nursing Services. The hospital census was 21.

Based on observation, interview, record review and policy review, the hospital failed to ensure infection prevention policies were followed when:
- The hospital failed to ensure that Staff D, Interim Director Quality Management (DQM), was qualified by experience, training, education, or certification to be the hospital's Infection Preventionist.
- Staff failed perform hand hygiene (washing hands with soap and water or alcohol-based hand sanitizer) when providing care for seven patients (#4, #6, #10, #14, #15, #23, and #33) of 11 patients observed.
- Staff failed to appropriately don and doff personal protective equipment (PPE, such as gloves, gowns, goggles and masks) for eight patients (#2, #6, #10, #14, #15, #16, #23, and #43) while providing care.
- Staff failed to prepare a clean work surface prior to performing patient care for six (#2, #6, #14, #16, #23, and #33) of eight patients observed.
- Staff failed to ensure that intravenous (IV, in the vein) sites were properly labeled with the date, time, and initials for five patients (#1, #6, #10, #18, and #35) of 13 patients observed.
- Staff failed to ensure that all IV tubing was properly labeled with a date and time to be changed for six patients (#1, #6, #11, #18, #35, and #45) of 12 patients observed.
- Staff failed to properly cleanse an IV injection port for two patients (#10 and #34) of two IV injections observed and one insulin (medication that regulates the amount of sugar in the blood) pen tip for one patient (#23) prior to attaching the needle.
- Staff failed to ensure the proper storage of urinals at the bedside of two patients (#18 and #23).
- Staff failed to properly date food items that were located in the kitchen refrigerator, kitchen freezer, the dry goods, and refrigerator of the patient nutrition room.
- Staff failed to remove expired food items from stock in the kitchen refrigerator and the patient nutrition room refrigerator.
The hospital census was 21.

The severity and cumulative effects of these systemic practices resulted in the hospital's non-compliance with 42 CFR 482.42 Condition of Participation: Infection Prevention and Control and Antibiotic Stewardship Programs and resulted in the hospital's failure to ensure quality health care and safety. Refer to A-0748 and A-0749 for details.

Based on observation, interview, record review and policy review, the hospital failed to provide a safe environment for patients when they did not respond with urgency to repair their malfunctioning call light system or provide adequate alternative communication devices for patient and staff to utilize in the interim and failed to ensure the Consent for Treatment and Important Message from Medicare (IM, information about a patient's right to appeal discharge) letters were supplied to two patients (#2 and #44) and/or their representative in a timely manner. The hospital census was 21.

Findings included:

1. Review of the hospital's document titled, "SWC Pricing Summary," dated 02/08/23, showed that the hospital entered a contractual agreement with the company to remove an existing call light system and then install a new call light system. Work was to commence on the project within two to eight weeks from receipt of the approval.

Review of the contract for the new call light system showed the contract was signed 11 days after the malfunction of the hospital's call light system.

Review of the hospital's document titled, "Amazon.com Final Details for Order #111-0463095-9170644," dated 02/06/23, showed that the hospital ordered 15 handheld call bells. Five bells were shipped on 02/06/23, with the remaining 10 bells being shipped on 02/08/23. The handheld bells were not ordered for the patients until nine days after the malfunction of the hospital's call light system.

Review of the hospital's document titled, "EBay External Order," dated 03/24/23, showed that the hospital received five new handheld radios. Additional handheld radios for staff member use were not ordered until 55 days after the malfunction of the hospital's call light system.

Review of the hospital's document titled, "External TwoWayRadio.com: New Order #300009655," dated 03/30/23, showed that the hospital ordered four replacement housings and one cloning cable for their handheld radios. The purchase of components to repair the hospital's broken handheld radios were not ordered until 61 days after the malfunction of the hospital's call light system.

Review of the hospital's document titled, "General Incident Report," dated 03/08/23, showed that Staff V, Monitor Technician (MT), reported to the hospital that there had been a delayed response of staff members to a call for assistance on Patient #12. She had alerted all staff members via handheld radio at 6:30 PM, to check on Patient #12 since her telemetry leads were off. She called a total of six times, over a period of one hour, for assistance and patient check. When a Respiratory Therapist finally responded, at 7:30 PM, Patient #12 was found to have de-cannulated (the process by which a tracheostomy tube is removed once the patient no longer needs it) herself.

Review of the incident involving Patient #12 showed that there was an obvious delay in response of staff members to requests over the handheld radio.

During an interview and concurrent observation, on 04/24/23 at 2:05 PM, Staff F, Facilities Manager, stated that the hospital staff had always used the handheld radios to communicate with each other. There were no cell phones allowed on the floor. Respiratory, nursing, and management are all on the same radio channel. All staff are able to hear requests over the handheld radio. The installation of a new call light system began a couple weeks ago. The installation was approximately halfway completed. The code blue buttons continue to function, they light up in the hallway. He then entered an empty patient room, pressed the code blue button on the wall, a light in the hallway lit up, but there was no auditory alert. Patients were asked to use handheld bells to call for staff assistance. If a patient could not use a handheld bell or a soft touch pad, they would require a bedside sitter at all times.

Observation on 04/24/23 at 2:05 PM, showed the handheld call bell sitting on the sink and the call light hanging on the wall of Patient #2's room. Neither were within reach of the patient.

Observation on 04/24/23 at 2:08 PM, showed the handheld call bell sitting on the sink and the call light hanging on the wall of Patient #3's room. Neither were within reach of the patient.

Observation on 04/24/23 at 2:10 PM, showed the handheld call bell sitting in the window and call light on the floor of Patient #1's room. Neither were within reach of the patient.

Observation on 04/25/23 at 10:30 AM, showed that Staff II, PCT, did not have a handheld radio on her person. Staff B, CCO, reminded her to carry the handheld radio at all times.

Observation on 04/24/23 at 2:30 PM, showed no handheld call bell and the call light hanging on the wall in Patient #8's room.

Observation on 04/27/23 at 9:15 AM, showed no handheld call bell and the call light lying on the floor of Patient #23's room.

Observation on 04/27/23 at 10:30 AM, showed no handheld call bell in Patient #35's room.

Concurrent observation and interview on 04/24/23 at 2:35 PM, showed Staff J, Registerd Nurse (RN), did not have a handheld radio on her person. She stated that she had left it laying at the nurse's station.

Concurrent observation and interview on 04/24/23 at 2:45 PM, showed no handheld call bell in Patient #7's room. Patient #7 stated she was aware of the call lights not working and would yell out for help.

During an interview on 04/24/23 at 2:00 PM, Staff E, MT, stated that a new call light system was being installed. Patients were able to use the call light, they would light up in the hallway, but there was no audible alert. The patients were provided with handheld bells to allow them to call for assistance. All staff members were to carry handheld radios. The radios are on the same radio channel. All staff members are able to hear where and when assistance has been requested. If pressed, a code blue light would light up and be visible in the hallway, but there would not be an audible alert.

During an interview on 04/24/23 at 2:25 PM, Staff H, Patient Care Technician (PCT), stated that the call system had stopped functioning several months ago. Administration ordered handheld bells to supplement the lights. The lack of an audible alert impedes the staff's ability to respond to patient requests in a timely manner. Staff use handheld radios to communicate needs to other staff members. Staff are unable to know which patient needs assistance first when they come out of a room and have multiple lights on
.
During an interview and concurrent observation on 04/24/23 at 2:55 PM, Staff I, PCT, stated that the patient call lights functioned and would light up in the hallway, but there was no audible alert. The audible alert quit functioning several months ago. It could sometimes be challenging to respond to lights in timely manner, staff were not able to determine which light came on first. Staff were to carry a handheld radio, but she did not have hers on her person, she "must have left it in a patient room". There were not enough handheld radios for all staff members until about one month ago, when the hospital purchased additional radios.

During an interview on 04/24/2 at 3:30 PM, Staff G, RN, stated that she had safety concerns with their current call light system. She has been employed at the hospital for several months and it has not worked since she started. She tries to watch the lights, but when she is in a room with a patient she cannot visualize them. The handheld bells are a backup system for patients to use when they need assistance, but they don't always use them. When multiple lights are on upon exiting a room, it is difficult to determine which one needs answered first. Staff are supposed to carry the handheld radios at all times, but she has left them in a patient's room or at the nurse's station. She voiced concern that there could be a delayed response to a code blue if staff members did not always carry the handheld radios.

