**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42693 Based on document review and interviews, the facility failed to ensure a registered nurse supervised and evaluated nursing care for all patients. Specifically, nursing staff failed to implement preventive measures in order to prevent a new pressure injury or prevent further injury to an existing pressure injury. Additionally, the nursing staff failed to notify a physician when a change in condition occurred with a patient (Patient #2). Findings include: Facility policies: According to the Wound Management policy, a complete skin assessment is required upon admission to the hospital. Documentation of skin assessments is required. Under subsection B of the policy, protection and prevention of skin breakdown is discussed. To minimize pressure, turning the patient every two hours is required. A specialty bed should be utilized as adjunct therapy but is not a replacement for turning the patient. The Bed Requests, Storage and Mattress Selection policy, provides information on the process for requesting and ordering specialty beds. Under subsection C, the indications for use of specialty mattresses are listed. Patient diagnosis and conditions automatically qualify for specialty mattress include but are not limited to, spinal cord injury with stabilized spine, myocutaneous flap surgery within the past 90 days, and bed bound patients. 1. The facility failed to implement preventative measures to include the use of specialty beds and turning the patient every two hours, to prevent skin breakdown and pressure injuries for a paraplegic patient resulting in the patient acquiring an immobility related pressure injury. A. Document Review (1) A review of Patient #2's medical record was completed. Review of Patient #2's medical record revealed she had a medical history to include paraplegia (the loss of the ability to move lower extremities). Patient #2 was admitted to the facility on [DATE] for increased oxygenation needs as well as a fractured leg. The initial nursing assessment documented by Registered Nurse (RN #13) on 11/19/19 at 9:00 p.m. revealed Patient #2 was non-ambulatory due to paralysis (unable to move) of her lower extremities. Under the skin assessment, an abrasion on the patient's right hand was documented. There was no documentation of a pressure injury to the coccyx or sacrum upon admission. Two days later, on 11/22/19 at 2:52 p.m., the Occupational Therapist (OT) documented communication with the registered nurse (RN) caring for the patient in regards to the patient needing an immersion mattress instead of a normal hospital bed due to the patient's paraplegia. On 11/22/20, the Registered Nurse (RN #13) documented she ordered a specialty bed and noted an abrasion on the patient's lower back and coccyx. On 11/23/19 @ 10:57 a.m., Physician #8 documented in the Hospitalist Progress Note the patient had a stage one sacral ulcer and a wound consult was ordered. On 11/25/19 at 8:00 a.m., the RN for the patient documented a pressure injury - immobility related on posterior right buttocks. On 11/25/19 at 1:41 p.m., the wound nurse conducted a new consult on Patient #2. Prior to the discovery of the wound on 11/22/19, there was no evidence in the medical record a specialty mattress had been ordered to prevent skin break down for Patient #2. Additionally, there was no indication in the medical record the patient was turned/repositioned every two hours. The facility failed to implement preventative measures according to facility policy resulting in a patient acquiring a pressure injury. B. Interviews (1) On 10/15/20 at 11:05 a.m., Registered Nurse (RN #3) was interviewed. RN #3 stated a skin assessment should be completed upon admission of a patient. RN #3 stated it was important to complete a skin assessment upon admission in order to obtain a baseline assessment of the patient. RN #3 stated on the general surgery floor, there was a turn-team for all the patients who needed to be turned. RN #3 further stated every two hours, two staff members turned all the patients assigned to the turn-team. RN #3 stated when the patient was turned, it was not documented every time the turn was completed. (2) On 10/15/20 at 12:20 p.m., an interview was conducted with Registered Nurse (RN #5). RN #5 stated she was a wound care nurse and assessed patients when a wound care consult was placed by the physician. RN #5 stated other RN's admitting patients or caring for patients had pressure injury guidelines at their disposal in order to provide preventive measures. RN #5 stated RN's could initiate these preventive measures themselves. Patient #2's medical record was reviewed with RN #5. RN #5 explained deep tissue injuries (DTIs), which was the diagnosis of Patient's #2 pressure injury, evolve from the bone outward and would take time for it to show at the skin level. RN # stated extended amount of continuous pressure could cause the injury to progress faster. (3) On 10/15/20 at 3:17 p.m., an interview was conducted with Registered Nurse (RN #12). RN #12 explained she worked on the orthopedic and spine unit. RN #12 explained paraplegic and quadriplegic patients should be on a specialty mattress and receive turns every two hours. RN #12 stated it was important for these patients to receive preventative measures because they did not have sensation (feeling) where the patient's body was paralyzed and paraplegic patients were often unable to shift their body weight in order to relieve pressure. RN #12 stated when a patient was on a specialty bed, she would document when a patient was turned. RN #12 further stated it was important to document the turns in order to show the task was completed. (4) The Director of General Surgery (Director #9) was interviewed on 10/19/20 at 9:07 a.m. Director #9 stated her role was to manage nurses on the general surgery unit and ensure they had the proper education and tools to do their job. Director #9 stated patients less mobile were more likely to have had skin breakdown. Director #9 stated her staff participated in turn-team for all immobile patients and patients needing assistance to turn. Director #9 stated turn-team was completed every two hours and it was the responsibility of the two staff members assigned at the time to turn all the patients on the unit. Director #9 explained the two hour turns were not documented on every patient, every time the turn was performed, rather it was assumed the patient was turned if the patient was listed on the turn team board. Director #9 further explained when a patient refused to be turned, staff were to document the refusal in the chart. Director #9 stated it was important to implement preventative measures in order to prevent harm to the patient. 2. The nursing staff failed to report a change in condition to the physician overseeing a patient's care. A. Document review (1) A review of Patient #2's record was conducted. On 11/22/20 at 8:00 p.m., the Registered Nurse (RN #13) documented she ordered a specialty bed and noted an abrasion on the patient's lower back and coccyx. Upon review of the medical record, there was no documentation to provide evidence the RN alerted the physician to the new skin concern noted on assessment of Patient #2. (2) On 10/19/20 at 8:37 a.m., a policy outlining the requirements for a registered nurse to report a change in condition to the physician overseeing the care of the patient was requested. The facility was unable to provide a policy or procedure prior to the exit of the survey. B. Interviews (1) On 10/19/20 at 11:21 a.m., an interview was conducted with Registered Nurse (RN #10). RN #10 stated she had worked on the general surgery floor as a registered nurse for four years. RN #10 stated a change in condition was when a patient experiences any change between assessments or when something was noted different from the report received by the following registered nurse. RN #10 stated a new skin issue would be considered a change in condition since it was a change in assessment. RN #10 stated a change in condition should be reported to the primary physician overseeing care of the patient as soon as the change in condition was discovered. RN #10 further explained she would document the conversation with the physician in the patient's medical record. RN #10 explained it was important to notify the provider of a change in condition so the provider could implement necessary changes in the patient's plan of care. (2) On 10/19/20 at 12:19 p.m., a second interview was conducted with Director #9. Patient #2's medical record was reviewed with Director #9. The RN documentation of the Patient's skin issue noted on 11/22/20 at 8:00 p.m. was discussed. Director #9 stated based upon the documentation the RN completed, the change in skin should have been reported to the provider overseeing care of the patient. Director #9 stated it was important to report the change in condition to the physician so the physician was aware and could order a wound consult if needed.

43412 Based on document review and interviews the facility failed to ensure arrangements for post-hospital care were included in discharge planning needs of the patient. Specifically, the facility failed to arrange and provide oxygen services at discharge for a patient being transferred out of state and establish follow up appointments with orthopedics for a right tibia (leg bone) fracture, cardiology for newly diagnosed diastolic heart failure and any additional services needed. Findings; Facility Policy: According to Oxygen Therapy and Titration, the purpose was to provide guidelines to deliver supplemental oxygen therapy to spontaneously breathing patients including the goals of the oxygen therapy. Continuous oxygen therapy requires an order from a physician or advanced practice provider. Respiratory Therapists (RT) and Registered Nurses (RN) were expected to execute the order and determine the appropriate delivery device to meet the goal of the ordered therapy. Discharge of a Patient read, discharge instructions will be completed with an interdisciplinary approach. Staff were expected to complete a final discharge assessment of the patient ' s condition, the physician was to be notified immediately of any abnormalities or if the condition was not safe for discharge. These instructions must include but were not limited to any home care needs, follow up appointments, and medications needed post discharge. 1. The facility failed to ensure a patient being discharged and transported to their home located out of state had oxygen therapy established upon arrival to the out of state location. Documentation a. Medical record review was conducted for Patient #2. The record revealed the patient was admitted with a fractured tibia requiring a surgical repair and had a diagnosis of acute respiratory failure, newly diagnosed acute diastolic heart failure, and anemia secondary to a GI bleed during the admission. The record revealed a new oxygen requirement on the final physician note prior to discharge date d 11/30/19 at 5:47 p.m. The new oxygen requirement was listed as 3.5 liters of oxygen per minute (L/min) on the physician note. The final complete set of vital signs recorded showed the patient was on 2 L/min at 9:30 p.m. on 11/30/20. The patient was discharged at 7:01 a.m. but there was no documentation of vital signs taken prior to discharge. Oxygen therapy was listed on the 12/1/19 air lift transportation documentation which stated the patient would require 2 L/min via nasal cannula to maintain oxygen saturation over 94% during transport. No further oxygen therapy arrangements were documented in the record for the patient's final location when transport was completed to the patient's home. Interviews a. An interview was conducted on 10/15/20 at 11:05 a.m., with RN #3, who stated the discharge was unusual due to the patient being discharged to an out of state location. RN #3 stated it was important to follow the physician recommendation and order for oxygen therapy because the physician would know the patient's needs. RN #3 stated it was the role of respiratory therapy and case management to evaluate and set up home oxygen needs. b. An interview was conducted on 10/14/20 at 2:06 p.m., with Assistant Director of Case Management (Director #11) who stated her role was to assist with more complex discharges and provide resources to discharging patients for care after their hospital stay. Director #11 stated the oxygen therapy had been set up for the air lift transportation on 12/1/19. Director #11 stated home oxygen needs were set up by the respiratory therapy department. Director #11 stated respiratory therapy should arrange home oxygen and case management should set up a home health visit to evaluate the patient at home for new needs related to a new diagnosis. c. An interview was conducted on 10/15/20 at 1:57 p.m., with Director of Case Management (Director #6). Director #6 stated the record revealed the patient had been on 2 L/min on both 11/28/19 and 11/29/19. The oxygen needs of the patient changed on 11/30/19 and it ranged from 2 L/min to 3.5 L/min. Director #6 stated the transfer should have been stopped due the increase in oxygen demands during the day shift on 11/30/19. Director #6 stated the facility expected respiratory therapy to set up home oxygen therapy when needed for patients who had discharged from the facility needing oxygen therapy. Director #6 was unable to locate a home oxygen evaluation for the patient by respiratory therapy. Director #6 stated there was no one scheduled to assess the patient's oxygen needs once she returned to her out of state home. Director #6 stated without clear follow up the patient was at risk to decompensated without the oxygen therapy. d. An interview was conducted on 10/15/20 at 3:59 p.m., with Interim Director of Respiratory Therapy (Director #7). Director #7 stated once a home oxygen evaluation order had been placed the Respiratory Therapist (RT) would assess the patient's oxygen needs while breathing without oxygen therapy. The patient would need to be at 87% or below to qualify for oxygen therapy. The RT would work with the patient's insurance, verify where the patient lived, and determine what equipment would be needed at the patient's home. Director #7 stated once the physician order was placed, the information was put in the computer to be forwarded to the physician to sign off on the order which will be provided to the outside company who fulfilled the order and equipment needs. No evidence was found in the patient's discharge record regarding home oxygen therapy. e. An interview was conducted on 10/19/20 at 8:02 a.m., with Physician#8. Physician #8 stated the patient had multiple medical issues, including but not limited to atelectasis, diastolic heart failure, and chronic opioid use, which can cause respiratory depression, all contributed to her new need for oxygen therapy. Physician #8 stated the patient could have benefited from a home oxygen evaluation. Physician #8 stated the physician's role was to put the order in for RT to follow up with a home oxygen evaluation. A home oxygen order was not placed for the patient. 