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Based on interview and record review, the facility failed to monitor and adjust tube feedings according to patient needs and document water flushes for 1 (P-1) of 12 patients reviewed resulting in less-than-optimal outcomes for the patient. Findings include:

On 1/2/2024 at 1500, the physician signed P-1's "Registered Dietician Medical Nutrition Therapy Protocol,". The protocol revealed that "When the Registered Dietician (RD) is consulted for "RD to eval and treat per MNT (Medical Nutrition Therapy) protocol" or "Inpatient consult to Nutrition Services" the RD may write orders within their scope of practice per the MNT protocol:" "Manage enteral feedings in collaboration with physician."

P-1 was admitted on 1/2/2024 and P-1's Pre-Admission Screening report on 1/2/2024 revealed that P-1's tube feeing rate and goal "(Tube Feeding) @ 40 milliliters (mL)/hour."

On 1/2/2024 at 2029, P-1's admission orders included an initial tube feeding order for (Tube Feeding) to run at 20 mL/hour.

On 1/5/2024 at 1339, the RD Staff F initial consultation nutrition note revealed that P-1's "Clinical Characteristics of Malnutrition" was determined to be "Severe Malnutrition."

On 1/5/2024 at 1335, RD Staff F initial consultation note revealed that "requested (Tube Feeding) to be (increased) to goal of 40 mL/hour (Physician Staff V notified).

According to the P-1's medical record,there was no order written to increase tube feeding to a goal of 40 mL/hour and there was no attempt on 1/5/2024, 1/6/2024, and 1/7/2024 to gradually increase P-1's tube feeding rate towards the goal of 40 mL/hour. The tube feeding rate as documented in the medical record for 1/5/2024, 1/6/2024, and 1/7/2024 was 20 mL/hour.

On 1/8/2024 at 1420, the tube feeding order was changed to (Tube Feeding) as tolerated at "40 mL/hour" and 20 mL water flush as per a telephone order from RD Staff F to Physician Staff V.

On 5/26/2024, P-1's enteral order was (Tube Feeding) 1.5 at 65 mL/hour and water flush at 10 mL/hour q 2 hours. On 5/26/2024 from 1900 to 0700 the following day, there was no documentation that the water flush was performed.

On 12/18/2024 at 1300, CNO Staff B was asked if they expected staff to follow the facility's policy and procedures, and they said "yes."

According to the facility's policy "Gastric/Duodenal Tube Guidelines: PEG, Gastronomy Tube, Small-Bore Nasal Tube, Nasogastric Tube, Orogastric (OG)," dated 7/1/2024, guidelines for maintaining continuous enteral feedings, "Nurses are responsible for programming the pump and clearing feeing pumps every shift for I (input) & O (output) purposes." The policy also revealed that "Flush tubing every shift with 20 mL of tap water to maintain patency unless otherwise ordered" and "add the amount of flush to the total intake" and under documentation and "I and O completed - Intake should reflect flush amount separate from feeding amount."

Based on observation, interview, and record review, the facility failed to follow medication administration standards in administering medication to 1 (P-12) of 12 patients reviewed, resulting in less-than-optimal outcomes for the patient. Findings include:

On 12/18/2024 at 1300, P-12's medical record was reviewed and P-12 had two separate orders on 12/18/2024 for pantoprazole, pantoprazole-sodium bicarbonate 2 mg/mL enteral liquid 40 mg, PO (orally)/per tube 2 times per day, and pantoprazole EC (enteric coated)/DR (delayed release) tablet 40 mg oral two times per day. According to P-12's medication administration record, Nurse Staff T administered two pantoprazole doses in the morning on 12/18/2024, one 40 mg enteric coated tablet at 1055 and one 40 mg dose in a liquid at 1056.

On 12/18/2024 at 1515 during chart reivew with Nurse Staff N and Nurse Staff T, Nurse Staff T was queried how they administered the tablet, and they said they "crushed" the tablet. According to the pantoprazole medication administration instructions, the instructions revealed "Swallow whole: Do not crush, open, chew or split capsule." Chart reviewer Nurse Staff N, confirmed that both doses of pantoprazole should not have been administered in the morning.

According to the facility's policy, "Medication Administration," dated 7/1/2024, "Determine medications to be administered. Check/consider the following information:" including but not limited to "all entries on the medication record" and "comment section." The policy revealed that for "Administration of Medication:" "Verify medication against MAR/eMAR as preparing medications" and "Check medications again against the MAR/eMar as they are opened at bedside or final prep area." "Consult eMAR for medication due for administration."