During an interview on 04/24/23 at 3:45 PM, Staff L, RN, stated that she was concerned over the call lights not working. She stated that some days the system of using the hand held radios worked but other days it did not work. She stated that at one point, approximately a month ago not everyone had access to hand held radios and that it was very difficult to work and answer call lights. Staff are to carry the handheld radios at all times, but she has left the radio in a patient's room or at the nurse's station. She stated that she was concerned that if there was a code blue she would have to yell for help. There was the potential for a bad outcome. She stated that about a month ago when the census was in the 30's a patient's family was very upset about the call lights not working. She was not aware of any incident reports or grievances that were filed. The Charge Nurse spoke with family, they attemped to ease their concerns. She voiced her concerns about the call light system to Staff A, CEO.

During an interview on 04/25/23 at 10:45 AM, Staff P, PCT, stated the call light system malfunctioned on January 28, 2023. Administration were made aware of it at that time. The hospital decided to order handheld bells to supplement the lights, but not until February. The handheld radios were to be used by staff to communicate, but up until a couple weeks ago, there were not enough for all the clinical staff working the floor to each have one. Administration had told staff that there had been some delays, but the contractor just started working on the system last week.

During an interview on 04/24/23 at 2:30 PM, Staff B, Chief Clinical Officer (CCO), stated there should be handheld call bells in all patient rooms.

2. Review of the hospital's policy titled, "Patient Rights - General Consent to Medical Treatment," dated 01/2022, showed that every patient admitted to the hospital must have a completed Consent to Treat form. Appropriate signatures should be obtained at the time the patient is admitted.

Review of the hospital's document titled, "Medicare Beneficiary Notices - Timeframe for Delivery of IM," dated 03/2023, directed that staff should deliver an initial IM letter and obtain a signature of delivery at the time of admission. If not able to deliver the IM form and obtain a signature upon admission, it must be delivered within two days of admission. If the patient was admitted after business hours or on a weekend or holiday, the Charge Nurse must deliver the initial IM letter and obtain a signature indicating patient receipt at the time of admission.

Review of the medical record for Patient #2 on 04/24/23 at 2:30 PM, showed that he was admitted on 04/20/23 and there was not a signed Consent to Treat form or a signed initial IM letter.

During an interview on 04/24/23 at 2:30 PM, Staff D, Interim Director Quality Management (DQM), stated that all patients should have a signed Consent to Treat form and if required an initial IM letter upon admission. The signatures are obtained and the forms are scanned into the medical record once received from the nurse.

During an interview on 04/24/23 at 2:35 PM, Staff E, Unit Secretary, stated that she was unable to locate any forms for Patient #2 within the documents waiting to be scanned into patient medical records.

Review of the hospital's document titled, "Scanned Admission Paperwork," received on 05/02/23 at 3:20 PM, showed signed copies of Patient #2's Consent to Treat form and his initial IM letter, signed by two staff members and backdated to 04/20/23 at 6:00 PM.

Review of the medical record for Patient #44, on 05/02/23 at 9:30 AM, showed that Patient #44 was admitted on 04/28/23 and there was not a signed Consent to Treat form or a signed initial IM letter until 05/01/23.

During an interview on 05/02/23 at 3:20 PM, Staff D, Interim DQM, stated Patient #2 did not have a signed Consent to Treat or an initial IM letter when his chart was reviewed on 04/24/23. Staff must have backdated the consent and the IM letter since then.

Based upon observation, interview, and policy review, the hospital failed to safeguard the Protected Health Information (PHI, any information about health status, provision of health care, or payment for health care that can be linked to a specific individual) in the hallway outside of the patient rooms of the hospital. This failure had the potential to affect the confidentiality of all patients in the hospital. The hospital census was 21.

Findings included:

Record review of the hospital's policy titled, "Confidentiality of Patient Information," revised 11/2022, showed that patient specific medical information should not appear anywhere that can be accessed by other patients or visitors. Patients have the right to have his/her medical record read only by individuals directly involved in his/her treatment or the monitoring of quality and by other individuals only on his/her written authorization. The patient has the right to expect that any discussions or consultation involving his/her case will be conducted discreetly.

Observation on 05/02/23 at 9:00 AM, showed a computer monitor that was left unattended. The computer monitor faced the hallway where patient information (names, medications, diagnosis) was visible by staff and visitors, who were not involved in the patient's care.

Observation on 05/02/23 at 10:40 AM, showed a computer monitor that was left unattended. The computer monitor faced the hallway where patient information was visible by staff and visitors, who were not involved in the patient's care.

Observation on 05/02/23 at 11:10 AM, showed a computer monitor that was left unattended. The computer monitor faced the hallway where patient information was visible by staff and visitors, who were not involved in the patient's care.

Observation on 05/02/2023 at 11:15 AM, showed a computer monitor that was left unattended. The computer monitor faced the hallway where patient information was visible by staff and visitors, who were not involved in the patient's care.

Observation on 05/03/2023 at 11:05 AM, showed a computer monitor that was left unattended. The computer monitor faced the hallway where patient information was visible by staff and visitors, who were not involved in the patient's care.

During an interview on 05/02/23 at 11:00 AM, Staff B, Chief Clinical Officer, stated that computer monitors should not be left unattended with visible patient information facing the hallway where staff and visitors could visualize. She stated that the expectation should be that all computers should face the patient room and that if left unattended, they should minimize the computer screen.

During an interview on 05/04/23 at 10:15 AM, Staff A, Chief Executive Officer, stated that computer monitors should not be left unattended showing patient information to anyone walking in the hallway. She stated that her expectation would be that all computer screens should be minimized if staff was not present and that computer monitor's should be facing patient rooms.

Based on observation, interview, record review and policy review, the hospital failed to ensure that the Chief Clinical Officer (CCO) provided adequate oversight and supervision of nursing personnel when the staff managing the wound care program were not properly trained or qualified in wound care management and treatment.

These failures had the potential to affect the quality of care for all patients in the hospital. The hospital census was 21 with 14 patients receiving wound care.

Findings included:

Review of the hospital's policy titled, "Clinical Practice Guidelines," dated 01/2023, showed staging and classification for wounds and pressure injuries would be completed by the Wound Care Nurse (WCN). All patients with skin breakdown or changes would receive a Wound Care Consult.

Review of the hospital's job description titled, "Wound Specialist," dated 11/2022, showed:
- The essential functions of the WCN include coordinating and implementing treatment, establishing goals, evaluating treatments and the outcomes of treatments for patient wounds.
- The WCN should utilize their training and knowledge of wound care to document the progress of the wound treatments.
- They are responsible for providing referring hospitals, patients, families, and staff members with education regarding wound management, prevention of pressure ulcers, support surfaces, dressing selections, and other therapies used in wound care.
- The WCN acts as a resource for physicians and clinical staff for wound management.
- A requirement of five years of focused wound care experience.
- Required licensure and certifications to include a valid license, BLS, ACLS, and Wound Care Certification or acquired certification within 90 days of employment.

Review of the personnel file for Staff N, WCN, showed a signed job description dated 01/13/23. There were no wound care certification documents in the file.

Review of the personnel file for Staff Q, WCN, showed a signed job description dated 01/12/23. There were no wound care certification documents or annual training certificates in the file.

Although requested, the hospital failed to provide a legible copy of Staff Q's wound care certification.

During an interview on 04/25/23 at 10:15 AM, Staff N, WCN, stated that she was currently working as a WCN, but was not wound care certified. She was responsible for assessing, documenting, and treating patient wounds.

During an interview on 04/25/23 at 1:25 PM, Staff Q, WCN, stated that she was currently working as a WCN and was certified. She was responsible for assessing, treating, and documenting patient wounds. Most patients, about 75% of the patients admitted, were treated for some type of wound. She had struggled with the documentation portion of her position. She was behind in documenting, but the treatments had been completed. Staff N, WCN, had been assigned to assist with documenting. She was going back through medical records to identify what portions of the documentation were missing, then entering that data. She had been out on family leave for about four weeks, no one covered her position, and no documentation had been completed.

During an interview on 05/04/23 at 10:10 AM, Staff B, Chief Clinical Officer (CCO), stated that the WCN should have wound care certification.

During an interview on 05/04/23 at 10:20 AM, Staff A, Chief Executive Officer (CEO), stated that the WCN should have wound care certification. The hospital should change Staff N's title, she does not have wound care certification.
Review of an electronic mail received from the hospital, dated 05/09/23 at 2:05 PM, showed Staff Q had been terminated due to inability to provide documentation of her wound care certification.

Based on observation, interview, record review and policy review, the hospital failed to:
- Establish and implement an effective wound care and prevention program that prevented new or worsening wounds from occurring for two current patients (#6 and #15) and two discharged patient (#47 and #48 ) of four patient's records reviewed that had received wound care;
- Provide appropriate hygiene for six patients (#6, #14, #15, #17, #23, and #49) of six patients' medical records reviewed; and
- Appropriately turned and reposition four patients (#6, #35, #43, and #44) of four patients' medical records reviewed.