2. The facility failed to ensure follow up care appointments were arranged in the patient's home state for post-surgical orthopedic care, newly diagnosed diastolic heart failure cardiology care and GI care following a GI bleed. Documentation a. A medical record review was conducted on 10/13/20 of patient #2. The record revealed the patient was admitted with a fractured tibia requiring a surgical repair and had a diagnosis of acute respiratory failure, newly diagnosed acute diastolic heart failure, and anemia secondary to a GI bleed during the admission. Documentation in the medical record showed the patient's fractured tibia was surgically repaired with an open reduction and internal fixation (ORIF) procedure on 11/21/19. The patient was followed by cardiology, GI and orthopedic teams during her admission. Discharge paperwork showed the patient was transferred to her home, out of state, via air lift transportation on 12/1/19. The discharge paperwork showed the patient was to schedule her orthopedic follow up appointment within 10-14 days postoperatively for suture removal and was provided with a local Colorado phone number to schedule the appointment in Colorado. The patient returned to her out of state home early on the 10th day after the surgical repair. No information was provided to the patient on whom she should follow up with in her home state for postoperative orthopedic care and suture removal. The patient was provided with the name of a GI physician in her home state, however contact information was not provided. Finally the patient was told to follow up with her primary care physician (PCP) to get a referral to a cardiologist for follow up on her newly diagnosed diastolic heart failure and fluid overload needs. No appointments were scheduled for the patient in her home state. Interviews a. An interview was conducted on 10/15/20 at 11: 05 a.m., with RN #3. RN #3 stated the patient discharged early in the morning as she was being airlifted back to her home located out of state. RN #3 stated the patient had discharge instructions to follow up with her PCP to get the cardiac referral, and phone numbers were provided for follow up visits here in Colorado. No appointments were set up prior to discharge in the patient's home state. RN #3 stated these follow up appointments were to be set up by case management. RN #3 stated follow up care ordered by the physicians was important as the patient needs the care to monitor ongoing issues. RN #3 stated if a patient was discharged to another state, the discharge paperwork should reflect the follow up appointments. No follow up appointments were found in the discharge paperwork. b. An interview was conducted on 10/14/20 at 2:06 p.m., with the Assistant Director of Case Management (Director #11). Director #11 stated discharge planning begins day one of an admission. Her role as Assistant Director was to assist case managers with more complex discharges to help them work through the issues prior to discharge. Director #11 stated case managers help with all aspects of the patients needs. Director #11 stated she became aware of Patient #2 when her discharge became complicated due to the patient ' s need to be airlifted to her home state. Director #11 was unable to locate recommendations for the patient in the chart and did not see case manager notes regarding the discharge plan. Director #11 stated the patient was wheelchair bound and home health services should have been offered, however she did not see these services were offered. Director #11 stated the case manager needed to set up a home health visit to evaluate any changes in needs after the surgery, new diagnosis of diastolic heart failure and GI bleed. c. An interview was conducted on 10/15/20 at 1:57 p.m., with the Director of Case Management (Director #6). Director #6 stated she was unable to locate any information Patient #2 had scheduled appointments for orthopedic post-surgical care established in her home state. A GI physician's information was in the record, without contact information. The cardiac follow up was contingent upon Patient #2 scheduling a visit with an unnamed PCP. Director #6 stated the follow up care after discharge was not clear in the record and was not typical of case manager discharge documentation.

36873 Based on interviews and document review the facility failed to obtain restraint orders immediately after the restraint was applied in 1 of 3 restraint medical records reviewed (Patient #1). This failure created the potential for an unsafe patient care environment in which the responsible attending physician or LIP was not aware of the patient's medical needs and current health status. FINDINGS POLICY According to Restraint/Seclusion an order for restraint or seclusion must be obtained from a Licensed Independent Practitioner (LIP) /physician who is responsible for the care of the patient prior to the application of restraint or seclusion. When an LIP/physician is not available to issue a restraint or seclusion order, an RN with demonstrated competence may initiate restraint or seclusion use based upon face-to-face assessment of the patient. In these emergency situations, the order must be obtained during the emergency application or immediately (within minutes) after the restraint or seclusion is initiated. 1. The facility did not obtain a restraint order immediately after the restraint was initiated for Patient #1. a) On 01/31/17, a review of Patient #1's medical record was completed. Documentation revealed restraints were applied to Patient #1 on 11/2/16 at midnight. Further review revealed a physician's order for restraints was obtained on 11/2/16 at 8:41 a.m. Patient #1 was restrained for 8 hours and 41 minutes before an order for restraints was obtained. b) During an interview on 02/01/17 at 2:49 p.m., Registered Nurse (RN) #2 stated if a restraint order had not been obtained before restraint application an order should have been obtained immediately after a patient was restrained. RN #2 stated s/he thought an order needed to be obtained within one hour of restraint application during these emergency situations. c) During an interview on 02/02/17 at 8:38 a.m., Director of Patient Care (Director) #6 stated restraint orders needed to be obtained immediately after application of restraints. S/he stated Patient #1's restraint order was not obtained quick enough. Director #6 stated Patient #1's restraint documentation did not follow facility policy. d) During an interview on 02/02/17 at 10:00 a.m. a review of Patient #1's medical record was done with Director of Clinical Education (Director) #4. Director #4 stated Patient #1's restraint documentation was not ok. S/he further stated restraint orders needed to be obtained within minutes of restraint application. e) During an interview on 02/02/17 at 11:15 a.m. Chief Nursing Officer (CNO) #7 stated staff was expected to follow facility policy. CNO #7 stated the restraint order for Patient #1 was obtained too late.

36873 Based on observations and interviews, the facility failed to provide a sanitary environment with a lack of adherence to professionally acceptable standards of practice for infection control during medication administration. Additionally, the facility failed to follow approved policies and professionally acceptable standards during blood transfusions and intravenous (IV) medication administration. This failure created a potential for the transmission of infectious organisms and negative patient outcomes. FINDINGS: POLICY According to the Hand Hygiene policy, if hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all other clinical situations described below. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient as well as a patient chart that has been taken to the bedside and handled during the assessment. Decontaminate hands after removing gloves. Decontaminate hands before inserting indwelling urinary catheters, peripheral vascular catheters, or other invasive devices that do not require a surgical procedure. According to Blood/Blood Component Transfusion, the blood infusion rate will be no greater than 120 milliliters (ml)/hour for the first 15 minutes unless indicated by age of clinical condition. The blood infusion rate will be increased to infuse the unit as fast as tolerated or per physician order if no adverse reaction occurred within the first 15 minutes of blood transfusion. Vital signs will be checked and documented: prior to transfusion (within 30 minutes). REFERENCE According to Peripheral IV and Central Line Maintenance Review, flush before and after each use using vigorous pulsatile technique, wiping with Chlorhexidine Gluconate (CHG)/Alcohol antiseptic wipe for 10 seconds between every flush. According to the Centers for Disease Control and Prevention (CDC) Guideline for Hand Hygiene in Health-Care Settings, hand contamination may occur as a result of small, undetected holes in examination gloves, contamination may occur during glove removal, and wearing gloves does not replace the need for hand hygiene. Indications for hand hygiene were: contact with a patient's intact skin (taking a pulse or blood pressure, performing physical examinations, lifting the patient in bed), contact with environmental surfaces in the immediate vicinity of patients, and after glove removal. According to the CDC, Proper hand hygiene should be performed before handling medications and the rubber septum should be disinfected with alcohol prior to piercing it. According to the World Health Organization (WHO) Guideline for Hand Hygiene in Health - Care Settings wash hands with soap and water when visibly dirty or visibly soiled with blood or other body fluids or after using the toilet. If exposure to potential spore-forming pathogens is strongly suspected or proven, including outbreaks of C. Difficile, hand washing with soap and water is the preferred means. Use an alcohol-based handrub as the preferred means for routine hand antisepsis in all other clinical situations if hands are not visibly soiled. If alcohol-based handrub is not obtainable, wash hands with soap and water. Perform hand hygiene: a) before and after touching the patient, b) before handling an invasive device for patient care, regardless of whether or not gloves are used, c) after contact with body fluids or excretions, mucous membranes, non-intact skin, or wound dressings, d) if moving from a contaminated body site to another body site during care of the same patient, e) after contact with inanimate surfaces and objects (including medical equipment) in the immediate vicinity of the patient, f) after removing sterile or non-sterile gloves Before handling medication or preparing food perform hand hygiene using an alcohol-based handrub or wash hands with either plain or antimicrobial soap and water. Soap and alcohol-based handrub should not be used concomitantly. 1. The facility failed to ensure patient care staff administered medication according to established guidelines and approved medical staff practices regarding hand hygiene and IV medication administration. a) On 01/30/17 at 1:50 p.m., Registered Nurse (RN) #1 was observed administering medication to Patient #6. RN #1 accessed the Pyxis medication system and obtained Patient #6's medication. S/he then entered Patient #6's room without performing hand hygiene. RN #1 documented the medication administration via the computer keyboard in Patient #6's medical record. S/he then opened the medication, put the pills into a medication cup, and administered them to Patient #6. RN #1 did not perform hand hygiene after documenting on the keyboard or before handling the medication and administering it to Patient #6. RN #1 did not perform hand hygiene when exiting Patient #6's room. These observations were in contrast to facility policy. b) On 02/01/17 at 8:35 a.m., RN #11 prepared an injection for Patient B. RN #11 removed the IV medication from the Pyxis medication system, checked to ensure the correct medication was removed, and obtained a needle to instill sterile saline into the medication vial. RN #11 did not scrub the hub of the medication vial before inserting the needle into the medication vial. This was in contrast to CDC standards of care. c) On 02/01/17 at 10:22 a.m., RN #2 was observed administering medication to Patient C. RN #2 touched Patient C's arm with clean gloved hands, s/he then touched the computer keyboard to document into Patient C's electronic medical record. RN #2 touched Patient C with the same-gloved hands and scanned Patient C's wristband, s/he then documented on the computer keyboard with the same contaminated gloves. RN #2 then changed gloves without performing hand hygiene. Next, RN #2 drew up the IV medication to administer. Before administering the medication to Patient C, RN #2 leaned over, picked trash up off the floor,and discarded it. RN #2 then touched the Patient C's IV tubing and administered the IV medication with the same contaminated gloved hands. RN #2 washed hands with soap and water for approximately 2-3 seconds. These observations were in contrast to facility policy. During the same observation, RN #2 prepared the IV medication for administration via a peripheral line in Patient C's left hand. RN #2 removed the plastic cap off the medication vial; s/he did not scrub the rubber hub on the medication vial before drawing up the medication. It was noted that RN #2 retrieved a sterile saline syringe