Based on observation, and interview, and record review, the facility failed to maintain a clean and sanitary environment as part of an Infection Prevention and Control program, resulting in the potential for the transmission of infection and negative outcomes for the 21 patients at the facility at the time of observations. Findings include:

On 12/17/24 at 1100, observation of 2 empty, patient ready rooms (769, 773), revealed medication boxes, mounted on walls in both rooms had interior rust and loose rubber gasket seals, exposing a sticky residue. Staff B confirmed the above findings at time of observation.

On 12/17/24 at 1045 during unit tour, Staff O was observed stepping outside doorway of room, from inside a patient isolation room, and immediately typing on keyboard of a computer workstation in doorway, without hand washing or changing gloves. Staff O asked if she should be wearing gloves, and she said she was signing out medication. CNO Staff B at time of observation was asked if this was appropriate practice, and she stated removal of gloves and hand hygiene should have been performed before touching keyboard.

On 12/18/24 at 1215, record review of policy titled, "Standard Precautions", dated, April 2023, revealed: "Standard Precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection ...Gloves will be changed after every patient contact, when moving from dirty to clean task ...Gloves must be removed before one leaves the in room ... Patient care equipment known to be contaminated with infective material should be cleaned ...or discarded ...The hospital cleaner/germicide used for cleaning surfaces and terminal cleaning of rooms is effective for cleaning of rooms ...".


45246

During initial tour of the facility on 12/17/24 from 1040 to 1130, 2 empty, patient ready rooms #764 and 769 were observed for cleanliness. Bathroom in room #764 was observed to have a shower door covered with white stains on outside. The edge and the frame of the shower was covered with white residue.
Room #769 was observed with infection control nurse, Staff N. The outer rim and the frame of the shower door had white stains on them. Ceiling tile above the head of the bed was observed stained with small brown stains and lose in a coner, hanging about 1 inch from the ceiling. Head light above the patient's head of the bed noted to have dust. The privacy curtain was observed to have a blue sticky subartance on it. Wall across from the bathroom had a dry wall exposed in multiple places. Sharps container was noted to be full. Staff N confirmed the findings.

Policy titled, "Standard Precautions", dated, April 2023, was reviewed and revealed:

M. Housekeeping Issues:
1. The hospital cleaner/germicide used for cleaning surfaces and terminal cleaning of
rooms is effective for cleaning of rooms and is effective for cleaning items which
were in contact with patients, such as beds, stretchers, wheelchairs, etc. All surfaces
must remain in contact with solution for time suggested by manufacturer guidelines.

P. Safe Injection Practices
6. Needle boxes must be disposed of as infectious waste when over three quarters full by
Housekeeping staff.




50585

On 12/17/2024 at 1015, during a tour of the medication management room, a 1,000-milliliter (mL) bag of 0.45% Sodium Chloride (NaCl) intravenous (IV) solution with the protective overwrap removed was observed in the bin with other 1,000 mL bags of 0.45% NaCl IV solutions with the overwrap present. CNO Staff B confirmed that the plastic overwrap was removed from the IV bag at the time of discovery.

On 12/17/2024 at 1020, during a tour of the facility's pharmacy, ten bags of 0.9% NaCl, 50 mL without the plastic overwrap were observed stored in a bin. Director of Pharmacy Staff Q was queried what the expiration dates were assigned to the bags after the bags were removed from the plastic overwrap, and they said, "28 days." Later, Staff Q acknowledged through a letter from the manufacturer, that the expiration date once the bags were removed from the plastic overwrap was 15 days.

On 12/17/2024 at 1108, during a tour of the facility's patient care unit, a stained ceiling tile was observed in the storage room (E70E) and CNO Staff B confirmed the presence of the stained ceiling tile at the time of discovery.

On 12/17/2024 at 1235, during an inspection of the public restroom, a box of medical exam gloves was observed on the surface of a wooden table in the corner of the restroom. After removing the box of gloves, both blackened and non-blackened paper was observed to be embedded on the wooden surface of the table. The wall adjacent to the edge of the wooden table was observed to be missing paint and exposing the wallboard. Respiratory Therapist Staff U confirmed the findings of the unkept wooden surface and missing paint and when queried whether staff use the restroom, Staff U said "yes."

According to the letter from the manufacturer of the 0.9% NaCl IV solutions, dated 8/30/2024, "Out of the Overwrap Stability Parameters for Injection Solutions" packaged in "plastic container" for "
According to the faciltiy's policy "Labeling of Medications," dated 7/2024, "Beyond Use Dates must be based on the manufacturer's recommendations in the product literature or clinical letters from the manufacturer" for "Multi-Dose Injectable Medications."