These failures had the potential to lead to poor outcomes, impaired skin integrity, and overall increased risk of health status deterioration for every patient admitted to the hospital. The hospital census was 21.

Findings included:

Review of the hospital's policy titled, "Clinical Practice Guidelines," dated 01/2023, showed pictures of wounds would be taken upon admission during the patient admission assessment along with measurements and a full description.

Review of the hospital's policy titled, "Wound Care Scope of Services," dated 01/2023, showed:
- An interdisciplinary approach to wound prevention and care would be established and followed by members of the patient care team. This would begin with a complete skin assessment upon admission and continue with ongoing re-assessments.
- The wound care practitioner was responsible for coordinating the skin and wound care program, including patient management and ongoing treatment.
- Nursing completes a head to toe assessment and a comprehensive wound assessment within 24 hours of admission, along with photo documentation of wounds and/or pressure injuries, and then continues as part of the daily nursing shift assessment.
- Assessments and routine wound care treatments were to be provided by assigned nursing staff based on the wound care orders.

Review of the hospital's policy titled, "Pressure Ulcer Prevention Strategies," dated 01/2023, showed documentation guidelines included daily skin assessments, positioning and repositioning, skin care, interventions, and an individualized plan of care. All wounds identified during admission and/or shift assessment should be addressed.

Review of the hospital's policy, "Personal Care and Hygiene," revised on 11/2021, outlined the frequency of certain tasks for staff to complete in order to ensure that quality patient care and standards of care were upheld. Patients are to be bathed, have their hair washed, given oral hygiene, and be shaved daily. If a patient refuses personal care it should be documented in the medical record and reported to the attending nurse. Documentation should include the reasons for the decision and potential concerns. Nursing is accountable for the appropriate delegation and oversight of the completion of personal care needs. Personal hygiene is expected and encouraged daily per shift.

Review of the medical record of Patient #6 showed:
- He was a 39 year old male admitted on 03/29/23 for comprehensive wound care and completion of antibiotic therapy. His medical history included incomplete quadriplegia (partial loss of the ability to use both arms and legs, typically caused by a spinal cord injury; some sensation remains), multiple chronic wounds with wound vacuum assisted closure (wound VAC, a device that decreases air pressure on a wound to help it heal more quickly) on his right elbow.
- The initial wound assessment was documented as being completed on 3/29/23, the entry was not entered until 04/18/23, by Staff Q, Wound Care Nurse (WCN).
- A total of seven wounds were identified upon admission, each labeled one through seven.
- On 3/29/23 at 8:00 PM, the number of wounds decreased to five, two less than originally identified.
- On 03/30/23 at 10:40 AM, one wound was documented.
- On 03/30/23 at 9:30 PM, a total of six wounds were documented.
- On 04/02/23, wound #7's location was changed from the top of the left foot to the right inner ankle.
- On 04/04/23, wound #4 was documented as the right great toe instead of the left great toe, wound #5 was documented as the right great toe inferior instead of the right lateral foot, wound #6 was documented as the right lateral foot instead of left plantar heel, and wound #7 was documented as the top of the left foot instead of the right inner ankle.
- On 04/18/23, staff identified wound #8 on his coccyx, which measured 5 cm by 2.7 cm, and was not present on admission.
- On 4/25/23 at 5:45 PM, physician orders were placed for wound number one to have a daily dressing change.
- On 4/26/23 at 12:35 AM, the order for wound #1, bilateral buttocks, showed the frequency of dressing changes changed from daily to twice per week.
- On 04/26/23 at 12:35 AM, the documentation indicated that the dressing was changed on 04/25/23, no wound care, dressing change, or wound description was documented.
- On 4/26/23 at 5:27 PM, wound #1, bilateral buttocks, documentation indicated that the dressing was changed on 04/26/23, no wound care, or wound description was documented.
- On 4/27/23 at 12:23 AM, wound #1, bilateral buttocks, documentation indicated that the dressing was changed on 04/26/23, no wound care, dressing change, or wound description was documented.
- On 4/27/23 at 4:07 PM, wound #1's location was changed to the left gluteal, with a daily dressing change, and wound #2 was changed to the right gluteal, with a twice weekly dressing change. There was no documentation that the wound care, dressing change, or wound description of either wound had been completed.
- On 04/27/23 at 9:00 PM, there was no documentation of wound care or a dressing change.
- On 4/28/23 at 4:04 PM, there was no documentation of wound care or a dressing change.
- On 4/29/23 at 11:39 AM, documentation indicated that the dressing was changed, but no wound description was documented.
- On 04/29/23 at 9:30 PM, documentation indicated that the dressing had been changed on 04/29/23, but no wound description was documented.
- On 4/30/23 at 6:04 PM, documentation showed that a dressing change had been completed by the wound care team but no wound description was documented.
- Review of the wound photographs showed inconsistency with the labeling and location of the wounds and they lacked assessment dates, wound measurements, and the staff initials for the person documenting.

Although requested, the hospital failed to provide an incident report related to the identification of a hospital acquired pressure injury, wound #8 for Patient #6 on 04/18/23.

During an interview on 04/26/23 at 5:30 PM, Patient #6's significant other stated that the nursing staff was not completing his wound care and dressing changes. She was completing it on her own each evening since it was not being done.

Review of the medical record for Patient #15 from 04/09/23 through 04/13/2013, showed:
- He was a 66 year old male admitted on 4/8/23 for comprehensive wound care and completion of antibiotic therapy. His history included a VRE (infection in the blood that is resistant to antibiotic therapy) infected sacral wound, and osteomyelitis (infection of the bones).
- On 04/07/23 at 7:13 PM, wound #1 was described as "multiple wounds, some with exposed tendon and bone, see wound care admission notes".
- On 04/08/23 at 1:58 AM, a total of four wounds were documented, no numbers or locations were indicated.
- On 04/08/23 at 9:03 AM, a total of seven wounds were documented, no numbers or locations were indicated.
- On 04/08/23, Staff N, RN, identified a total of seven wounds.
- On 04/09/23 at 3:08 AM, seven wounds were documented.
- On 04/09/23 at 11:24 AM, there was no documentation for wound #3 or wound #6.
- On 4/10/23 at 1:40 AM, there was no documentation of wound care or dressing assessments.
- On 04/10/23 at 10:30 AM, there were only five wounds documented; wound #2's location was changed to left lateral ankle, right proximal hip and left lateral foot; wound #3's location was changed to left posterior wrist; wound #4's location was changed to left proximal and distal hip; and wound #5's location was changed to right lateral foot.
- On 04/11/23 at 1:30 AM, there was no documentation of wound care or dressing assessments.
- On 04/11/23 at 8:30 AM, wound #1's dressing was assessed; wound #2 was documented as changed and no wound description entered; wound #3 was not assessed; wound #4 was documented as changed, no wound description entered; and wound #5 was not assessed.
- On 04/12/23 at 2:23 AM, there was no documentation of wound care or dressing assessments.
- On 04/12/23 at 7:30 AM, wound #1 was documented as changed, no wound description entered; wound #2 was not assessed; wound #3 was documented as changed, no wound description entered; wound #4 was documented as changed, no wound description entered; and wound #5 was not addressed. The total number of wounds listed was seven, but only five were listed.
- On 04/12/23 at 7:45 PM, there was no documentation of wound care or dressing assessments.
- On 04/13/23 at 4:38 PM a total of 6 wounds were documented: wound #1, left hip; wound #2, left posterior wrist; wound #3, left lateral ankle; wound #4, proximal right hip; wound #5, left lateral foot; wound #6, left medial wrist. The documentation showed inconsistent wound identification.
-On 4/13/23 at 5:32 PM, Staff N, WCN, identified a total of seven wounds; she labeled wound #2 as the right lateral ankle, which was inconsistent with the initial wound assessment. Her documentation of wound #5 showed she placed a wound vac on his left hip, the wound measured 13.5 cm x 9 cm x 1 cm with complete tendon showing and a 100% increase in size from the initial measurements on 04/09/23 (8.4 cm x 3.9 cm x 1.1 cm). Photos were documented but were not numbered or identified.
The wound care documentation in Patient #15's medical record was inconsistent. The wound numbers and locations changed multiple times within five days, making the wound care orders unclear and confusing. Dressing changes were not completed as ordered and showed that wound #5 progressed and required a wound vac placement.