to flush Patient C's IV before administering the medication. RN #2 scrubbed the end of the saline flush syringe, but did not scrub the hub of the IV before administering the flush. During the same observation, RN #2 noticed Patient C's left hand peripheral IV was leaking when the IV flush was administered. Patient C stated s/he felt fluid running between his/her fingers when RN #2 flushed the IV. RN #2 wiped the extra fluid coming from the IV and continued to administer IV medication into the leaking IV. After administering the IV medication, RN #2 wiped the extra fluid leaking around Patient C's IV. d) On 02/01/17 at 2:50 p.m. an interview was conducted with RN #2. S/he stated hand hygiene was to have been performed when entering and exiting a patient's room. RN #2 further stated if patient's surroundings were touched, hands had to be cleaned before you touched the patient. RN #2 reported hand hygiene was to help prevent an infection and so patient's surroundings were not contaminated. RN #2 stated s/he could not be certain Patient C was given the full dose of their IV medication due to the IV leaking when the medication was administered. e) During an interview on 02/02/17 at 10:56 a.m., Infection Preventionist (RN) #3 stated hand hygiene should be done when gloves were changed. S/he also stated hand hygiene needed to be performed after touching the computer keyboard and before touching a patient. RN #3 stated hand hygiene also must be performed again after touching the patient and before touching the computer. RN #3 stated if a nurse removed trash from the floor s/he should have removed their gloves after picking up the trash, perform hand hygiene and then put on a clean pair of gloves before performing patient care. RN #3 reported that the required time to effectively perform hand hygiene with soap and water was 15 to 20 seconds. S/he stated the reason for hand hygiene was to stop infections and make sure one did not cause transmission of an infection. RN #3 stated hand hygiene was known to protect the patients and was the number one way to stop the spread of infection. S/he further stated the cultural expectation for all staff regarding hand hygiene was based on the World Health Organization (WHO) five moments in hand hygiene. f) During an interview on 02/02/17 at 10:00 a.m., Director of Education #4 (Director) stated staff were educated and expected to follow policy regarding hand hygiene during medication and blood product administration. g) During an interview on 02/02/17 at 10:00 a.m., RN #5 stated s/he also assisted in staff education. S/he stated staff were educated and expected to follow policy regarding hand hygiene during medication administration. h) On 02/02/17 at 8:38 a.m., the Director of Patient Care (Director #6) was interviewed regarding hand hygiene. Director #6 stated staff were expected to follow the policy regarding hand hygiene, as it was the number one action to prevent infection between patients and staff. S/he also stated the length of time required for safe hand hygiene when soap and water were used was to sing the ABC song and use friction, 2-3 seconds of friction was not sufficient. Director #6 stated hand hygiene should always be performed after touching the computer and before touching the patient. S/he also stated hand hygiene should have been performed after picking trash up from floor and before contact with the patient. i) During an interview on 02/02/17 at 11:15 a.m., Chief Nursing Officer (CNO #7) stated s/he expected all staff to follow the facility's policies. CNO #7 stated their cultural expectation with regard to hand hygiene was based on the WHO five moments in hand hygiene and should have always been done before patient care. CNO #7 further stated IV medication administration could not be guaranteed if the the medication was administered through an IV which was leaking. 2. The facility failed to ensure patient care staff administered blood products according to established guidelines and approved medical staff practices regarding the rate of administration. a) During an observation on 01/30/17 at 3:34 p.m., RN #9 administered a blood product to Patient A. RN #9 scrubbed the central line hub with alcohol and flushed the line with a saline syringe. RN #9 then attached the IV tubing for blood product administration to the central line without scrubbing the hub of the central line catheter with alcohol. RN #9 then started the infusion rate at 125 ml per hour. This was a faster rate than the facility policy stated for blood product administration. b) During an observation on 02/01/17 at 11:45 a.m., RN #12 administered a blood product to Patient D. RN #12 explained s/he would start the infusion at 120 ml per hour. RN #12 stated all blood products were started at this rate to monitor the patient for a transfusion reaction. RN #9 then set the blood product to infuse at a rate of 125 ml per hour. This was in contrast to his/her explanation and facility policy. c) During an interview on 02/02/17 at 10:56 a.m., RN #3 (Infection Preventionist) stated it was important not to introduce microorganisms into central lines due to the risk of infection. RN #3 stated staff was provided education on peripheral IV and central line maintenance. As referenced above and stated by RN #3 the education stated to wipe the central line access with CHG/Alcohol wipe between every flush and for each access. RN #3 stated RN #9 should have scrubbed the hub of the central line after the saline flush and before the blood product was attached. d) During an interview on 02/02/17 at 8:38 a.m., Director #6 stated the policy did not state to start the blood product administration at 120 ml per hour. However, review of the policy confirmed the blood infusion rate will be no greater than 120 ml per hour for the first 15 minutes. e) During an interview on 02/02/17 at 11:15 a.m., CNO #7 stated RNs should have followed the blood product administration policy regarding the rate to start blood product infusion.

36873 Based on interviews and document reviews the facility failed to integrate support services and assess discharge readiness to ensure a safe transition of care from the emergency room in 3 out of 20 patients (Patients #1, #5 and #13). This failure created the potential for patients with ongoing medical conditions to be discharged to inappropriate environments without the ability to manage medical conditions due to lack of services, equipment, and resources. POLICY According to Guidelines for Nursing Care of the Emergency Department (ED) Patient, the plan of care will be individualized and based on patient needs or condition, the plan will be developed through collaboration among members of the health care team and the patient, documentation will reflect the standard of care specific to the patient's presenting problem. Documentation will include ongoing assessment, reassessment and evaluation. Care/focused assessment and vital signs of the patient will be documented a minimum of every 2 hours based on patient's clinical condition. Vital signs will be reassessed within thirty (30) minutes prior to discharge, excluding non-urgent patients with normal vital signs at presentation. All finding from nursing assessment and reassessment will be documented. In addition to ED nursing care, ancillary services such a social service, chaplain, psychiatric services, and home health care will be provided when indicated. At patient's discharge assure the patient is capable of self-care or has access to support services. Arrangement for home health care may be initiated by the ED Case Manager or the patient's primary nurse. The patient will be assessed for readiness to will which will include cognitive understanding. Documentation will indicate patient condition and aftercare instructions provided to the patient and/or family prior to discharge. 1. The facility failed to provide post-discharge resources to Patient #1 to ensure a safe discharge and transition from the emergency room to home/self-care. a) A review of Patient #1's medical record revealed s/he presented to the Emergency Department (ED), on 06/27/16, on 3 liters (L) oxygen (O2) via nasal cannula (NC) upon arrival by ambulance. It was noted in Patient #1's medical record s/he suffered from chronic obstructive pulmonary disease (COPD) and lived in a skilled nursing facility. At 06/28/16 at 1:57 p.m. the medical record revealed Case Manager #1 had reported the nursing home did not want the patient to return there to live. The family was to be notified and they could arrange for placement. Case Manager #1 documentation on 06/28/16 at 4:57 p.m., revealed disposition to an acute living facility was discussed with the brother and a senior blue book was provided as a community resource. However, the patient was discharged home in the care of his/her brother. No additional post-discharge resources were noted as provided or discussed with the patient to ensure a safe transition home. There was no documentation the patient was set up with home oxygen services prior to discharge. Patient #1 was discharged at 6:30 p.m. on 06/28/16. b) During an interview on 09/21/16 at 9:18 a.m., Case Manager #4 stated part of his/her job included assisting patients with transfers to hospice, home health set up, resources regarding addictions and follow-up services. S/he would also assist with transfers to Skilled Nursing Facilities. The case managers worked with families and provided a list of facilities. Patients would stay in the ED until placement was made and until the facility could ensure the environment the patients were going to was safe for them. S/he assumed a patient would stay in the ED if a discharge home was not safe for them. S/he further stated the facility needed to ensure a safe plan for the patient. c) During an interview with Case Manager #1 on 09/22/16 at 11:20 a.m., s/he stated the case manager position was a lot of self-discovery, it was his/her responsibility to decide if an emergency room patient needed case management services. Case Manager #1 did not have a checklist or flowsheet to determine patient needs to get home from the ED safely. Case Manager #1 admitted patients in need of his/her services in the emergency room could most definitely be missed with the current process. During the same interview on 09/22/16 at 11:20 a.m. Case Manager #1 reviewed the medical record of Patient #1. S/he stated Patient #1's medical needs were not discussed with the long term facility from which Patient #1 was brought. Case Manager #1 was unaware and did not question if the patient needed medical equipment or services for a safe discharge home with family. Case Manager #1 stated medical equipment was typically something families and patients needed to figure out on their own. S/he further stated s/he did not have a discharge plan in place for Patient #1. d) During an interview on 09/22/16 at 1:32 p.m., The Director of Case Management (Director #2) stated s/he expected the ED case managers to assess the patient's physical and medical needs. The case manager needed to determine if a patient needed home health at time of discharge. Director #2 expected to see this documented in the medical record. Upon review of Patient #1's medical record during the interview, Director #2 stated s/he expected to see documentation of the other facility being notified and medical equipment and supplies reviewed. S/he further stated more information was needed in the medical record to determine if Patient #1's discharge to home was safe. 2. The facility failed to assess patient's vital signs and O2 saturation levels within 30 minutes prior to discharge pursuant to the policy. a) A review of Patient #1's medical record revealed s/he presented to the ED on 3L O2 via NC upon arrival by ambulance. It was noted in Patient #1's medical record s/he suffered from COPD and lived in a skilled nursing facility. Respiratory assessments per the emergency department revealed Patient #1 had an oxygen saturation of 97% with administered O2 on 06/27/16 at 10:31 p.m. during his/her initial ER assessment. Further documentation review revealed the patient remained on O2 with documentation of O2 saturation levels through 06/28/16 at 8:48 a.m. On 06/28/16 at 12:19 p.m. documentation revealed Patient #1's oxygen saturation was 94%, it was not documented if the patient was on room air or remained on O2. No further vital signs for oxygen saturations were recorded for the patient and a room air oxygen saturation was not recorded. There was no documentation respiratory therapy was notified regarding a COPD patient on O2. Patient #1 was discharged to home from the ED at 6:30 p.m. on 06/28/16. b) A review of Patient #5's medical record revealed s/he was discharged at 4:22 p.m. on 07/14/16. The last set of vital signs assessed for patient #5 was at 3:10 p.m. on 07/14/16. This was not in accordance with facility policy regarding the timeframe of patient assessment prior to discharge. A review of Patient #13's medical record revealed his/her vital signs were taken at 5:49 p.m. on 09/07/16. The next set of vital signs were recorded at 10:05 p.m. This was outside the facility policy timeframe of 2 hours to assess the vital signs of an emergency room patient. c) During an interview on 09/22/16 at 12:19 p.m., RN #5 stated if a patient was on oxygen a room air saturation must be charted as well. A room air saturation was not documented on Patient #1's chart. S/he stated vital signs and assessments of an emergency department patient should follow the policy. RN #5 further stated it was the case manager's responsibility to ensure the patient's discharge was safe. S/he stated patients were able to stay overnight in the emergency department if a safe place to discharge was not determined. d) During an interview with [NAME] President of Emergency Services (VP) # 3 on 09/22/16 at 2:16 p.m., s/he stated s/he would expect to see a set of vital signs and a physical assessment of patients at discharge. S/he was unsure if a room air challenge was needed on patient's receiving oxygen while in the Emergency Department. VP #3 stated the Department relied on family to know the needs of the patient. S/he further stated that the facility did not get involved with medical equipment for a patient if it was after business hours.

