**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 39463 Based on record reviews, interview, and review of the hospital's policy and procedures, the hospital failed to ensure a physician or LIP order was obtained for the use of restraint for 1 of 3 concurrent patient charts reviewed for restraints. (Patient 2) The findings are: Random observations on 3/11/2019 at 11:45 AM in the Surgical-Trauma Intensive Care Unit revealed Patient 2 in bilateral upper arm soft wrist restraints. Review of Patient 2's chart revealed the patient was admitted on [DATE] status post moped trauma. Review of the patient's chart revealed the patient was in bilateral upper arm soft wrist restraints on 3/8/2019 and 3/9/2019, but there was no physician order for restraints on 3/8/2019 or 3/9/2019. On 3/11/2019 at 11:50 AM, Registered Nurse 2 verified the finding. Hospital policy, titled, Patient restraint Policy, reads, If reassessment indicates an ongoing need for restraint, a new order must be written each calendar day by the licensed independent practitioner/physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 39463 Based on record reviews, interview, and review of the hospital's policies and procedures, the hospital failed to ensure ongoing assessment and monitoring of the patient's condition for 2 of 3 concurrent patient records reviewed for restraints. (Patient 2 and Patient 3) The findings are: Random observations on 3/11/2019 at 11:45 AM in the Surgical-Trauma Intensive Care Unit revealed Patient 2 in bilateral upper arm soft wrist restraints. Review of Patient 2's chart revealed the patient was admitted on [DATE] status post moped trauma. Further review of the patient's chart revealed the patient was in bilateral upper arm soft wrist restraints on 3/10/2019 and 3/11/2019, but monitoring of the patient at intervals determined by the hospital policy did not occur at the following times: 3/10/2019 from 03:00 AM - 07:00 AM 3/11/2019 from 01:40 AM - 05:29 AM Random observations on 3/11/2019 at 11:45 AM in the Surgical-Trauma Intensive Care Unit revealed Patient 3 in bilateral upper arm soft wrist restraints. Review of Patient 3's chart revealed the patient was admitted on [DATE] with a skull fracture and left temporal epidural/subdural hematoma. Review of the patient's chart revealed the patient was in bilateral upper arm soft wrist restraints on 3/11/2019, but monitoring of the patient at intervals determined by the hospital policy did not occur at the following time: 3/11/2019 from 03:00 AM - 07:00 AM On 3/11/2019 at 12:00 PM, Registered Nurse (RN) 2 verified the findings of missing restraint monitoring documentation for Patient 2 and Patient 3. Hospital policy, titled, Patient Restraint Policy, reads, An RN will assess the patient at least every two (2) hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 39463 Based on record reviews, interview, and review of the hospital's policy and procedure, the hospital failed to ensure that nursing care is provided to all patients as needed for 1 of 40 patient charts reviewed. (Patient G1) The findings are: On 3/11/2019 at 3:00 p.m., review of Patient G1's medical record revealed the patient was admitted on [DATE] with status Asthmatic and Pneumonia. The patient's record revealed the patient had a venous left antecubital 20 gauge peripheral catheter, and the patient received normal saline Intra-Venous (IV) on 3/11/2019 in the emergency room with no physician order for an intravenous catheter. There was no documentation of the insertion of the intravenous catheter in the patient's medical record. On 3/12/2019 at 11:40 a.m., Registered Nurse 4 verified the finding, and stated There was no order set or order for the insertion of an intravenous catheter that I could find. Hospital policy, IV Therapy, reads, Documentation 1. Initial Venipuncture: Document the date, time, location of insertion site, size of cathlon, number of cathlons used, amount and type of solution, flow rate, pump used, and patient's response to procedure.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 39463 Based on record reviews, interviews, and hospital policy and procedure, the hospital's laboratory failed to show documentation in the patient's medical record of the notifications or attempts by the hospital to give the required notification for 2 of 2 closed patient records of patients who received potentially infected blood products or blood components. (Patient G1 and Patient G2) The findings are: On 3/12/2019 at 3:30 p.m., in an interview with Lab Employee G3 revealed there were cases in the past three years when the hospital was required to notify patients of exposure to potentially HIV(Human Immunodeficiency Virus) or HCV(Hepatitis C Virus) infectious blood or blood products. Patient G1 On 3/14/2019 at 10:00 a.m., review of the hospital's HCV/HIV/[NAME] Lookback Tracking Checklist revealed a notification letter was sent to the patient on 3/21/2018 and 5/23/2018, but there was no documentation in Patient G1's closed medical record of the hospital's notification and attempts to notify the patient who received potentially infected blood products or blood components. Patient G2 On 3/14/2019 at 10:00 a.m., review of the hospital's HCV/HIV/[NAME] Lookback Tracking Checklist revealed notification letters were sent to the patient's physician on 3/21/2018 and 5/23/2018, but there was no documentation in Patient G2's medical record of the hospital's notification or attempts to notify the patient who received potentially infected blood products or blood components. On 3/14/2019 at 10:15 a.m., Registered Nurse G10 verified there was no documentation in either patient's closed medical record related to notification or attempts to notify the patient who potentially received infected blood products or blood components. Hospital policy, HIV/[NAME] Lookback Notification, reads, If the unit is an HIV look back, then use the physician letter to notify the patient ' s physician and the physician's opportunity to notify the patient. If the physician elects this option, no further involvement is required by our facility other than documenting that the physician will contact the patient. If the physician declines, they must return the notification letter back to the transfusion service indicating their decline, within two weeks. At this point (facility) will attempt to locate the patient and notification should begin with a phone call (if possible) and followed up by written notification ..