Review of the medical record for Patient #47, from 02/15/23 through 03/07/23, showed:
- She was a 58 year old female admitted to the hospital on 02/14/23 for wound care.
- On 02/15/23, Staff Q, WCN, identified five wounds, there were 11 photos, with two wound locations able to be identified, none of the photos were numbered; wound #1, left inner thigh, cleanse apply PolyMem pink (an absorbent dressing used to facilitate healing, relieve pain, and reduce inflammation) and mepilex, change daily and PRN; wound #2, left outer thigh, apply Dakins moistened gauze and mepilex, change daily and PRN; wound #3, lower leg ulcers, cleanse, apply lidocaine gel, alginate (natural wound dressing made from seaweed and used for heavily draining wounds), ABD pads and kerlix (a gauze roll), change daily and PRN; wound #4, femoral breakdown left side, apply skin prep; wound #5, buttocks, apply barrier cream daily and PRN.
- On 02/19/23 at 8:32 PM, Staff O, Adult Health Clinical Nurse Specialist (ACNS), documented a total of four wounds; wound #1, left leg debridement, wrap with petroleum gauze, change daily; wound #2, right leg debridement, wrap with petroleum gauze, change daily; wound #3, left leg below the knee, apply Dakin's moistened gauze, change daily; and wound #4, left leg below the knee, apply Dakin's moistened gauze, change daily.
- On 02/19/23 at 9:01 PM, Staff O, ACNS, documented a total of four wounds along with treatment instructions; wound #1, left leg debridement, apply Unna boot (a boot that provides pressure compression; usually stays in place for three to seven days) and change twice a week and PRN; wound #2, right leg debridement, apply Unna boot and change two times a week and PRN; wound #3, left leg below the knee, apply honey (medical grade honey, used in wounds to provide moisture and prevent infection), alginate, and Unna boot, change two times a week and PRN; and wound #4, left leg below the knee, apply honey, alginate, and Unna boot, change two times a week and PRN. The treatments are different from the previous treatments she entered 29 minutes earlier.
- On 02/20/23, Staff Q, WCN, documented five photos, none of them were numbered or identified. Only wound #1 was assessed, the dressing change protocol was listed as cleanse with NS, apply alginate, cover with mepilex, and change. No frequency was ordered.
- On 02/22/23 at 11:10 AM, Staff O, ACNS, documented a total of four wounds along with treatment instructions: wound #1, right leg wounds, apply Unna boots, change every other day; wound #2, left calf leg wounds, apply Unna boots, change every other day; wound #3, left leg wound below the knee, apply honey, alginate, Unna boot, change every other day and PRN; and wound #4, left leg wound below the knee, apply honey, alginate, Unna boot, change every other day and PRN.
- On 02/27/23 at 9:07 AM, Staff O, ACNS, documented a total of four wounds and their treatments: wound #1, left leg wound below the knee, apply honey, alginate, and Unna boot, change every other day and PRN; wound #2, left leg wound below the knee, apply honey, alginate, and Unna boot, change every other day and PRN; wound #3, right leg wounds, apply Unna boots, change every other day; and wound #4, left leg calf wound, apply Unna boots, change every other day.
- On 02/27/23 at 9:20 AM, Staff O, ACNS, documented four wounds and their treatments: wound #1, left leg wound below the knee, apply honey, alginate, and Unna boot, change every other day and PRN; wound #2, left leg wound below the knee, apply honey, alginate, and Unna boot, change every other day and PRN; wound #3, right leg wounds, apply Unna boots, change every other day; and wound #4, left leg calf wound, apply Unna boots, change every other day. Staff O, ACNS, documented the exact same treatments 13 minutes after her original documentation at 9:07 AM.
- On 02/27/23 at 12:12 PM, Staff O, ACNS, documented a total of four wounds and their treatments: wound #1, left leg wound below the knee, apply honey, alginate, and Unna boot, change every other day and PRN; wound #2, left leg wound below the knee, apply honey, alginate, and Unna boot, change every other day and PRN; wound #3, right leg wounds, apply Unna boots, change every other day; and wound #4, left leg calf wound, apply Unna boots, change every other day. Staff O, ACNS, documented the exact same treatments 2 hours and 52 minutes after her original documentation at 9:07 AM.
- On 03/01/23, Staff Q, WCN, documented five photos. None of the photos were numbered or identified. One wound #1, left inner thigh ulcer, was assessed, the dressing change protocol was listed as cleanse with NS, apply alginate, cover with optilock, wrap with Unna boot and kerlix. There was no dressing change frequency ordered.
- On 03/06/23, Staff Q, WCN, documented five photos with three wound locations able to be identified, none of the photos were numbered; wound #1, left inner thigh, was documented as resolved; wound #2, left outer thigh, was assessed with the dressing change protocol listed as cleanse with sterile water, pat dry, apply alginate, wrap with Unna boot and kerlix, no frequency ordered; and wound #3, lower leg ulcers, were assessed with the dressing change protocol listed as alginate, optilock, Unna boot and kerlix, and no dressing change frequency ordered.
- On 03/07/23 at 2:40 PM, Staff O, ACNS, documented four wounds with their treatments: wound #1, left leg wound below the knee, resolved, Unna boot twice a week; wound #2, left leg wound below the knee, apply alginate and Unna boot, change twice a week and PRN; wound #3, right leg wounds, apply alginate, optilock, and Unna boots, change twice a week; and wound #4, left leg calf wound, apply alginate, optilock, and Unna boot, change twice a week.
- On 03/09/23, Staff Q, WCN, documented five photos with two wound locations able to be identified, none of the photos were numbered; wound #1, left inner thigh, was documented as resolved; wound #2, left outer thigh, was assessed with the dressing change protocol listed as cleanse with sterile water, apply alginate, wrap with Unna boot and kerlix, no frequency ordered; and wound #3, lower leg ulcers with the dressing change protocol listed as alginate, optilock, Unna boot, and kerlix, and no dressing change frequency ordered.
- The wound care documentation in Patient #47's medical record was very inconsistent. The documentation showed that the wound numbers and locations changed multiple times. These inconsistencies created confusion.

Review of the medical record for Patient #48, from 12/21/22 through 12/28/22, showed
she was an 81 year old female admitted to the hospital on 12/21/20 for wound care.
- On 12/22/22, Staff Q, WCN, identified four wounds in her Admission Assessment: #1 Left Lower Extremity (LLE), apply Unna boot, wrap with kerlix, wrap with ace wrap, change once a week; #2 Right Lower Extremity (RLE) medial (inner side), apply alginate, cover with foam, change two times a week; #3 skin tears L elbow, cleanse, dry, apply mepilex; and #4 Buttocks, cleanse with soap and water, apply moisture barrier cream. There were six photos, three were appropriately labeled with the date and location of the wound, and three wound locations were not identifiable.
- On 12/23/22, Staff O, ACNS, identified four wounds in her progress note and ordered treatments: #1 LLE - apply Unna boot and change weekly; #2 RLE - apply alginate and foam, change twice a week; #3 Left elbow - apply mepilex, change twice a week; and #4 Buttocks - apply moisture barrier cream twice daily (BID) and as needed (PRN). There were no wound photos, but a treatment plan was entered for each wound. The progress note was not signed until 04/25/23 at 11:42 PM, four months after the patient's admission and two months after she was discharged.
- On 12/26/23, Staff Q, WCN, examined the patient. She identified four wounds in her wound care assessment note and ordered treatments: #1 LLE - cleanse with wound cleanser, place a layer of Xeroform (a non-adherent gauze-type dressing covered with petroleum), and loosely wrap with kerlix (a gauze roll) daily; #2 RLE - cleanse with wound cleaner, apply honey and cover with kerlix, change every three days; #3 Left hand/arm - cleanse with wound cleanser, apply Xeroform, wrap with kerlix, change daily; and #4 Buttocks - cleanse with soap and water, apply moisture barrier cream BID and PRN. There were four photos taken, the left hand, left arm, and LLE were easy to identify, however none of the photos were labeled with the corresponding wound location or number.
- On 12/28/22, Staff O, ACNS, documented four wounds in her Progress Note: #1 LLE - debridement (the removal of damaged tissue from a wound), apply calcium alginate and kerlix, change on Thursday; #2 RLE - medial debridement, apply alginate and foam, change twice a week; #3 RLE - lateral (outer side) debridement, apply alginate and foam, change twice a week; and #4 buttocks - apply barrier cream BID and PRN. The progress note was not signed until 04/26/23 at 12:18 AM, four months after the patient's admission and two months after she was discharged.
- On 12/28/22, Staff Q, WCN, documented four wounds: #1 LLE - apply Xeroform and kerlix, change daily; #2 RLE - apply thera-honey and kerlix, change every three days; #3 left hand - apply thera-honey and mepilex, change two times a week; and #4 Buttocks - apply moisture barrier cream. Three photos were attached, none of them were labeled with the corresponding wound location or number.
The wound care documentation in Patient #48's medical record was very inconsistent. She was a patient for a total of 11 weeks. The documentation showed that the wound numbers and locations changed multiple times within just one week. These inconsistencies created confusion.