33044 Based on the nature of standard level deficiencies referenced to the Condition, it was determined the Condition of Participation º482.51, SURGICAL SERVICES, was out of compliance. A-0951 - Standard: Delivery of Service - Surgical services must be consistent with needs and resources. Policies governing surgical care must be designed to assure the achievement and maintenance of high standards of medical practice and patient care. The facility failed to ensure duties performed in the surgical department were conducted in accordance with established high standards of care and facility policies. This failure resulted in the potential for transmission of health care acquired infections to patients receiving care in the facility. In addition, this failure created the potential for unauthorized staff, patients, and visitors to divert or tamper with accessible medications and supplies. Furthermore, this failure created an increased risk of fire in the surgical department.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 33044 Based on observations, interviews, and document review the facility failed to ensure duties performed in the surgical department were conducted in accordance with established high standards of care and facility policies to ensure positive patient outcomes. This failure resulted in the potential for transmission of health care acquired infections to patients receiving care in the facility. In addition, this failure created the potential for unauthorized staff, patients, and visitors to divert or tamper with accessible medications and supplies. Furthermore, this failure caused an increased risk of fire in the surgical department. FINDINGS: POLICY According to Purchasing-Receiving/Medication Availability, Products will be stored under appropriate conditions to preserve integrity. According to Temperature & Humidity Control in the Operating Room (OR), The current requirements per Association of periOperative Registered Nurses (AORN) and National Fire Protection Association are ,d+[DATE]% humidity. If the temperature and humidity ranges fall out of the recommended levels, the OR staff will notify facilities management as soon as possible. According to Reprocessing of Flexible Endoscopes, Hang the endoscope vertically with the distal tip hanging freely in a clean, well-ventilated, dust free area. According to Surgery/Delivery In-Between Case Cleaning, Equipment and Supplies included a lobby dust pan and broom. According to Terminal Cleaning Sterile & Delivery Areas, Equipment and Supplies included a lobby dust pan and broom. According to Clinical Guidance: Blanket/Fluid/Solution Warming - Refrigeration Guidelines, For IV fluids in Fluid Warmers, remove on or before 14 days. According to Temperature Control of Surgical Patients, The manufacturer's guidelines will be followed when bagged fluids are warmed through a fluid warming device. According to Intravenous Therapy and Central Lines - Adult, IV solution bags/bottles will be timed and dated when hung. According to Re-Use of Disposable Medical Supplies and Equipment, Single-use or disposable medical supplies and equipment shall not be re-used or resterilized. If a single-use sterile item is opened and not used, it shall be discarded. REFERENCE According to the Association of periOperative Registered Nurses (AORN), Guidelines for Perioperative Practice, 2015: Recommendation IVe.1. (page 276), The relative humidity in a restricted area should be maintained within a range of 20% to 60%. Recommendation IX.a. (page 594), Flexible endoscopes should be stored in a closed cabinet and hanging in a secure vertical position. When flexible endoscopes are hung in the vertical position, coiling or kinking is prevented, allowing any remaining moisture to drain out of the endoscope and decreasing the potential development of an environment conductive to microbial growth in the endoscope. Recommendation II.d. (page 13), Floors should be mopped with damp or wet mops. Dry methods of environmental cleaning (i.e., dusting, sweeping) should not be used in semi-restricted and restricted areas. Recommendation II.b. (page 12), All horizontal surfaces in the OR (e.g., furniture, surgical lights, [NAME], equipment) should be damp dusted before the first scheduled surgical or other invasive procedure of the day. Recommendation II.b.1 (page 530), Fluids kept in a warming cabinet should be labeled with an expiration date based on the manufacturer's recommendation for storage above room temperature. According to the Manufacturer's Instructions for the Olympus Evis Exera II Ultrasound Gastrovideoscope, Hang the endoscope in the storage cabinet with the distal end hanging freely. Make sure that the insertion section hangs vertically and as straight as possible. 1. The facility did not ensure medications and supplies used for the administration of medications were secured in a manner to avoid diversion or tampering. a) On [DATE] at 9:45 a.m., a tour of the Main Preoperative (Preop) Unit and the Main Post Anesthesia Care Unit (PACU) was conducted with the Director of the Operating Room (Director #1) and a Registered Nurse in the Preop Unit (RN #9). Observations revealed the following unsecured medications and supplies: - In Bay #9 of the Main Preop Unit, the top drawer of a storage cabinet was unlocked and revealed one 10 milliliter (ml) manufactured saline syringe out of its packaging and with no cap on the end of the syringe. The syringe was filled with an unknown clear liquid. The storage cabinet was accessible to patients, visitors, and staff. Upon finding the syringe, RN #9 stated the syringe should have been discarded and proceeded to empty the syringe of unknown liquid in a sink located at the nurses' station. - In the Difficult Intubation Cart located adjacent to the Main PACU, the top drawer was unlocked and revealed one 50 ml bottle of topical 4% Lidocaine solution. The bottle was approximately ,d+[DATE]th full of an unknown liquid. Upon finding the bottle, Director #1 stated medications should not have been stored in the Difficult Intubation Cart and proceeded to remove the bottle from the cart. b) On [DATE] at 9:32 a.m., a tour of the Gynecological (GYN) OR was conducted with the Clinical Nurse Coordinator (CNC #10) of the Preop Unit and the PACU. Observation of GYN Preop Bay #5 revealed a storage cart with the top drawer unlocked which was filled with packaged prefilled saline syringes, needles, and syringes. The cart was accessible to patients, visitors, and staff. CNC #10 stated the drawer should have been locked at all times and proceeded to lock the drawer. c) On [DATE] at 10:25 a.m., an interview was conducted with the Assistant [NAME] President of Surgical Services (AVP #2) who confirmed the expectation was for all medications to be secured from unauthorized use. AVP #2 stated the facility considered manufactured prefilled saline syringes to be medications that needed to be secured in the same way all medications were secured. AVP #2 further stated s/he had been conducting random monitoring checks throughout the surgical department; however, s/he was not documenting the performance of the monitoring checks or if any corrective actions or education were necessary as a result of the checks. 2. The facility did not maintain humidity levels in the Main OR suites at levels required by policies and national standards of care. a) A tour of OR #7 was conducted on [DATE] at 12:15 p.m. with Director #1. Director #1 explained the facility followed AORN guidelines for determining the acceptable humidity levels in the OR, which were between ,d+[DATE]%. Observation of the thermostat in OR #7 revealed the humidity level was 16.5%. Director #1 stated s/he would not be concerned if the humidity level fell below the accepted range. This was not in accordance with the policy which instructed staff to contact facilities management as soon as possible if temperatures and humidity ranges fell out of the required level. Further observations from the same tour revealed the following OR suites' humidity levels: - OR #8's humidity level was 16%. - OR #2's humidity level was 15.9%. b) Review of the Main OR Humidity Log from [DATE] to [DATE] (40 days total) revealed the following examples of humidity levels falling below the acceptable range: - OR #1's humidity levels fell below the acceptable range 25 of 40 days reviewed. The lowest humidity level during the reviewed time frame was 6.3% on [DATE]. - OR #2's humidity levels fell below the acceptable range 26 of 40 days reviewed. The lowest humidity level during the reviewed time frame was 7.3% on [DATE]. - OR #3's humidity levels fell below the acceptable range 18 of 40 days reviewed. The lowest humidity level during the reviewed time frame was 6.9% on [DATE]. c) On [DATE] at 10:25 a.m., an interview was conducted with AVP #2 who confirmed the expected humidity range in the OR suites was between ,d+[DATE]%. AVP #2 stated the reason it was important to keep humidity levels above 20% was to reduce the risk of fire or spark hazards in the OR. 3. The facility did not store reprocessed endoscopes in a manner to avoid contamination or growth of microorganisms. a) On [DATE] at 1:30 p.m., the Main OR department's endoscope storage cabinet was observed with a Surgical Technician (ST #5). Inside the storage cabinet an endoscope was observed hanging from a hook with the distal tip wrapped around the hook, which created a complete coil in the endoscope. During the observation, ST #5 stated there probably was not ample space available when the scope was placed in the closet and that was the reason why it was looped around the hook. ST #5 then proceeded to readjust the endoscope to hang in a vertical position. b) On [DATE] at 9:37 a.m., an interview was conducted with Director #1 who confirmed the expectation was for scopes to be stored in a vertical position after reprocessing in order to be able to dry completely. c) On [DATE] at 10:25 a.m., an interview was conducted with AVP #2 who stated reprocessed endoscopes should have been stored vertically for any residual water to be able to drain out of the end. AVP #2 further stated there should have been staff members checking to ensure endoscopes were hung vertically. 