28883 Based on observations, interviews, and a review of the hospital's policy, titled, General Hand Hygiene, the hospital failed to ensure acceptable infection control practices were used by staff to reduce the potential risk of cross transmission of infectious agents in the hospital setting for 1 of 1 Nuclear Medicine Technician (NM 1) and 4 of 4 Registered Nurses who failed to use acceptable practices for infection control for hand hygiene in the provision of nursing care and for cleaning medication vials prior to withdrawing medications. (RN E1, RN G6, RN G9, and RN G7) The findings included: Nuclear Medicine Department Observation on 3/13/19 at approximately 9:50 AM revealed Nuclear Medicine Technician 1 in the hot room transferring the radioactive tracer into a syringe wearing gloves. Observations showed Nuclear Medicine Technician 1 touched multiple items in the room potentially contaminating the gloves and closed the door. Nuclear Medicine Technician 1 went to the patient's chairside, and wearing the same gloves opened clean supplies that included a normal saline syringe, an alcohol pad, and a saline lock. Nuclear Medicine Technician 1 attached the normal saline syringe to the lock, and primed the lock with normal saline. Nuclear Medicine Technician 1 removed the soiled gloves and placed the soiled gloves into the trash. Without performing hand hygiene, Nuclear Medicine Technician 1 donned clean gloves. Nuclear Technician 1 placed a tourniquet on the patient's arm, and felt for a vein with gloved fingers. After cleaning the patient's skin with an alcohol pad, Nuclear Technician 1 removed tape from a roll, and used gloved fingers to palpate for a vein again contaminating the site that had been cleaned with alcohol. Nuclear Medicine Technician 1 failed to clean the patient's the skin again with alcohol, and inserted the intravenous catheter into the patient's skin, attached the saline lock, and taped the intravenous catheter in place. Without wiping the saline lock port with disinfectant, Nuclear medicine Technician 1 attached the syringe containing the radioactive tracer, and injected the patient. Without wiping the port with disinfectant, Nuclear Medicine Technician 1 attached the normal saline syringe to the lock and flushed the the lock with normal saline. After completing the injection of the intravenous tracer, Nuclear Medicine Technician 1 removed the intravenous catheter/saline lock and placed a bandage over the site. Nuclear Medicine Technician 1 went back to the hot room to dispose of the supplies, put the code into the door lock mechanism, and touched the door handle, wearing the same gloves used to remove the intravenous catheter. During an interview on 3/13/19 at approximately 10:22 AM, the findings were reviewed with Nuclear Medicine Technician 1 who verified the concerns related to the observation. On 3/14/19, review of the procedural skills for nursing for saline lock flushing revealed staff should scrub the infusion port with a facility-approved antiseptic solution and allow it to dry before flushing the port. Review of the hospital's policy, entitled, General Hand Hygiene, revealed Indications for Hand Washing and Hand Antisepsis included the following: .1. Before direct contact with patients or their environment. 2. Before donning sterile gloves or clean exam gloves. 3. After contact with the patient's intact skin. 4. After contact with body fluids, excretions, mucous membranes, non-intact skin and wound dressings if hands are not visibly soiled .6. After contact with inanimate objects, including medical equipment, in the vicinity of the patient. 7. After removing gloves .. 39208 Registered Nurses On 3/11/2019, observations during the provision of care from 11:35 a.m. to 11:51 a.m. revealed Registered Nurse E1 failed to perform hand hygiene after removing the soiled gloves used when changing the patient's dressing and before donning clean gloves to continue the patient's dressing change. The finding was verified by Registered Nurse E1 at 11:51 AM on 3/11/2019. 39463 On 3/11/2019 at 2:30 p.m., random observations of Registered Nurse (RN) G7 in the emergency room revealed RN 7 failed to perform hand hygiene prior to donning clean gloves and insertion of a peripheral intravenous (IV) catheter. During an interview with RN G7 on 3/11/2019 at 2:50 PM, RN G7 verified the finding. On 3/11/2019 at 2:40 p.m., random observations in the emergency room revealed RN G6 failed to perform hand hygiene prior to donning clean gloves and performing insertion of a peripheral intravenous (IV) catheter, and failed to perform hand hygiene after glove removal following the intravenous catheter insertion. During an interview with RN G6 at 2:45 P.M., RN G 6 verified the findings. On 3/13/2019 at 9:25 a.m., observations in Neuro Intensive Care Unit revealed that when administering medications to Patient G6, Registered Nurse (RN) G9 failed to disinfect the medication vial septum of Mannitol 50 gms(gram) vial prior to piercing and withdrawing the medication into a syringe. In an interview with RN G9 at 9:30 a.m. on 3/13/2019, RN G9 verified the finding.