Review of the wound documentation for Patient #6, #15, #47, and #48 showed inconsistency with the wound identification numbers and wound locations, making it difficult for staff to determine when dressings had been changed, were due to be changed, and what type of dressings were to be applied. The progress notes from Staff O, ACNS, were not part of the medical record. Her notes were documented in a different system and forwarded to the hospital to be scanned into the medical records. The notes were not signed or scanned into the charts in a timely manner. These failures resulted in infected wounds, new wounds and wound deterioration.

During an interview on 04/25/23 at 10:15 AM, Staff N, WCN, stated that she was assisting with wound care since the hospital's wound care nurse was out on leave. Patients were seen at least once a week by the wound care nurse. They document the wound with photos, measurements, and descriptions. The bedside nurses were to follow the wound care treatment plan for routine dressing changes.

During an interview on 04/25/23 at 10:25 AM, Staff O, ACNS, stated that she had wound care certification. She was contracted with the hospital to provide assessments and treatment plans for the wound patients admitted. Between her and the WCN, all wound patients were seen once a week to have their wounds documented. The bedside nurses were responsible for the routine dressing changes. She would expect all dressings to be dated and initialed when applied.

During an interview on 04/25/23 at 1:25 PM, Staff Q, WCN, stated that Staff N had been instructed to go through the wound care patients to identify what portions of the wound charting were missing and to document those items. She had entered no wound care discharge notes since the last state survey in April 2022. Administration was aware of the lack of charting related to wound care. In addition to evaluating, treating, and documenting wound care, she was now responsible for ordering wound care supplies. The hospital contracted Staff O, ACNS, to evaluate and treat wound care patients but her documentation was in a separate program. Staff O's notes are emailed to the hospital and then scanned into the medical records.

During an interview on 05/02/23 at 8:15 AM, Staff AA, RN, stated that there were multiple nurses that fill in for wound care, there was no consistency with the orders and could be difficult to find them.

Review of the medical record for Patient # 6 showed he was admitted on 03/22/23. He received seven baths and one shower during the 37 days of hospitalization.

Review of the medical record for Patient #14 showed she was admitted on 04/20/23. She received two baths during 13 days of hospitalization.

Review of the medical record for Patient #15 showed he was admitted on 04/07/23. He received nine baths during 26 days of hospitalization.

Review of the medical record for Patient #17 showed he was admitted on 04/20/23. He received four baths during the 13 days of hospitalization.

Review of the medical record for Patient #23 showed he was admitted on 04/22/23. There was one refusal of a bath documented and two baths were given during 22 days of hospitalization.

Review of the medical record for Patient #49 showed he was admitted on 04/25/23. There was one refusal of a bath documented and one bath documented out of eight days of hospitalization.

During an interview on 04/26/23, Patient #6's wife stated that he had not had a bath in days and that she was having to bathe him.

Review of the medical record for Patient #6 on 04/15/23, showed that he was turned and repositioned only two times in that 24 hours.

During an interview on 04/26/24 at 5:30 PM, Patient #6's significant other stated that he does not get turned and repositioned. He has developed a new pressure ulcer on his buttocks since his admission.

Review of the medical record for Patient #35 showed she was admitted on 04/24/2023. She had a history of diabetes (a disease that affects how the body produces or uses blood sugar, and can cause poor healing) and required a urinary catheter (a small flexible tube inserted into the bladder to provide continuous urinary drainage). On 05/02/23 documentation showed she was turned and reposition only five times in a 24 hour period.

Review of the medical record for Patient #43 showed that she was admitted on 05/02/2023. She required a ventilator and had a wound vac. On 04/27/23 documentation showed she was turned and repositioned two times in a 24 hour period.

Review of the medical record for Patient #44 showed she was admitted to the hospital on 04/27/23. She required ventilator (a machine that supports breathing) support, had a tracheostomy (an opening created in the neck in order to place a tube into a person's windpipe that allows air to enter the person's lungs), and a urinary catheter. On 05/01/23 documentation showed she was turned and repositioned five times in a 24 hour period.

During an interview on 05/04/2023 at 10:15 AM, Staff A, CEO, stated that her expectations were that every patient received daily bathing. If a patient refused a bath, it should be documented. The patients should be turned and repositioned every one to two hours. The RN or PCT should be documenting this as well.

During an interview on 05/03/23 at 4:00 PM, Staff B, Chief Clinical Officer, stated that her expectations were for staff to follow the policy on personal hygiene. They were to document all bathing, refusals, and other personal hygiene. Patients should also be turned and repositioned every two hours. This should be documented as well.

Based on observation, interview, record review and policy review, the hospital failed to ensure that staff follow the medication administration policies for two current patient (#6 and # 23) and three discharged patients (#29, #30, and #31) of 10 reviewed. This failure increased the risk of medication errors placing all patients at risk for negative outcomes. The hospital census was 21.

Findings include:

Review of the hospital's policy titled, "Drug Administration - Timing of Administration of Medications," dated 10/2021, showed that Time Critical Medications (medications that when administered early or late may cause harm or have a negative impact to the intended therapeutic effect), such as rapid and/or short acting insulins, or medications for which an early or late administration of greater than 30 minutes from the scheduled time may cause harm or have significant negative impacts and should be administered within the 30 minute time frame.

Review of the hospital's policy titled, "Controlled Drug Administration," dated 10/2021, directed staff to document the time of administration as the time that the medication was given to the patient.

Review of the hospital's policy titled, "Drug Administration - Patients' Personal Drugs," dated 05/2013, showed a patient's personal drugs should only be administered when specifically authorized by the prescribing practitioner. Any personal medications should be sent home with an appropriate family member or packaged, labeled with the patient's name and then stored in the pharmacy.

Review of the hospital's policy titled, "Drug Administration General," dated 06/2022, directed staff to verify the five rights (right patient, right drug, right dose, right route, and right time) prior to administering medications and to verify the patient's identity by checking the name band and/or asking the patient to state his/her name.

Review of hospital's document titled, "Incident and Accidents," dated 12/01/23 through 04/26/23, showed a total of 132 incidents with 117 documented as medication errors.

During an interview on 04/26/23 at 5:30 PM, Patient #6's significant other, stated there were medications that were kept in a drawer in a cabinet in patient #6's room. They were Dulcolax suppositories (a solid medical preparation in a cone shape, designed to be inserted into the rectum to dissolve and treat constipation) that had been prescribed as part of his bowel regimen. The previous hospital had sent them with Patient #6 when he was transferred and she usually ended up being the one to administer them. The nursing staff were aware that they were in the drawer but they did not routinely administer them.

During an interview and concurrent observation on 05/03/23 at 12:30 PM, Patient #6, stated there were Dulcolax suppositories located in the top drawer of the cabinet. They had been sent with him when he was transferred from another hospital. The nursing staff were aware they were there. In the top drawer of the cabinet were six Dulcolax suppositories and one syringe of a heparin flush (medication used to prevent blood from clotting and forming an occlusion in a peripherally-inserted central catheter).

Review of Patient #6's medical record showed Dulcolax suppositories were listed to be given every other day per transfer documentation from the previous hospital.

Review of the medical record for Patient #6 showed an order dated 03/29/23 for a Dulcolax suppository to be administered every 48 hours.

Review of Patient #6's medication administration record (MAR) showed that he received Dulcolax suppositories on 03/30/23, 03/31/23, and 04/01/23. On 04/04/23, Staff EE, Registered Nurse (RN), documented the suppository as given, entering a note stating that Patient #6's significant other was in-route to the hospital to perform his bowel regimen.