4. The facility used dry dusting brooms to clean OR suites. a) On [DATE] at 10:55 a.m., a tour of the Main OR Department revealed the following brooms located in the restricted areas of the department: - One broom was observed on a janitor's cart located in a hallway outside of OR #5, OR #6, OR #7, and OR #8. - One broom was observed on a janitor's cart located in a hallway outside of the sub-sterile room located between OR #1 and OR #2. - One broom was observed in the janitor's closet located in the restricted area of the surgical department. b) On [DATE] at 12:45 p.m., an interview with two Environmental Service Staff Members (Employee #3 and Employee #4) was conducted. Employee #3 stated s/he would use brooms to sweep the OR suites. Employee #4 explained s/he would begin cleaning OR suites by using a black broom to sweep the floor followed by using a wet mop. c) On [DATE] at 11:00 a.m., an interview was conducted with Director #1 who stated s/he was unaware that Environmental Staff were using brooms to sweep the floors in the OR suites. Director #1 further stated the expectation was for staff to first dry mop the floors and then use a wet mop. This was in contrast with AORN guidelines which stated damp or wet mops should have been used to mop floors. d) On [DATE] at 10:25 a.m., an interview was conducted with AVP #2 who explained the facility followed AORN standards for guidance with cleaning the surgical department. AVP #2 stated sweeping the floors of the OR suites was a common practice done at the facility. AVP #2 then stated s/he was not aware of the AORN guideline instructing against the use of dry dusting or sweeping in semi-restricted and restricted areas of the surgical department because of the possibility of aerosolizing infectious particles in the air. 5. The facility did not clean OR suites in accordance with national standards of care before the first scheduled procedure of the day. a) On [DATE] at 9:12 a.m., an interview was conducted with an OR Registered Nurse (RN #6) who stated s/he would not routinely clean the OR suite s/he was assigned to before the first scheduled procedure of the day unless s/he noticed something in the room that needed to be cleaned. On [DATE] at 9:17 a.m., an interview was conducted with Surgical Technicians (ST #11 and ST #12). ST #11 revealed s/he was precepting ST #12 who was on orientation. ST #11 stated s/he would not wipe down horizontal surfaces in OR suites before the first case of the day because they had been terminally cleaned the night before. On [DATE] at 1:44 p.m., an interview was conducted with an OR RN (RN #7) who stated since OR suites were terminally cleaned overnight staff did not clean them before the first procedure of the day unless they were visibly soiled. RN #7 further stated s/he felt there would not be enough time to clean OR suites before the first case of the day. b) On [DATE] at 9:37 a.m., an interview was conducted with Director #1 who revealed OR suites were terminally cleaned each night between 7:00 p.m. and 4:00 a.m. Director #1 stated s/he did not think it was necessary to clean the OR suites in the morning before the first case of the day since they had been terminally cleaned the night before. This was in contrast to the AORN recommendation which stated all horizontal surfaces in the OR should be damp dusted before the first scheduled surgical or other invasive procedure of the day. c) On [DATE] at 10:25 a.m., an interview was conducted with AVP #2 who confirmed cleaning horizontal surfaces in OR suites before the first scheduled case of the day had not been a standard expectation at the facility. AVP #2 further stated s/he was not aware of the AORN recommendation which stated all horizontal surfaces in the OR should be damp dusted before the first scheduled surgical or other invasive procedure of the day. 6. The facility did not ensure intravenous (IV) fluids stored in warming cabinets were safe for patient use. a) On [DATE] at 10:55 a.m., a tour of the Main OR department revealed the following IV fluid bags stored in fluid warming cabinets past the expected discard date: - In the sub-sterile room located between OR #7 and OR #8, one 1000 ml bag of Lactated Ringer's IV fluid was observed in a fluid warming cabinet with the date of ,d+[DATE] written on the bag. - In the sub-sterile room located between OR #9 and OR #10, two 3000 ml bags of 0.9% Normal Saline IV fluid were observed in a fluid warming cabinet with the date of ,d+[DATE] written on the bag. b) On [DATE] at 9:37 a.m., an interview was conducted with Director #1 who confirmed the date written on the IV fluid bags indicated the date the fluid should have been discarded. Director #1 explained the facility followed AORN guidelines and facility policies when storing IV fluids in the warming cabinets, which instructed to discard IV fluids in warming cabinets after 14 days. c) On [DATE] at 10:25 a.m., an interview was conducted with AVP #2 who confirmed the expectation was for IV fluids in warming cabinets to be discarded when they were expired. 7. The facility did not ensure IV fluids were labeled to ensure safety for patient administration. a) On [DATE] at 10:00 a.m., observations in Bay #5 of the Main Preop Unit revealed one 1000 ml bag of Lactated Ringer's IV fluid hanging on an IV pole at the head of the bed. IV tubing was attached to the bag of fluid; however, there was no label noted on the bag or tubing indicating when the tubing had been attached to the bag. This was in contrast to the policy which stated IV solution bags/bottles would be timed and dated when hung. During the same observation, a Preop Unit RN (RN #9) stated s/he was preparing for a patient to arrive in Bay #5 and had attached the IV tubing to the bag of IV fluid. RN #9 further stated s/he did not have a chance to label the IV fluid bag but it should have been labeled with the date and time of when it was hung. b) On [DATE] at 9:37 a.m., an interview was conducted with Director #1 who confirmed the expectation was for staff to label all IV fluids being administered to patients. 8. Staff in the Pre-Operative Unit did not ensure single use patient care supplies were stored in their protective packaging and safe for patient use. a) On [DATE] at 9:45 a.m., a tour of the Main Preop Unit and the Main PACU was conducted. Observations during the tour revealed the following patient care supplies: - In the Preop Unit Medication Room, two sets of IV tubing without the manufacturer's protective packaging were observed on a shelf. - In Bay #5 of the PACU, one oxygen mask with the manufacturer's protective packaging ripped open was observed in the third drawer of a storage cart. b) On [DATE] at 10:08 a.m., an interview was conducted with the Director of the Preop Unit and PACU (Director #8), who stated any patient care supplies found out of their packaging should not have been used and should have been discarded. c) On [DATE] at 10:25 a.m., an interview was conducted with AVP #2 who stated opened supplies available for patient use was a sloppy practice and created a potential risk for patients to receive contaminated items.

26833 Based on the nature of standard level deficiencies referenced to the Condition, it was determined the Condition of Participation º482.25, PHARMACEUTICAL SERVICES was out of compliance. A-494 - Standard: Current and accurate records must be kept of the receipt and disposition of all scheduled drugs. The facility failed to maintain accurate drug records which showed disposition of controlled medications and reconciliation of any variances which occurred. Additionally, the facility failed to have a standard process to investigate improper practices regarding controlled medication which would minimize the time frame between detection and determination of the extent of loss or diversion. This failure created the potential for drug diversion and had the potential to affect all patients within the facility. A-505 - Standard: Outdated, mislabeled, or otherwise unusable drugs and biologicals must not be available for patient use. The facility failed to ensure outdated medications were removed from stock according to the manufacture's expiration date. This failure created the potential for patients to receive expired medications.

35253 Based on interviews and document review, the facility failed to maintain accurate drug records which showed disposition of controlled medications and reconciliation of any variances, which occurred during transfer from the pharmacy's Automatic Dispensing Cabinet (ADC) to the patient care units. Additionally, the facility failed to have a standard process to investigate improper practices regarding controlled medications, which would minimize the time frame between detection and determination of the extent of loss or diversion. This failure created the potential for drug diversion and had the potential to affect all patients within the facility. FINDINGS: POLICY According to the policy, Medication Diversion Prevention Policy (Section V-Preparing and Dispensing), for Automatic Dispensing Cabinets (ADC), the authorized staff member would stock the ADC and verify the inventory count. The verification could occur electronically (e.g. Pyxis CII Safe Compare Report) or the authorized staff member would print a proof of deliver report. This would be reconciled and signed by the Pharmacist, Administrator or Practice Manger, filed and stored. Further, the policy noted any remaining controlled medication packaged in an amount larger than the dose being administered must be wasted immediately. The CEO, Administrator, or Practice Manager, along with the Director of Pharmacy is responsible for controlled medication oversight, including tracking and reporting of inappropriate controlled medication usage. Each facility should form a multidisciplinary team that is charged with developing a coordinated and systematic approach to prevention and detection of medication diversion. 1. Pharmacy staff did not reconcile Pyxis CII Safe Compare Reports (Compare Reports) to ensure controlled medications (a drug for which control and regulation has been declared due to the danger of addiction, abuse, physical and mental harm, trafficking by illegal means and the dangers from actions of those who have used the substances) removed from the pharmacy's ADC were delivered to the intended patient care unit. Additionally, the facility did not have a process in place to ensure the Compare Reports were printed and reconciled. a) On 02/11/16 at 11:31 a.m., an interview was conducted with a Pharmacy Technician (PT #19) who stated the Compare Report would show controlled medications removed from the main pharmacy ADC not yet stocked at the intended unit's ADC. S/he further stated, at the end of each PT shift the Compare Report should have been printed and if there was a variance on the report, the PT should have noted the reason for the variance. PT #19 stated the report verified what medications were removed from the main pharmacy safe and sent to the patient care units. S/he further stated the report ensured everything removed from the pharmacy safe was delivered to the intended destination. PT #19 stated the report needed to be reconciled in order for variances to be investigated as soon as possible. PT #19 stated all PTs had been trained on the Compare Report process. b) Review of the Compare Report, printed 12/10/15 at 4:00 p.m., revealed 20 Pregabalin 100 milligram (MG) capsules (a medication used to treat epilepsy, neuropathic pain, fibromyalgia and generalized anxiety disorder) were sent from the main pharmacy ADC with the intent to be stocked in the 6th floor ADC at 6:55 a.m. There was no evidence the controlled medication was stocked on the 6th floor at the time the report was printed. The variance listed on the report was not reconciled and lacked evidence of an investigation. Approximately 4 1/2 hours later a second Compare Report was printed at 8:27 p.m. The 20 Pregabalin 100 mg capsules remained listed on this report. The second report showed no evidence pharmacy staff investigated the variance. Four days lapsed without any evidence showing the 20 Pregabalin capsules were stocked in the 6th floor ADC. c) The Compare Reports were not printed for 16 of 31 days for the month of December 2015. Out of the 15 days the reports were printed, only 3 of those days had a report for each shift (2 shifts per day). Furthermore, the reports lacked evidence pharmacy staff investigated and reconciled the variances listed on the reports. Review of January 2016 Compare Reports revealed 9 of 31 days did not have Compare Reports printed. Out of the 22 days the reports were printed, only 6 of those days had a report for each shift (2 shifts per day). d) Review of the Compare Report, printed on 02/04/16 at 4:33 p.m., revealed a variance for 10 Oxycodone CR 10 mg tablets (an opioid pain medication used to treat moderate to severe pain) which were sent from the main pharmacy's ADC to the Surgical Orthopedic Center (SOC) medication station at 4:24 p.m. There was no evidence pharmacy staff reviewed the Compare Report or printed follow up reports showing the medication was stocked in the SOC's ADC. The next Compare Report printed was dated 02/09/16 at 3:09 p.m. Four days lapsed without any evidence showing the controlled medication was received at the intended location. e) On 02/10/16 at 1:08 p.m., an interview was conducted with the Director of Pharmacy (Pharmacist #14) who stated the Compare Reports were used to track the movement of controlled medications from the main pharmacy ADC to the patient care unit's ADCs. Pharmacist #14 stated if the controlled medication was not loaded into the unit's ADC, it would show on the Compare Report as a variance. All pharmacy staff present for the interview confirmed a lapse of Compare Reports from 02/05/16 through 02/08/16. All agreed this was too long of a time frame to wait for a variance to be found. f) On 02/12/16 at 11:15 a.m., an interview was conducted with Pharmacist #14 who stated the variance report was printed each shift so PTs could track the controlled medication transferred from the pharmacy ADC to the patient care unit ADC locations. Pharmacist #14 stated PTs were responsible for reviewing and reconciling the report each shift. S/he further stated the investigation process for the variances listed on the Compare Reports could use more detail. Pharmacist #14 stated s/he was now aware of the missing Compare Reports, and stated the lack of reports and variance reconciliation could lead to a drug diversion being overlooked. 2. The facility failed to complete monthly Compare Report audits to ensure variances listed on the audits were reconciled. a) On 02/10/16 at 1:08 p.m., the surveyor requested the monthly variance report audits for the prior 6 months. At 5:07 p.m., (4 hours later), Pharmacist #14 provided the monthly Compare Report audits. Pharmacist #14 stated there may be gaps in the audits provided by him/her and the Pharmacy Clinical/Operations Specialist (Pharmacist #20) was still looking for the missing audits. b) On 02/11/16 at 12:46 p.m., an interview was conducted with Pharmacist #20 who stated s/he was responsible for the monthly audits of the Compare Reports printed by the pharmacy technicians. Pharmacist #20 stated s/he was responsible for monitoring and reconciling the Compare Reports for variances. Audits were requested for December 2015 and January 2016. Review of the audits, provided by Pharmacist #20, revealed the audits were not conducted until after the meeting with the surveyor on 02/10/16 at 12:30 p.m. (1 day prior). The Compare Reports attached to the audit sheets had a print date of 02/10/16 at 4:39 p.m. Pharmacist #20 was asked if audits were completed prior to the survey, and s/he stated no. Pharmacist #20 then stated his/her priority was nursing diversion audits, and when s/he had time, the other pharmacy department audits would be done. c) On 02/12/16 at 11:15 a.m., an interview was conducted with Pharmacist #14 who stated Pharmacist #20 audited the Compare Reports once a month to ensure the facility was tracking controlled medications dispensed from the pharmacy safe to the nursing units. Pharmacist #14 stated s/he was now aware of the missing audits and reports, and confirmed this failure could lead to a drug diversion being overlooked. 26833 3. The facility failed to have a standard process to investigate improper practices regarding controlled medications which would minimize the time frame between detection and determination of the extent of loss or diversion. a) An interview with Pharmacist #14, on 02/10/16 at 10:06 a.m., revealed the facility had a Diversion Management Committee which met monthly to review individuals who did not meet the facility's expectations for managing controlled medications or were at risk for drug diversion. Meeting minutes were requested from the Diversion Management Committee meetings. Pharmacist #14 stated there were no formal meeting minutes from the committee. The Pharmacist stated pharmacy staff would monitor the RxAuditor reports, a report that identified staff who were statistically significant above peers in accessing, administering and wasting controlled medications, monthly to help identify outliers. The Pharmacist would bring those findings to the committee meetings to discuss. If Pharmacist #14 had a concern or the committee wanted to do a deeper dive on an identified staff member s/he would create an individual tracking folder to bring to the committee. Pharmacist #14 provided a tracking folder for Registered Nurse #15 (RN). The folder revealed the facility had a concern in October 2014 regarding RN #15's practices with controlled medications. Inside the front cover it was noted the committee met regarding RN #15 on 10/20/14. The committee noted RN #15 was a contracted employee who would be counseled and repeat audits would be conducted. Pharmacist #14 confirmed the information during an interview on 02/12/16 beginning at 11:16 a.m. There was no additional information in the tracking folder on what was discussed with RN #15 or if the RN was counseled. Additionally, there was no documentation to show if drug diversion had been investigated and ruled out. During an interview with Pharmacist #14 and the Chief Nursing Officer (CNO #16), on 02/12/16 at 11:16 a.m., CNO #16 stated the facility would have met with RN #15 but it would have been up to the contracting agency to complete the counseling. CNO #16 stated the contracting agency would maintain documentation of the counseling and s/he was not sure if the facility had a copy. As of the survey exit, on 02/12/16 at 4:00 p.m., no documentation of counseling for RN #15 had been provided. b) Review of RN #15's tracking folder showed the facility identified subsequent concerns and began auditing RN #15's controlled medication practices again in September 2015. According to the Controlled Substance Audit Summary for September 2015, 17 patients cared for by RN #15 were reviewed with 3 discrepancies noted. - On 09/02/15, RN #15 withdrew Fentanyl 100 mcg/2ml amp (a powerful synthetic opiate analgesic similar to but more potent than morphine). RN #15 administered 50 mcg. There was missing documentation of waste for remaining 50 mcg. - On 09/12/15, RN #15 withdrew Hydromorphone 1 mg/ml syringe (an opioid pain medication) and administer 0.5 mg. There was no documentation of waste or administration for remaining 0.5 mg. - On 09/22/15, the RN withdrew Fentanyl 100 mcg/2ml amp and administered 50 mcg. There was no documentation of waste or administration for the remaining 50 mcg. The Controlled Substance Audit Summary for October 2015, showed RN #15 had 9 patients reviewed which resulted in 9 discrepancies. As example: - On 10/21/15 RN #15 removed Fentanyl 100 mcg from the Pyxis at 10:04 a.m. At 1:48 p.m. (over 3 3/4 hours later) the RN had a late restock of the entire dose. - On 10/13/15 RN #15 removed Fentanyl 100 mcg and administered 50 mcg. Additionally the RN removed Hydromorphone 1 mg and administered only .75 mg. The excess Fentanyl 50 mcg and Hydromorphone .25 mg were not wasted until 3 hours after they had been removed from the Pyxis. Review of the November 2015 Controlled Substance Audit Summary, showed the facility reviewed 29 patients cared for by RN #15 and identified 5 discrepancies. As example: - On 11/11/15 RN #15 removed Fentanyl 100 mcg at 10:41 a.m. S/he did not administer and waste the excess medication until 1:40 p.m., 3 hours after it had been removed from the Pyxis. - On 11/12/15 the RN removed Fentanyl 100 mcg. There was no documentation of administration, waste or return associated with the removal. c) Review of an undated log sheet, provided by Pharmacist #14 and used to track individuals the Diversion Management Committee met on, showed the committee once again met to discuss RN #15 on 12/02/15. The log noted the committee reviewed 15 patients who RN #15 cared for and had an issue with late wasting and late restocking with controlled medications. The action identified on the log was to have the director meet with the employee and according to the log an email was sent to the Assistant [NAME] President of Surgical Services (AVP #2) on 12/07/15. On 02/11/16, the surveyor requested any emails AVP #2 had received regarding RN #15. AVP #2 presented an email, dated 11/26/13 (over 2 years earlier), which showed the facility had a concern with RN #15's wasting of controlled substances. AVP #2 had no additional documentation regarding RN #15. There was no documentation the facility met with RN #15 to discuss identified concerns and determine if drug diversion had occurred. Subsequent to the committee's meeting on 12/02/15, RN #15 continued to have discrepancies noted on the Controlled Substance Audit Summary. According to the December 2015 report, 15 patients were reviewed and 5 discrepancies were noted. As example: - On 12/29/15 RN #15 removed Fentanyl 100 mcg at 10:00 a.m. S/he administered 50 mcg and did not waste the remaining 50 mcg until 1:04 p.m., more than 3 hours after removal and administration. - On 12/30/15 the RN removed Fentanyl 100 mcg at 9:17 a.m. and administered 50 mcg. There was no documentation of administration or waste for the remaining Fentanyl 50 mcg. During an interview, on 02/11/16 at 3:49 p.m., AVP #2 stated s/he had not had any conversations regarding controlled medication discrepancy concerns with RN #15 until the day before. AVP #2 stated Pharmacist #14 stopped him/her in the hall on 02/10/16 (after the Pharmacist's interview with the surveyors) and told him/her RN #15 was holding on to controlled medications for too long. AVP #2 stated the expectation was for PACU (post-anesthesia care unit) staff to administer the controlled medication within 5-10 minutes. S/he noted holding on to controlled medications for 60 minutes or more was not acceptable. AVP #2 stated s/he had a conversation with RN #15 about medication practices but it was informal and not documented. Review of documents provided showed the facility had intermittently monitored and identified concerns with RN #15's practices for management of controlled medications for over 2 years. As of the survey exit there was no documentation the facility and contracting agency met with RN #15 after identified concerns regarding controlled medication practices for each of the previous 5 months, to determine if drug diversion had occurred.

35253 Based on observation, interviews, and document review, the facility failed to ensure outdated medications were removed from stock according to the manufacturer's expiration date. This failure created the potential for patients to receive expired medications. FINDINGS: POLICY According to policy, Outdated Drugs/Drug Disposal, all medication stock will be inspected to insure the prompt removal of outdated drugs from stock and subsequent storage and disposition. 1. The facility failed to ensure outdated medications were removed from patient care units and not available for patient use. a) On 02/10/16 at 8:51 a.m., a tour of the 7th floor Neuro/Spine unit was conducted with Director #27 and Charge Nurse #28. During the tour, 6 outdated multi-dose vials of 0.9% Sodium Chloride (30 milliliter vials) were found in the patient supply room. The vials had a manufacturer expiration date of November 2015. Charge #28 stated the Central Supply Department was responsible for monitoring outdated supplies. S/he further stated the outdated vials should have been discarded. b) On 02/10/16 at 9:30 a.m., an interview was conducted with Pharmacist #30 who stated 0.9 % Sodium Chloride vials were used when intravenous antibiotics needed to be diluted prior to being administered to patients. Pharmacist #30 stated outdated medication vials should have been discarded per the manufacture's date on the vial. c) On 02/11/16 at 11:31 a.m., an interview was conducted with Pharmacy Technician #19 who stated medications should have been discarded by the manufacturer recommendations printed on the vial.