Review of incident reports related to Patient #6 showed that:
- Since his admission on 03/29/23, there were six incidents documented related to medication errors.
- On 03/29/23, a dose of Pregabalin (used to treat nerve and muscle pain, as well as seizures) was charted as given at 9:27 PM, but not removed from the medication dispenser until 10:16 PM.
- On 04/02/23, two oxycodone (synthetic pain medication with a high risk for misuse) tablets were removed from the medication dispenser at 6:01 PM, then charted as not being given, patient sleeping. The medication was not returned or wasted in the medication dispenser. When investigated it was found that the nurse and charge nurse had wasted the medication but did not document appropriately.
- On 04/03/23, a dose of alprazolam (a sedative used to treat anxiety that can impair judgement, memory and coordination) was charted as given at 7:35 AM, but not removed from the medication dispenser until 8:35 AM.
- On 04/20/23, a dose of pregabalin was charted as given at 9:28 PM, but not removed from the medication dispenser until 10:28 PM.
- On 04/23/23, a dose of Meropenem (a medication used to treat severe infections of the skin, stomach and bacterial meningitis [infection that causes inflammation of the tissue that covers the brain and spinal cord]) intravenous (IV, in the vein) was documented as given, but the dose was not given and later found in the refrigerator.
- On 04/24/23, a dose of Unasyn (a penicillin antibiotic used to treat bacterial infections) IV was not given, the nurse did not to wake the patient to administer the medication which was ordered every four hours, which delayed treatment.

During an interview and concurrent observation on 05/02/23 at 9:36 AM, Staff BB, RN, entered the 200 hall medication room, removed two Morphine 10 mg solution cups from the medication dispense cabinet, and immediately charted them as given on Patient #23's MAR when she exited the medication room, without verifying the patient's name, date of birth, or scanning the patient's bracelet. She stated that she charted Patient #23's Morphine because it would be time for his next dose when she arrived at his room. Staff are only allowed 15 minutes from the time they pull a narcotic until it has to be documented as given. So she charted it immediately after pulling it out of the medication dispenser.

Observation and concurrent interview on 05/02/23 at 9:45 AM, showed Staff BB, RN, enter Patient #23's room, hand him the insulin syringe, and allow him to inject the 13 units of Humalog insulin (a rapid-acting blood-glucose-lowering medication that regulates the amount of sugar in the blood) based on the sliding scale ordered and blood sugar level obtained at 7:00 AM. She then administered liquid Morphine that she had previously charted. She stated that Patient #23's insulin dose was late and she was not sure what time his blood sugar was obtained. Patient #23 gives his own insulin, but there was not an order for that.

Review of the medical record for Patient #23, dated 05/02/23, showed that the scheduled 7:00 AM blood sugar was obtained at 7:04 AM and resulted as 163 mg/dl. There was no order for self-administration of insulin.

Review of the 200 hall's medication dispenser "Event Report," dated 05/02/23, showed that two Morphine 10mg solution cups were dispensed at 9:36 AM.

Review of Patient #23's MAR," dated 05/02/23, showed that two Morphine 10mg solution cups were documented as administered at 9:38 AM, and that 13 units of Humalog insulin were documented as administered at 8:23 AM. Neither medication was actually given until 9:45 AM.

Review of incident reports related to Patient #29 showed that:
- During his admission from 11/16/22 through 04/01/23, there were 11 incidents documented related to medication errors.
- On 12/06/22, a dose of Lomotil (a controlled medication which contains opioids, used to control diarrhea) was documented as given at 9:11 PM, but was not removed from the medication dispenser until 12/07/23 at 12:10 AM.
- On 12/11/22, a dose of Lomotil was documented as given at 9:36 PM, but was not removed from the medication dispenser until 10:33 PM.
- On 12/14/22, a dose of Lomotil was documented as given at 4:29 PM, but was never removed from the medication dispenser.
- On 12/15/22, a dose of Lomotil was documented as given at 9:49 AM, but was not removed from the medication dispenser until 10:44 AM. The same nurse documented another dose of Lomotil as given at 2:51 PM, but was not removed from the medication dispenser until 5:49 PM.
- On 01/01/23, a dose of Lomotil was documented as given at 3:34 PM, but was not removed from the medication dispenser until 4:30 PM.
- On 01/05/23, a dose of Lomotil was documented as given at 4:30 PM, but was not removed from the medication dispenser until 5:26 PM.
- On 01/05/23, a dose of Lomotil was documented as given at 9:02 PM, but was never removed from the medication dispenser.
- On 01/06/23, a dose of Lomotil was removed from the medication dispenser at 8:22 AM, but was never documented as given, wasted, or returned.
- On 03/20/23, a dose of Lomotil was documented as given at 9:24 AM, but was not removed from the medication dispenser until 10:24 AM.
- On 03/22/23, a dose of Lomotil was documented as given at 9:07 AM, but was not removed from the medication dispenser until 10:06 AM.

Review of incident reports related to Patient #30 showed that:
- During her admission from 03/17/23 through 04/12/23, there were six incidents documented related to medication errors.
- On 03/17/23, a dose of oxycodone was documented as given at 5:34 PM, then the entire dose was wasted at 6:18 PM. A dose of Dilaudid (medication used to treat severe pain) was removed from the medication dispenser at 6:00 PM, but was never charted as being given, wasted, or returned.
- On 03/18/23, a vial of Hydromorphone was removed from the medication dispenser at 9:03 AM, but was never charted as being given, wasted, or returned. A dose had been previously removed at 8:57 AM, six minutes prior and charted as being given.
- On 03/19/23, a dose of Oxycodone was removed from the medication dispenser, but was never charted as being given, wasted, or returned.
- On 03/28/23, a dose of Ativan (a medication that has a calming effect, used to treat anxiety or sleep difficulty) was documented as given at 6:59 AM, but was never removed from the medication dispenser.
- On 04/02/23, a vial of Fentanyl (a medication used to treat severe pain, and is a high risk drug for theft and personal use) was removed from the medication dispenser at 4:30 PM, but never documented as being given. Upon investigation, the nurse stated that she had given the medication, but "forgot to chart it".
- On 04/11/23, a vial of Ativan was removed from the medication dispenser at 4:41 PM, but was never charted as given.

Review of incident reports related to Patient #31 showed that:
- During her admission from 02/03/23 through 03/17/23, there were three incidents documented related to medication errors.
- On 02/05/23, a dose of daptomycin (antibiotic used to treat infection) was not given, the nurse overlooked the medication on the MAR.
- On 02/17/23, a dose of alprazolam (a sedative used to treat anxiety that can impair judgement, memory and coordination) was documented as given at 10:30 PM, but was not remove from the medication dispenser until 10:40 PM.
- On 02/28/23, a tube of hydrocortisone (a medication used to reduce inflammation, pain, and itching) 1% cream was removed from the medication dispenser without a valid order.

During an interview on 04/26/23 at 10:50 AM, Staff D, Interim Director Quality Management, stated that the hospital had a very high number of medication related incidents reported. She was not aware of specific issues, that Staff W, Pharmacist, was the staff member that entered them into the reporting system.

During an interview on 04/26/23 at 10:55 AM, Staff W, Pharmacist, stated that 98% of the incident reports that she submitted were related to controlled substances. The documentation errors were related to staff pulling medications and not charting them, charting medications as given even though they were never given or pulled from the medication dispenser, or actually pulling medications hours after they were documented as given. Staff B, Chief Clinical Officer (CCO), was responsible for following up with the nursing staff. Overall, the nurses are not following the policies for medication dispensing and documentation.

During an interview on 05/02/23 at 4:00 PM, Staff B, CCO, stated that the hospital did not have a policy that dictates the process of pulling medications. Staff are allowed to pull medications early as long as they are secured in patient specific bins within the medication rooms. No medications should be stored at the bedside of the patient, they should always be secured in the locked medication room. Medications should never be charted prior to administration. Any narcotics or controlled substances should be pulled, given, and documented immediately. Time critical medications should be given within the allowed time frame. Insulin should be given within 30 minutes of their scheduled blood sugar testing, not hours afterwards. Staff should never change administration times. Medications should be documented in real time. She was aware that there were numerous incident reports related to medication administration. No staff members have been counseled regarding medications. She stated that she would not make medication errors punitive.

During an interview on 05/04/23 at 10:20 AM, Staff A, Chief Executive Officer, stated that no medications should be kept at the bedside and any personal medications should be sent home, or secured in the pharmacy. She would expect staff to document and administer medications at their scheduled times. Insulin should be given within the time frame allowed. She was not aware that there were 117 medication related incidents since 12/01/22. The expectations for medication administration and documentation should be better communicated.

Based on interview and record review, the hospital failed to ensure that Staff D, Interim Director Quality Management (DQM), was qualified by experience, training, education, or certification to be the hospital's Infection Preventionist. This failure to provide training placed all patients at risk for inappropriate infection control compliance and protection. The hospital census was 21.

Findings included:

Review of the hospital's job description titled, "Director of Quality Management (DQM)," showed an essential function of the DQM was providing staff education, orientation, and annual recertification in Infection Control. The DQM was responsible for planning, developing, implementing, and managing the Infection Prevention and Control Program. Required licensure and certifications included an active clinical license, such as a Registered Nurse (RN) or Respiratory Therapist (RT), Certified Professional in Healthcare Quality (CPHQ) or ability to gain certification within two years of hire, and Certification Board of Infection Control (CIC) study and test within two years of hire.

Review of the hospital's document titled, "Infection Control Designation," dated 12/14/22, showed Staff D had been designated as the Infection Preventionist for the hospital.

Record review of personnel file for Staff D, Interim DQM, showed no prior experience or training for infection control.

During an interview on 05/02/23 at 4:00 PM, Staff B, Chief Clinical Officer (CCO), stated that she and the Interim DQM shared the role of Infection Preventionist. She was responsible for the clinical side of the job. Such was providing education and real time coaching to clinical staff. Staff D, Interim DQM, was responsible for entering the required data into reports.

During an interview on 05/03/23 at 9:00 AM, Staff D, Interim DQM, stated that she was not an RN and did not have any clinical training. She had no formal Infection Prevention training, but had been provided some on the job training by the previous DQM. She had voiced concerns about her qualifications for the Infection Preventionist role to the corporate DQM. She was told that she could enter the data and that the CCO would handle the clinical aspects of the job.

Based on observation, interview and policy review, the hospital failed to ensure they followed infection prevention policies when:
- Staff failed to perform hand hygiene (washing hands with soap and water or alcohol-based hand sanitizer) when providing care for seven patients (#4, #6, #10, #14, #15, #23, and #33) of 11 patients observed.
- Staff failed to appropriately don and doff personal protective equipment (PPE, such as gloves, gowns, goggles and masks) for eight patients (#2, #6, #10, #14, #15, #16, #23, and #43) while providing care.
- Staff failed to prepare a clean work surface prior to performing patient care for six (#2, #6, #14, #16, #23, and #33) of eight patients observed.
- Staff failed to ensure that intravenous (IV, in the vein) sites were properly labeled with the date, time, and initials for five patients (#1, #6, #10, #18, and #35) of 13 patients observed.
- Staff failed to ensure that all IV tubing was properly labeled with a date and time to be changed for six patients (#1, #6, #11, #18, #35, and #45) of 12 patients observed.
- Staff failed to properly cleanse an IV injection port for two patients (#10 and #34) of two IV injections observed and one insulin (medication that regulates the amount of sugar in the blood) pen tip for one patient (#23) prior to attaching the needle.
- Staff failed to ensure the proper storage of urinals at the bedside of two patients (#18 and #23).
- Staff failed to properly date food items that were located in the kitchen refrigerator, kitchen freezer, the dry goods, and refrigerator of the patient nutrition room.
- Staff failed to remove expired food items from stock in the kitchen refrigerator and the patient nutrition room refrigerator.

These failures had the potential to expose all patients, visitors and staff to cross contamination and increased the potential to spread infection. The hospital census was 21.

1. Review of the hospital's policy titled, "Hand Hygiene," dated 02/2023, showed that all hospital personnel should follow Centers for Disease Control and Prevention (CDC) guidelines on hand hygiene. Hands hygiene should be performed with soap and water or alcohol-based rubs:
- Before and after contact with all patients.
- After contact with body fluids and substances, mucous membranes, non-intact skin, and inanimate objects likely to be contaminated by microorganisms.
- After removing gloves.
- Before performing procedures.

Review of CDC Hand Hygiene Guidelines at www.cdc.gov/handhygiene, directed healthcare personnel to use an alcohol-based hand rub or wash with soap and water for the following clinical indications:
- Immediately before touching a patient.
- Before performing an aseptic task (placing an indwelling device) or handling invasive medical devices.
- After touching a patient or the patient's immediate environment.
- After contact with blood, body fluids, or contaminated surfaces.
- Immediately after glove removal.

Observation on 04/24/23 at 2:45 PM, showed Staff K, Registered Nurse (RN), failed to perform hand hygiene prior to entering the room of Patient #10 and when she removed a cell phone from her pocket, texted a message, returned the phone to her pocket and continued patient care.

Observation on 04/24/23 at 2:50 PM, showed Staff I, Patient Care Technician (PCT), failed to perform hand hygiene upon exiting Patient #4's room, after assisting her to a chair at the bedside.

Observation on 04/25/23 at 2:10 PM, showed Staff N, RN, failed to perform hand hygiene when she entered the room of Patient #6.

Observation on 05/01/23 at 3:40 PM, showed Staff Z, RN, failed to perform hand hygiene between glove changes while assisting with Patient #15's dressing change.

Observation on 05/02/23 at 8:20 AM, showed Staff DD, RN, failed to do hand hygiene when entering Patient #14's room.

Observation on 05/02/23 at 9:15 AM, showed Staff BB, RN, failed to perform hand hygiene when she entered Patient #23's room.

Observation on 05/02/23 at 11:15 AM, showed Staff N, Wound Care Nurse (WCN) failed to perform hand hygiene when performing patient care for Patient #33 when:
- She entered the room;
- She opened the door with gloves on, obtained additional supplies from the wound cart, and reentered the room to perform a dressing change.
- She removed an ink pen from her hair and used it.

During an interview on 04/24/23 at 2:55 PM, Staff I, PCT, stated that hand hygiene should be performed when entering and exiting patient rooms.

2. Review of the hospital's policy titled, "Transmission Based Precautions," dated 05/2022, showed that when entering a contact precautions (precautions used to minimize the risk of infection spreading through touching an infected person or contaminated object) room:
- Staff should perform hand hygiene before entering a patient room;
- Isolation gowns should be worn, securely tied, a new gown worn each time, and removed prior to leaving the room.
- Gloves should be worn upon entry, changed after contact with infective material (fecal or wound drainage) and removed prior to leaving the room.
- Hand hygiene should be conducted before and after glove use, in between glove exchanges and immediately upon exit.

Review of the hospital's policy titled, "Standard Precautions," dated 02/2023, showed that staff should:
- Wear gloves when having direct patient contact;
- Change gloves between patients, performing hand hygiene when gloves are removed;
- Remove gloves prior to leaving any patient's room or work area;
- Wash their hands after patient contact regardless of glove use;
- Gowns should never be worn out of the patient's room or work area into the hallway, regardless of the state of cleanliness;
- Use aseptic technique in the preparation and administration of medications via injection route;
- Ensure medication preparation areas are clean; and
- Perform hand hygiene before and after preparation/administration of injectable medications.

Observation on 04/24/23 at 2:45 PM, showed Staff K, RN, failed to don gloves while administering an IV push medication of normal saline (NS, solution made of salt and water) in the room of Patient #10.

Observation and concurrent interview on 04/25/23 at 2:00 PM, showed Staff N, RN, entered and exited Patient #6's room three times with dressing change supplies without wearing an isolation gown or gloves. Staff N stated she could enter the room without PPE as long as she didn't touch anything.

Review of the medical record for Patient #6 dated 04/25/23, showed he was on contact precautions for Methicillin-Resistant Staphylococcus aureus (MRSA, highly contagious bacteria, that causes infections in different parts of the body and is resistant to many common antibiotics).

Observation on 05/01/23 at 3:40 PM, showed Staff Q, WCN, removed her isolation gown and gloves at the foot of the bed, in the middle of Patient #15's room.

Observation on 05/01/23 at 3:40 PM, showed Staff Z, RN, opened drawers on the bedside table with gloves on, then held Patient #15's leg, without changing gloves.

Record review of the medical record for Patient #15 on 05/01/23, showed he was on contact precautions (a set of precautions intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the patient or the patient's environment) for Vancomycin-resistant Enterococci (VRE, highly contagious bacteria, that causes infections in different parts of the body and is resistant to many common antibiotics).

Observation on 05/02/23 at 8:20 AM, in the room of Patient #14, showed Staff DD, RN, failed to use gloves while administering medications.

Observation on 05/02/23 at 8:55 AM, showed Staff BB, RN, opened Patient #2's medication pill packets, touched multiple tablets and placed them into a cup. She then placed each pill from the cup into the pill crusher. Once crushed, she emptied into apple sauce and fed to Patient #2, all without wearing gloves.

Observation and concurrent interview on 05/02/23 at 9:15 AM, showed Staff BB, RN, entered Patient #23's isolation room and failed to apply a gown or gloves to scan his identification bracelet. Staff BB stated that she could enter the room without PPE as long as she didn't touch anything.

Review of the medical record for Patient #23 dated 05/02/23, showed he was on contact precautions for VRE.

Observation on 05/02/23 at 9:45 AM, showed Staff BB, RN, failed to put on gloves when opening oral medications for administration to Patient #23. She touched pills with her bare hands when placing them in a paper cup. She then donned a gown and gloves, but failed to securely tie the gown before entering the room.