33044 Based on the nature of standard level deficiencies referenced to the Condition, it was determined the Condition of Participation º482.42, INFECTION CONTROL, was out of compliance. A-0749 - Standard: The infection control officer or officers must develop a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel. The facility failed to maintain appropriate infection control processes in the areas of humidity levels in the surgical department, integrity of patient care supplies, and cleaning/disinfection of surgical supplies, equipment and operating rooms. These failures created the potential for transmission of health care acquired infections to patients receiving care in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 33044 Based on observation, interviews and document review, the facility failed to maintain appropriate infection control processes in the areas of humidity levels in the surgical department, integrity of patient care supplies, and cleaning/disinfection of surgical supplies, equipment and operating rooms. Additionally, the facility failed to ensure staff followed infection control processes when performing patient care tests at the bedside in 1 of 1 observations conducted (Patient P). These failures created the potential for transmission of health care acquired infections to patients receiving care in the facility. FINDINGS: POLICY According to Temperature & Humidity Control in the Operating Room (OR), The current requirements per Association of periOperative Registered Nurses (AORN) and National Fire Protection Association are ,d+[DATE]% humidity. If the temperature and humidity ranges fall out of the recommended levels, the OR staff will notify facilities management as soon as possible. According to Reprocessing of Flexible Endoscopes, Hang the endoscope vertically with the distal tip hanging freely in a clean, well-ventilated, dust free area. According to Surgery/Delivery In-Between Case Cleaning, Equipment and Supplies included a lobby dust pan and broom. According to Terminal Cleaning Sterile & Delivery Areas, Equipment and Supplies included a lobby dust pan and broom. According to Clinical Guidance: Blanket/Fluid/Solution Warming - Refrigeration Guidelines, For IV fluids in Fluid Warmers, remove on or before 14 days. According to Temperature Control of Surgical Patients, The manufacturer's guidelines will be followed when bagged fluids are warmed through a fluid warming device. According to Re-Use of Disposable Medical Supplies and Equipment, Single-use or disposable medical supplies and equipment shall not be re-used or resterilized. If a single-use sterile item is opened and not used, it shall be discarded. According to Nova Bedside Glucose Policy, Standard precautions will be observed for the collection and handling of all blood specimens. Only the meter and the test strip to be used should go into a patient's room. For a finger puncture, cleanse the fingertip with soap and water and wipe dry with cotton ball or allow to air dry. REFERENCE According to the Association of periOperative Registered Nurses (AORN), Guidelines for Perioperative Practice, 2015: Recommendation IVe.1. (page 276), The relative humidity in a restricted area should be maintained within a range of 20% to 60%. Recommendation IX.a. (page 594), Flexible endoscopes should be stored in a closed cabinet and hanging in a secure vertical position. When flexible endoscopes are hung in the vertical position, coiling or kinking is prevented, allowing any remaining moisture to drain out of the endoscope and decreasing the potential development of an environment conductive to microbial growth in the endoscope. Recommendation II.d. (page 13), Floors should be mopped with damp or wet mops. Dry methods of environmental cleaning (i.e., dusting, sweeping) should not be used in semi-restricted and restricted areas. Recommendation II.b. (page 12), All horizontal surfaces in the OR (e.g., furniture, surgical lights, [NAME], equipment) should be damp dusted before the first scheduled surgical or other invasive procedure of the day. Recommendation II.b.1 (page 530), Fluids kept in a warming cabinet should be labeled with an expiration date based on the manufacturer's recommendation for storage above room temperature. According to the Manufacturer's Instructions for the Olympus Evis Exera II Ultrasound Gastrovideoscope, Hang the endoscope in the storage cabinet with the distal end hanging freely. Make sure that the insertion section hangs vertically and as straight as possible. 1. The facility used dry dusting brooms to clean OR suites. a) On [DATE] at 10:55 a.m., a tour of the Main OR Department revealed the following brooms located in the restricted areas of the department: - One broom was observed on a janitor's cart located in a hallway outside of OR #5, OR #6, OR #7, and OR #8. - One broom was observed on a janitor's cart located in a hallway outside of the sub-sterile room located between OR #1 and OR #2. - One broom was observed in the janitor's closet located in the restricted area of the surgical department. b) On [DATE] at 12:45 p.m., an interview with two Environmental Service Staff Members (Employee #3 and Employee #4) was conducted. Employee #3 stated s/he would use brooms to sweep the OR suites. Employee #4 explained s/he would begin cleaning OR suites by using a black broom to sweep the floor followed by using a wet mop. c) On [DATE] at 11:00 a.m., an interview was conducted with the Director of the OR (Director #1) who stated s/he was unaware that Environmental Staff were using brooms to sweep the floors in the OR suites. Director #1 further stated the expectation was for staff to first dry mop the floors and then use a wet mop. This was in contrast with AORN guidelines which stated damp or wet mops should have been used to mop floors. d) On [DATE] at 3:39 p.m., an interview was conducted with the Infection Prevention Manager (IP #13) who confirmed the facility followed AORN guidelines for infection control practices in the surgical department. IP #13 stated s/he was unaware of brooms being used to sweep the OR suites and they should not have been used because of the possibility of aerosolizing infectious particles in the air. An additional interview with IP #13 was conducted on [DATE] at 2:44 p.m. During this interview, IP #13 explained s/he would spend approximately ,d+[DATE]% of his/her time focusing on infection control in the Surgical Department. IP #13 stated s/he would try to conduct monitoring rounds in one of the surgical units monthly which would involve looking for anything that would draw his/her attention to a breech in infection control. IP #13 then stated s/he did not document the rounds being done or if any findings were communicated to staff in the surgical department. 2. The facility did not store reprocessed endoscopes in a manner to avoid contamination or growth of microorganisms. a) On [DATE] at 1:30 p.m., the Main OR department's endoscope storage cabinet was observed with a Surgical Technician (ST #5). Inside the storage cabinet an endoscope was observed hanging from a hook with the distal tip wrapped around the hook, which created a complete coil in the endoscope. During the observation, ST #5 stated there probably was not ample space available when the scope was placed in the closet and that was the reason why it was looped around the hook. ST #5 then proceeded to readjust the endoscope to hang in a vertical position. b) On [DATE] at 9:37 a.m., an interview was conducted with Director #1 who confirmed the expectation was for scopes to be stored in a vertical position after reprocessing in order to be able to dry completely. c) On [DATE] at 3:39 p.m., an interview was conducted with IP #13 who stated the expectation was for endoscopes to be stored in a vertical position in order to decrease the risk of bacterial growth by allowing any residual water from reprocessing the endoscope to drain. 3. The facility did not clean OR suites in accordance with national standards of care before the first scheduled procedure of the day. a) On [DATE] at 9:12 a.m., an interview was conducted with an OR Registered Nurse (RN #6) who stated s/he would not routinely clean the OR suite s/he was assigned to before the first scheduled procedure of the day unless s/he noticed something in the room that needed to be cleaned. On [DATE] at 9:17 a.m., an interview was conducted with Surgical Technicians (ST #11 and ST #12). ST #11 revealed s/he was precepting ST #12 who was on orientation. ST #11 stated s/he would not wipe down horizontal surfaces in OR suites before the first case of the day because they had been terminally cleaned the night before. On [DATE] at 1:44 p.m., an interview was conducted with an OR RN (RN #7) who stated since OR suites were terminally cleaned overnight staff did not clean them before the first procedure of the day unless they were visibly soiled. RN #7 further stated s/he felt there would not be enough time to clean OR suites before the first case of the day. b) On [DATE] at 9:37 a.m., an interview was conducted with Director #1 who revealed OR suites were terminally cleaned each night between 7:00 p.m. and 4:00 a.m. Director #1 stated s/he did not think it was necessary to clean the OR suites in the morning before the first case of the day since they had been terminally cleaned the night before. This was in contrast to the AORN recommendation which stated all horizontal surfaces in the OR should be damp dusted before the first scheduled surgical or other invasive procedure of the day. c) On [DATE] at 3:39 p.m., an interview was conducted with IP #13 who explained since OR suites were terminally cleaned during the night it was not expected for staff to clean the suites before the first case of the day. IP #13 stated s/he was not aware of the AORN recommendation which stated all horizontal surfaces in the OR should be damp dusted before the first scheduled surgical or other invasive procedure of the day. IP #13 then stated the facility should have been cleaning the OR suites before the first case of the day in accordance with AORN guidelines. 4. The facility did not ensure intravenous (IV) fluids stored in warming cabinets were safe for patient use. a) On [DATE] at 10:55 a.m., a tour of the Main OR department revealed the following IV fluid bags stored in fluid warming cabinets past the expected discard date: - In the sub-sterile room located between OR #7 and OR #8, one 1000 ml bag of Lactated Ringer's IV fluid was observed in a fluid warming cabinet with the date of ,d+[DATE] written on the bag. - In the sub-sterile room located between OR #9 and OR #10, two 3000 ml bags of 0.9% Normal Saline IV fluid were observed in a fluid warming cabinet with the date of ,d+[DATE] written on the bag. b) On [DATE] at 9:37 a.m., an interview was conducted with Director #1 who confirmed the date written on the IV fluid bags indicated the date the fluid should have been discarded. Director #1 explained the facility followed AORN guidelines and facility policies when storing IV fluids in the warming cabinets, which instructed to discard IV fluids in warming cabinets after 14 days. c) On [DATE] at 3:39 p.m., an interview was conducted with IP #13 who confirmed the facility's expectation was for IV fluids to be removed and discarded from the fluid warming cabinet when they were expired in order to decrease the risk of bacterial growth in the fluid. 5. Staff in the Pre-Operative Unit did not ensure single use patient care supplies were stored in their protective packaging and safe for patient use. a) On [DATE] at 9:45 a.m., a tour of the Main Preop (pre-operative) Unit and the Main PACU (post-anesthesia care unit) was conducted. Observations during the tour revealed the following patient care supplies: - In the Preop Unit Medication Room, two sets of IV tubing without the manufacturer's protective packaging were observed on a shelf. - In Bay #5 of the PACU, one oxygen mask with the manufacturer's protective packaging ripped open was observed in the third drawer of a storage cart. b) On [DATE] at 10:08 a.m., an interview was conducted with the Director of the Preop Unit and PACU (Director #8), who stated any patient care supplies found out of their packaging should not have been used and should have been discarded. c) On [DATE] at 3:39 p.m., an interview was conducted with IP #13 who confirmed the expectation was for staff to discard opened supplies in order to decrease the risk of patients receiving potentially contaminated items. 6. The facility did not maintain humidity levels in the Main OR suites at levels required by policies and national standards of care. a) A tour of OR #7 was conducted on [DATE] at 12:15 p.m. with Director #1. Director #1 explained the facility followed AORN guidelines for determining the acceptable humidity levels in the OR, which were between ,d+[DATE]%. Observation of the thermostat in OR #7 revealed the humidity level was 16.5%. Director #1 stated s/he would not be concerned if the humidity level fell below the accepted range. This was not in accordance with the policy which instructed staff to contact facilities management as soon as possible if temperatures and humidity ranges fell out of the required level. Further observations from the same tour revealed the following OR suites' humidity levels: - OR #8's humidity level was 16%. - OR #2's humidity level was 15.9%. b) Review of the Main OR Humidity Log from [DATE] to [DATE] (40 days total) revealed the following examples of humidity levels falling below the acceptable range: - OR #1's humidity levels fell below the acceptable range 25 of 40 days reviewed. The lowest humidity level during the reviewed time frame was 6.3% on [DATE]. - OR #2's humidity levels fell below the acceptable range 26 of 40 days reviewed. The lowest humidity level during the reviewed time frame was 7.3% on [DATE]. - OR #3's humidity levels fell below the acceptable range 18 of 40 days reviewed. The lowest humidity level during the reviewed time frame was 6.9% on [DATE]. d) On [DATE] at 3:39 p.m., an interview was conducted with IP #13 who confirmed the humidity level range in the OR suites was expected to be between ,d+[DATE]% in accordance with AORN guidelines. IP #13 stated s/he was unaware humidity levels fell below 20% in the OR suites. IP #13 further stated this would be a concern due to an increased risk of fire in the OR suites. 35253 7. The facility did not ensure patient care supplies stored in nurse servers in patient rooms were discarded between each patient. Additionally, the facility failed to ensure nursing staff performed hand hygiene prior to removing supplies from the nurse servers; therefore, the facility could not ensure the supplies were not contaminated. a) On [DATE] at 9:36 a.m., a tour of the Critical Care Units (CCU) was conducted with Employee #21 and the CCU Director (Director #22). At 10:03 a.m., an observation of a medication pass was conducted with RN #23 in room [ROOM NUMBER]. A nurse server was found stocked with syringes, saline flushes, and additional patient care supplies. RN #23 obtained a disinfectant wipe and saline flush from the top drawer and then administered the intravenous (IV) medication Digoxin (used to treat congestive heart failure and to slow the heart rate in patients with atrial fibrillation) through Patient O's IV catheter. During the medication observation, RN #23 did not perform hand hygiene when entering the patient's room, prior to administering the IV medication through the patient's IV catheter, and after exiting the room. b) On [DATE] at 10:00 a.m., an interview was conducted with Director #22 who stated the supplies kept in the nurse servers were only disposed of, if the patient was on contact precautions. Director #22 stated nursing staff hands should not have been contaminated when removing supplies from the nurse servers. S/he further stated hand hygiene should have been done to prevent contamination of the supplies. Director #22 then stated if the supplies were contaminated, they should have been discarded. c) On [DATE] at 2:17 p.m., an interview was conducted with IP #13 who stated if the facility could not ensure sterility had been maintained after a patient was discharged , the supplies in the nurse servers should have been discarded. S/he further stated if the facility could not ensure hand hygiene had been done every time the drawers of the nurse servers were accessed, staff should have discarded those supplies. d) On [DATE] at 10:29 a.m., an interview was conducted with RN #25 who stated items were left in the nurse servers in patient rooms if the patient was not an isolation patient. RN #25 stated the carts should have been accessed with clean gloves or clean hands. e) On [DATE] at 10:37 a.m., an interview was conducted with RN #26 who stated the nurse servers should have been accessed with gloves and hand hygiene should have been done before accessing the supplies in the cart. S/he further stated, after patients were transferred, the nurse or tech would restock the nurse server; however, any supplies wrapped would remain in the nurse server. 8. The facility did not ensure patient care supplies used to conduct blood glucose tests were uncontaminated and safe for patient use. a) On [DATE] at 11:43 a.m., Patient Care Technician (PCT) #24 performed a blood glucose test on Patient P in room [ROOM NUMBER] (6th floor). PCT #24 carried a clear plastic bio-hazard bag containing multiple lancets and cotton balls into the patient's room, along with the container of test strips. PCT #24 used multiple lancets during the test. After the first unsuccessful attempt at collecting blood, PCT #24 removed his/her gloves and used his/her bare hands to obtain another lancet and cotton ball from the bag. PCT#24 did not perform hand hygiene prior to placing his/her hands into the bag. PCT #24 carried the same bag of supplies to patient room [ROOM NUMBER] and left the bag of supplies on the side rail connected to the wall outside of the room. PCT #24 did not disinfect the plastic bag when s/he exited room [ROOM NUMBER]. b) On [DATE] at 9:30 a.m., a tour of the 7th floor Neuro/Spine Unit was conducted with Director #27 and Charge Nurse #28. During the tour, a clear plastic bag filled with lancets and cotton balls was observed next to the glucometer dock station. Charge Nurse #28 stated the bag should not have been taken into patient rooms. c) On [DATE] at 9:32 a.m., an interview was conducted with PCT #24 who stated the bag containing the lancets and cotton balls could be taken into patient rooms. PCT #24 stated s/he changed the bag every shift. PCT #24 stated s/he would clean the bag of supplies after exiting an isolation room but would not disinfect the bag before or after taking care of other patients. d) On [DATE] at 9:34 a.m., an interview was conducted with the 6th floor unit Manager (Employee #29), who stated staff were expected to take lancets and cotton balls out of the clear plastic bag when performing glucose tests on patients. However, Employee #29 then stated it was okay for the bags to be brought into the room, unless the patient was on isolation precautions. S/he stated the bags should have been disinfected with the glucometer. e) On [DATE] at 2:17 p.m., an interview was conducted with IP #13 who stated the expectation was one lancet and one cotton ball was to be brought to one patient room at a time. S/he further stated re-education needed to be done with staff that performed blood glucose tests. 9. The facility failed to ensure patient's hands were washed with soap prior to glucose testing. a) On [DATE] at 11:43 a.m., PCT #24 performed a blood glucose test on Patient P in room [ROOM NUMBER] (6th floor). PCT #24 did not clean or disinfect the patient's fingertips prior to piercing the patient's fingertip with the lancet. PCT #24 pierced the patient's finger 3 times before s/he was able to collect a sufficient amount of blood for the test. After the observation, PCT #24 stated per protocol, staff should check patient's hands to see if they were visibly soiled, then staff would need to wash the patient's hand with soap and water. PCT #24's statement was in contrast to facility policy. b) On [DATE] at 3:39 p.m., an interview was conducted with IP #13 who stated s/he was not aware of the updated policy which stated for a finger puncture, staff should cleanse the fingertip with soap and water and wipe dry with cotton ball or allow to air dry. Neither PCT #24 and IP #13 were aware of facility policy.

31304 Based on staff interviews and document review the facility failed to ensure that 1 of 12 patients, Sample patient #6, received care in a safe setting. This failure resulted in Sample patient #6, a moderate fall risk patient, falling out of the wheelchair 2 times, causing injury to the patient. Findings: Policy According to the facility fall policy, adult patients are assessed to be at risk for a fall when he or she has a score of six (6) or greater on John Hopkins Fall Risk Tool (JHFRAT). Fall risk is determined at low or no risk (score of 0 to 5), moderate (score of 6 to 13) or high risk (score greater than 13). High Fall Risk: Use direct visual access. The facility did not implement identified interventions to prevent a patient falls. a) On 05/13/14, a review of medical record for sample patient #6 was conducted. The patient was admitted to the Rehabilitation Unit on 12/12/13. During an interview with the Director of the Rehabilitation Unit on 5/14/14 at 1:33 PM, it was confirmed that on admission to the unit, the patient was assessed to be a moderate fall risk with a score of 13, based on the JHFRAT. One of the safety measures documented in the patient care plan was the patient was not to be left alone while up in a chair. The patient's medical record revealed that on 12/14/13, the patient was up in a wheelchair having lunch in his/her room and was found at approximately 12:00 PM, on the floor by nursing staff. The medical record documented the patient ' s recall of the fall and that the patient struck her left cheek. The record also revealed on 12/14/13, at approximately 7:00 PM, the patient was at the nurses ' station in a wheelchair and got up to walk and fell . The patient did hit his/her head, sustained a laceration to her left eyebrow with swelling and bruising, was seen by a physician, a suture was placed and a CT scan of head and cervical spine was performed with no changes identified. b) On 05/14/14 at 1:30 p.m., an interview with the Director of the Rehabilitation Unit was conducted. The Director stated that the patient's family had been in the patient's room and had been requested to notify staff when they were leaving the patient. Family failed to notify staff that they were leaving as requested. S/he stated that if the patient's family left or were not present while the patient was up in a wheelchair that they would bring the patient to the nurses ' station to keep an eye on him/her. The Director stated on 12/14/13 at approximately 12:00 PM , the patient recalled bending over to pick up a piece of food that had fallen on the floor and tipped the wheelchair over falling to the floor sustaining an injury to his/her left cheek. Facility staff were unaware the patient was alone in his/her room in a wheelchair.

33044 Based on observations, interviews, and document review, the facility failed to administer blood transfusions in accordance with approved medical staff policies and procedures. This failure created the potential for negative patient outcomes through the possible spread of bloodborne pathogens and infectious disease. Findings: 1. The facility did not ensure that staff followed facility policies and procedures regarding standard precautions during blood administration. a) On 09/04/13 at 12:20 p.m., the surveyor reviewed the facility's policy titled, General Infection Control Policy: Isolation Precautions in Hospitals, last revision dated February of 2010. The policy stated that gloves Will be worn when it is possible that there will be contact with blood or any other body substance, mucous membrane or non-intact skin. b) On 09/04/13 at 11:30 a.m., a Registered Nurse (RN) was observed administering blood to a patient in the facility's Ambulatory Care Unit (ACU). The RN explained that he/she would be starting a second unit of blood for the patient and that the second unit would be attached to the same intravenous (IV) tubing used for the first unit of blood. Without donning gloves, the RN detached the empty first unit of blood from the IV tubing and attached the full second unit of blood to the IV tubing. The RN was then observed taking the empty unit of blood to a closed door, entering a code into a key pad located next to the doorknob, and opening the door, all without washing his/her hands first. The RN then discarded the empty unit of blood in a biohazard container and washed his/her hands at a sink located next to a coffee maker. c) On 09/04/13 at 12:05 p.m., the Director of Quality was interviewed about the surveyor's observations of an RN not wearing gloves while administering blood. the Director of Quality confirmed that the RN was not wearing gloves and that the expectation would be for staff to wear gloves while in contact with blood or body fluids.