Observation on 05/03/23 at 11:10 AM, showed Staff II, PCT, removed her isolation gown while inside of Patient #43's room, an identified contact precautions room.

During an interview on 05/01/23 at 3:40 PM, Staff Z, RN, stated that staff should not enter an isolation room without proper PPE. The line of demarcation was approximately three feet inside the doorway, near the trash can at the entrance to each room.

During an interview on 05/02/23 at 4:20 PM, Staff B, Chief Clinical Officer (CCO), stated that her expectations were for staff to wear gloves while administering medications.

3. Review of the hospital's policy titled, "Cleaning and Disinfecting Equipment," dated 03/2023, directed staff to clean and disinfect equipment and surfaces between patients.

Observation on 05/02/23 at 8:55 AM, showed Staff BB, RN, failed to sanitize the counter top in Patient #2's room prior to placing medications on the surface before crushing them.

Observation on 04/27/23 at 10:35 AM, showed Staff JJ, RN, failed to sanitize the counter top in Patient #16's room and placed medications on the counter surface.

Observation on 04/25/2023 at 2:10 PM, in the room of Patient #6, showed Staff N, WCN, failed to sanitize the surface of the bedside table, laid supplies out and provided wound care.

Observation on 05/02/23 at 10:40 AM, in the room of Patient #14, showed Staff DD, RN, failed to sanitize the surface of the bedside table and laid supplies on the table to start an IV.

Observation on 05/02/23 at 9:15 AM, showed Staff BB, RN, failed to properly cleanse the work surface of her workstation on wheels (WOW) before she placed Patient #23's medications including his insulin pen upon the surface.

Observation on 05/02/23 at 11:00 AM, in the room of Patient #33, showed Staff N, WCN, failed to sanitize the surface of the bedside table, laid supplies out and provided wound care.

4. Review of the hospital's policy titled, "Clinical Practice Guidelines," dated 05/2022, showed the following:
- All IV tubing will be labeled with a date and time to be changed.
- The needleless end cap valve on all IV's will be cleaned with alcohol before and after administering medications/solutions through the valve. Continue to "Scrub the Hub" with each use.
- All central, 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) and peripheral IV sites will be labeled with date and time to be changed along with the nurse's initial.

Observation on 04/24/23 at 2:10 PM, showed Patient #1's IV site dressing was not dated and their IV tubing was not labeled with a date or time.

Observation on 04/24/23 at 2:20 PM, showed Patient #6's PICC line dressing was not dated and their IV tubing was not labeled with a date or time.

Observation on 04/24/23 at 3:30 PM, showed Patient #10's IV site dressing was not dated.

Observation on 04/27/23 at 10:30 AM, showed Patient #35's IV site dressing was soiled and loose, dated 04/14/23, over 13 days old.

During an interview on 04/27/23 at 10:30 AM, Patient #35, stated that the IV site had not been changed since she had arrived.

During an interview on 04/27/23 at 10:30 AM, Staff B, CCO, stated that Patient #35 should have had her IV site dressing changed prior to 4/27/23.

Observation on 04/27/23 at 11:00 AM, showed Patient #18's IV site dressing was not dated and the IV tubing was not labeled with a date or time.

Observation on 04/27/23 at 9:35 AM, showed Patient #11's IV tubing was not labeled with a date or time and an IV antibiotic without a patient label.

Observation on 04/27/23 at 1:30 PM, showed Patient #35's IV tubing was not labeled with a date or time. She was admitted on 04/25/23.

Observation on 05/03/23 at 10:40 AM, showed Patient #45's IV tubing was not labeled with a date or time.

Observation on 04/24/2023 at 2:45 PM, showed Staff K, RN, failed to cleanse the needleless port of Patient #10's IV and administered a NS flush.

Observation on 04/27/2023 at 10:10 AM, showed Staff B, CCO, failed to cleanse the needless port of Patient #34's PICC line and administered a NS flush.

Observation on 05/02/23 at 9:15 AM, showed Staff BB, RN, failed to cleanse Patient #23's insulin pen when she attached the needle.

During an interview on 04/24/23 at 3:30 PM, Staff B, CCO, stated that all IV site dressings should be dated and initialed.

During an interview on 04/27/23 at 10:30 AM, Staff B, CCO, stated that all IV tubing should be dated and that IV site dressings should be changed every 7 days.

5. Observation on 04/27/2023 at 9:15 AM, showed Patient #23's urinal sitting on the bedside table.

Observation on 04/27/23 at 11:00 AM, showed Patient #18's urinal sitting on the bedside table.

Observation on 05/02/23 at 9:45 AM, showed Patient #23's full urinal sitting on the over the bed table next to his breakfast tray. Staff BB, RN, emptied the urinal and then returned it to the same location.

During an interview on 04/27/23 AM at 11:00 AM, Staff B, CCO, stated that urinals should not be sitting on the bedside table where patient drinks were sitting.

6. Review of the hospital's policy titled, "Shelf Life & Expiration Date," dated 10/2017, showed the following:
- Food Service Staff will check all refrigerators for outdated food items.
- The Food Service Director will monitor the expiration dates of all milk containers.
- Nursing and Patient Care staff will also be responsible for monitoring each respective unit's refrigerators for outdated items.
- Any items that have passed their expiration date will be discarded.
- Before placing fresh items into the unit refrigerators, the supervisor will check the dates of any food items already present in the refrigerator. Any items noted to be passed the expiration date will be removed.

Observation on 04/24/23 at 4:00 PM, showed the patient nutrition room refrigerator contained:
- One bag of outdated apples labeled with the date range of 1/31/23 through 4/23/23.
- Two unlabeled open gallons of milk without a date.
- 24 outdated individual gelatin containers with the expiration date of 04/10/23.

Observation on 04/24/2023 at 4:00 PM, showed the patient nutrition room cabinets contained:
- Multiple individual jelly packets within an open tub without an expiration date.
- Multiple individual graham crackers packages within an open tub without an expiration date.
- Multiple individual saltine crackers packages within an open tub without an expiration date.
- Multiple individual cereal containers within an open tub without an expiration date.

Observation on 04/24/23 at 4:45 PM, showed the kitchen refrigerator contained:
- Six cartons of expired heavy whipping cream;
- Numerous individual butter packets within an open container without an expiration date;
- A flat of eggs without an expiration date;
- An open container of coleslaw with three different dates written on the container;
- Three open partial loaves of bread without an opened or expiration date;
- Two open boxes of English muffins without an opened or expiration date;
- Two expired loaves of bread dated 3/18/23; and
- One tray of undated individual beverages for patient trays.

Observation on 04/24/23 at 4:45 PM, showed the kitchen freezer contained:
- One large bag of biscuits without an expiration date;
- Multiple opened bags of biscuits without an opened or expiration date;
- One opened bag of pork chops without an opened or expiration date;
- One bag of pork chops without an expiration date;
- One opened bag of sausage patties without an opened or expiration date;
- One expired bag of apples dated 12/18/23 through 03/18/23; and
- Three bags containing two head of lettuce each, with an extended able to use date of 04/21/23 through 07/21/23, or three months in length.

During an interview on 04/24/2023 at 4:00 PM, Staff B, CCO, stated that the Kitchen Manager was responsible for ensuring all food items were dated appropriately and that all expired items were removed. She would expect staff to date the gallons of milk in the patient nutrition refrigerator when they open them. She expected the condiments and crackers in the patient nutrition room to be stored in bins with an expiration date. All food delivered to the hospital kitchen should be labeled with the arrival date, the date opened, and the expiration date. The kitchen personnel are responsible for ensuring that all food items are properly dated and any expired items are discarded.

Review of an untitled, undated document regarding guidelines for food storage and concurrent interview with Staff M, Food Service Director, on 04/26/23 at 9:50 AM, showed a listing of individual food items and proper storage temperature. The list included those items stored in the refrigerator and freezer, along with non-perishables. The guidelines provided the time frames for use based on when they are received and when they are opened. Staff M stated she had just received these guidelines from her supervisor and she had not been labeling and dating food items appropriately. She was responsible for ensuring that all items were dated appropriately and any expired items removed from all food storage areas. The food storage areas should be inspected daily to ensure that nothing has expired.

During an interview on 05/04/2023 at 10:15 AM, Staff A, CEO, stated that her expectations was for all expired foods to be removed immediately by kitchen personnel. All food items in the kitchen should be labeled with the date received, the date they were opened, and the expiration date. Food items stored in bins should be labeled with the expiration date from the original container.